Nyu medical grand rounds clinical vignette
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NYU Medical Grand Rounds Clinical Vignette. Camila Deza Passias, M.D., PGY-3 2/14/2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medical Grand Rounds Clinical Vignette

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Nyu medical grand rounds clinical vignette

NYU Medical Grand Rounds Clinical Vignette

Camila Deza Passias, M.D.,

PGY-3

2/14/2012

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS


Chief complaint

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • The patient is a 62 year-old Asian man who presented to his primary care physician with abdominal discomfort for 1 month


History of present illness

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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


Additional history

Additional History

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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


Physical examination

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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


Laboratory findings

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • CBC: Hemoglobin 11.8, MCV 97.6, platelets 178

    • Remainder of CBC was within normal limits

  • Basic Metabolic panel:

    • Potassium 5.8, creatinine1.6

    • 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


Laboratory findings1

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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


Other studies

Other Studies

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • No imaging studies were performed at this time


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Working or Differential Diagnosis

  • The working diagnosis at this time was chronic hepatitis B infection with compensated cirrhosis


Nyu medical grand rounds clinical vignette

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


Nyu medical grand rounds clinical vignette

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


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Final Diagnosis

  • The final diagnosis was chronic hepatitis B infection with compensated cirrhosis, complicated by metastatic hepatocellular carcinoma


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