Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Camila Deza Passias, M.D.,
PGY-3
2/14/2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 62 year-old Asian man who
presented to his primary care physician with
abdominal discomfort for 1 month
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient has no known medical problems as
he had not received regular medical care since he
was a child
•His abdominal discomfort occurs is diffuse, dull
and non-radiating, without any relation to food
•He also began to notice swelling of his abdomen
over the last 2 weeks
•He denies nausea, vomiting, or change in bowel
habits
•He does endorse decreased appetite and an
unquantifiable weight loss
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Denies
•Past Surgical History:
•Denies
•Social History:
•Denies any alcohol or tobacco use. No h/o IVDU.
•The patient is from China, living in the United States for 15 years
•Family History:
•Denies
•Allergies:
•No Known Drug Allergies
•Medications:
•No prescription medications, vitamins, or herbal supplements
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: The patient appeared cachectic and
chronically ill but in no acute distress
•Vital Signs: list T: 98.6 BP: 118/76 HR: 87 RR: 12
and O2 sat: 98% on room air
•Abdomen was distended, diffusely tender with an
appreciable fluid wave, and normal bowel sounds
•Skin was mildly jaundice and sclera were icteric
•Remainder of the physical exam was
unremarkable
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: Hemoglobin 11.8, MCV 97.6, platelets 178
•Remainder of CBC was within normal limits
•Basic Metabolic panel:
•Potassium 5.8, creatinine 1.6
•Remainder of basic was within normal limits
•Coagulation panel: INR 1.2, PTT 36
•Hepatic panel:
•AST 66, ALT 134
•total bilirubin 2.7, conjugated bilirubin 0.3
•Remainder of hepatic panel was within normal
limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Hepatitis A, B, and C screening revealed a
reactive hepatitis B surface antigen
•Hepatitis B DNA viral load = 40,000 IU/mL
•Hepatitis B e-antigen was reactive
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•No imaging studies were performed at this
time
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• The working diagnosis at this time was
chronic hepatitis B infection with
compensated cirrhosis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient was admitted to the hospital for
large volume paracentesis which was
negative for spontaneous bacterial peritonitis
• Hospital Day 3:
– Liver MRI with contrast was consistent with
cirrhosis, and additionally revealed diffuse,
infiltrating enhancing lesions throughout the
liver with invasion into the portal vasculature
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 5:
– Palliative care was consulted
– After ongoing discussion with the patient and
family, the decision was made to discharge
the patient to home hospice care
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• The final diagnosis was chronic hepatitis B
infection with compensated cirrhosis,
complicated by metastatic hepatocellular
carcinoma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS