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Original Question

EMERGENCY DEPARTMENT Sex: M AGE: 50 DOS: 1/1/20XX CHIEF COMPLAINT: Jaundice. HISTORY OF PRESENT ILLNESS: This is a male with history of abdominal pain and bloating as well as mild chest pain, difficulty with urination, tenesmus, mild nausea, and poor appetite that has been ongoing and progressively worsening over the past week. He has been having some dry heaving with this. He has been having waxing and waning abdominal pain that he describes as being in the lower portion of his abdomen and was worse yesterday. It is somewhat improved today. He has been having some loose stools, more than his normal. He does feel that his symptoms are progressively worsening. He does have worsening symptoms lying down and feels that he has a hard time catching his breath as a result. He has had chills and a fever up to 100. He went to the store to get some milk today when the clerk told him that he looked extremely yellow and thought he should go to the doctor to get seen. He denies any history of this in the past. He does admit to drinking a 6-pack of beer a day. He denies any history of hepatitis. Denies any postprandial problems or pain but has not really had an appetite. He has not taken anything particularly for this. PAST MEDICAL HISTORY: Chronic back pain. PAST SURGICAL HISTORY: Lumbar fusion. MEDICATIONS: Acetaminophen/hydrocodone. Temazepam. Omeprazole. ALLERGIES: None. SOCIAL HISTORY: He smokes a pack a day and has drunk a 6-pack of beer per day consistently for the past month. FAMILY HISTORY: No known history of gallbladder disease. REVIEW OF SYSTEMS: As above, otherwise all other systems reviewed and negative PHYSICAL EXAM: GENERAL APPEARANCE: Markedly jaundiced-appearing male, resting quietly in no apparent distress. PSYCH: He is alert and oriented x4. VITAL SIGNS: Temperature 99. Pulse 111. Respiratory rate of 20. O2 sat 97% on room air which is normal for this patient. HEENT: Eyes – PERL. EOMs are intact. He does have quite a lot of icterus. Nose is patent. Oropharynx is pink, moist, well hydrated. No pharyngeal erythema. NECK: Supple. No masses. No lymphadenopathy. No JVD is apparent. CHEST: Symmetric with equal expansion. LUNGS: Clear to auscultation bilaterally. No wheezes, rales, rhonchi. CARDIOVASCULAR: Rate and rhythm are regular without murmurs or gallops. ABDOMEN: Obese. He has got some right upper quadrant tenderness as well as some mid abdominal tenderness. Certainly, no rebound or guarding or peritoneal signs are noted. There is no left upper quadrant tenderness. No CVA tenderness is noted. SKIN: Jaundiced but diffusely down to the upper portion of his legs. No petechiae or purpura is noted. NEUROLOGIC: Cranial nerves are grossly intact. No focal neuro deficits. LAB: WBCs 9.7, hemoglobin 11.8, hematocrit 33.3, platelets 174, neutrophils 69.8, lymphocytes 16.0, monocytes 13.1. Sodium 134, potassium 3.7, chloride 104, CO2 22, glucose 88, BUN 5, creatinine 0.7. Total bili is 16.5, alkaline phosphatase 280, ALT 57, AST 169, troponin less than 0.04. Lipase 291. INR 1.7. Urinalysis showed trace ketones, 4+ bilirubin, negative blood, 5 white cells, 1 red cell, 15 epithelials. Acetaminophen level was less 10. Magnesium is 2.1, phosphorus 2.1. IMAGING: Chest x-ray, 2 views, showed an enlarged heart, chronic changes, but no obvious infiltrate or effusion was noted. EKG showed a sinus tachycardia with nonspecific ST and T-wave abnormalities, interpreted by Dr. Thomas and over read by myself. COURSE: The patient was given fluids initially at 125 mL per hour but decreased to 50 mL per hour later on with thiamine, folate, and multivitamin added. Patient was titrated for pain with Dilaudid. He was also given Zofran, and blood cultures x2 were ordered as well. After review of the patient’s labs and imaging, I did speak with Dr. Thompson regarding his symptoms and she felt that his symptoms were likely consistent with acute alcoholic hepatitis which I would agree with. He denies any history of the viral hepatitides but certainly we will get a hepatitis panel. His ultrasound did show stones in the gallbladder but large gallbladder wall was mildly thickened with a common bile duct at 4.5 mm that was not dilated. Fatty liver, small amount of ascites. No hydronephrosis was noted. I do think it is reasonable to admit the patient for further evaluation and treatment. She did agree to admit him and did come to evaluate him here in the emergency room. He has otherwise remained hemodynamically stable here. I have reviewed with him the symptoms. He does agree with the plan and feels that this is appropriate. ASSESSMENT: 1. Acute alcohol hepatitis with ascites 2. alcohol abuse. 3. Nicotine – cigarettes dependent PLAN: The patient will be admitted for further evaluation and treatment. Dr. Jones has seen and evaluated the patient. All his questions were answered. He has remained stable here with pain reasonably well controlled on several rechecks.

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