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Med Surg Case Study #2

Presenting Complaint: A 45-year-old male patient presents to the clinic with complaints of persistent fatigue, abdominal discomfort, and swelling in his legs and abdomen. He also reports unexplained weight loss and yellowing of the skin and eyes (jaundice) over the past few months.


Patient Background: The patient, Mr. Ramirez, has a significant medical history:

  • Chronic alcohol use for the past 20 years, with a recent attempt to quit.

  • Type 2 diabetes, diagnosed 5 years ago, managed with oral hypoglycemics.

  • No known family history of liver disease.

  • He works as a construction laborer and reports occasional exposure to toxic chemicals at work.

Assessment:

  • Physical examination reveals:

    • Jaundice, with yellowing of the skin and sclera.

    • Ascites, with abdominal distention and shifting dullness on percussion..

    • Enlarged and tender liver on palpation.

    • Hepatic encephalopathy manifested by mild confusion and asterixis (flapping tremor).


1. What are the possible diagnoses for Mr. Ramirez's condition?



2.What diagnostics might be used to confirm the diagnosis?



3. What treatments might be needed for Mr. Ramirez's condition?


See answers below





Med Surg Notebook





Answers

1. What are the possible diagnoses for Mr. Ramirez's condition?

  • Possible diagnoses for Mr. Ramirez's condition include cirrhosis of the liver/ alcoholic liver disease. Given his history of chronic alcohol use and clinical findings, cirrhosis is a primary consideration.


2. What diagnostics might be used to confirm the diagnosis?

  • Diagnostics that might be used to confirm or assess the extent of liver damage include:

    • Liver function tests, including serum bilirubin, liver enzymes (AST and ALT), and albumin levels.

    • Imaging studies such as abdominal ultrasound or CT scan to visualize liver morphology and rule out HCC.

    • Liver biopsy to confirm cirrhosis and assess the degree of fibrosis and inflammation.


3. What treatments might be needed for Mr. Ramirez's condition?

  • Treatment for cirrhosis may include:

    • Alcohol cessation and substance use disorder counseling.

    • Medications to manage complications such as diuretics for ascites or lactulose for hepatic encephalopathy.

    • Nutritional support to address malnutrition and muscle wasting.

    • Regular monitoring and follow-up to prevent and manage complications.

    • Evaluation for liver transplantation in advanced cases.

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