Note: Sample only, done by a second-year visiting medical student from the USA in 1999. Just to illustrate the patient management processes.
RJA
Patient Management Process
Internal Medicine Case Presentation
CASE PRESENTATION:
General Data: ML is a 61 year-old female.
CC: Edema and jaundice.
HPI: Four months prior to admission (PTA), patient complained of epigastric pain with accompanying fever. Three months PTA, patient developed jaundice. One month PTA, patient had bipedal edema and was given Furosemide. One week PTA, patient had tremors and generalized body weakness, which worsened over the course of the week, prompting her to come to OMMC.
PE: Patient presented with jaundice. She also had an enlarged globular abdomen, palpable and firm non-tender liver, splenomegaly, and bipedal edema. Liver was palpable approximately 2 cm below the rib cage. The rest of the PE was normal. Diagram:
CASE DISCUSSION:
Clinical Diagnosis:
1) The data from the database which can serve as cues for a clinical diagnosis in this case come mainly from the PE (Signs).
2) Primary Clinical Diagnosis: Portal hypertension secondary to liver cirrhosis
Secondary Clinical Diagnosis: Portal hypertension secondary to hepatic tumor
Based on the signs found in the PE and by using pattern recognition, I concluded that the main problem is portal hypertension. This is mainly due to the splenomegaly and the edema. With portal hypertension as the primary problem, I then concluded that the liver was the source of the secondary problem due to the presence of jaundice and hepatomegaly. I chose liver cirrhosis over hepatic tumor due to prevalence. As far as the possible source of the liver cirrhosis, I determined that it could be due to alcoholism or hepatitis. Due to prevalence in the Philippines and the fact that the patient is not an alcoholic, I concluded that the most likely source is hepatitis.
Paraclinical Diagnostic Procedures:
1) Primary Clinical Diagnosis: Portal hypertension secondary to liver cirrhosis
Secondary Clinical Diagnosis: Portal hypertension secondary to hepatic tumor
2) Certainty Treatment Modality
Por. Hyp. (Cirrhosis) 80% Non-operative
Por. Hyp. (Tumor) 20% Operative
Since the certainty of the primary diagnosis is not significant in this case, and the treatment modalities are different for the two diagnoses, I conclude that a paraclinical diagnostic procedure is NECESSARY in this case. (I arrived at an 80% certainty for the primary diagnosis because there is no conclusive way to diagnose liver cirrhosis based on PE alone.)
3) Paraclinical Procedures:
4. Among these possible paraclinical procedures, I would choose to do an ultrasound. This is because an ultrasound will provide adequate enough resolution to determine if there is any scarring or nodules present on the liver. I would also be able to check for any beginning signs of shrinkage that is indicative of cirrhosis. Also, the absence of a mass would decrease the likelihood of a hepatic tumor and increase my certainty of my primary diagnosis from 80% to 90%. Although a biopsy could increase the certainty of my primary diagnosis to 99%, the cost would be too much of a factor. And, even though a CT Scan can provide a better image than an ultrasound, the cost again would determine the selection of an ultrasound. In essence, the ultrasound can provide good information that can aid me in firming my primary diagnosis to the necessary threshold of 90% certainty with acceptable cost and risk.
5. There is no data available on any paraclinical procedures done on this patient. However, I will assume that the ultrasound showed scarring and nodules, thereby confirming my primary diagnosis.
Treatment:
1) Primary Pretreatment Diagnosis: Portal hypertension secondary to liver cirrhosis
Secondary Pretreatment Diagnosis: Portal hypertension secondary to hepatic tumor
2) The goals of treatment for the primary diagnosis are controlling the progress of the liver cirrhosis, controlling the edema, and satisfaction of the patient.
3) Treatment Modality:
CONTROLLING PROGRESSION OF LIVER CIRRHOSIS:
CONTROLLING EDEMA:
Based on this data, I conclude that the best treatment for controlling the progression of the liver cirrhosis would be to strongly advise the patient to avoid alcohol and other substances that could further aggravate the liver cirrhosis. In this case, drugs would not provide that much added benefit and can introduce some risks, so advice should suffice. As far as controlling the edema, support is the best treatment since drugs also do not add much benefit and can introduce risks. Thus, the overall treatment would be to advise the patient to avoid alcohol and other substances and to instruct her to avoid staying on her feet for long periods of time and to elevate her legs when possible.
3) The outcome of the proposed treatment will be evaluated depending on how successful it is in achieving the goals of treatment stated above in relation to any negative effects that may have occurred.
4) No data is available on any treatments done on this patient or their outcomes.
Prevention and Health Promotion:
1) The final diagnosis is portal hypertension secondary to liver cirrhosis. The source of the cirrhosis is most likely hepatitis due to its prevalence in the Philippines and also due to the fact that the patient is not an alcoholic. (These factors make alcoholism less likely as a source of the liver cirrhosis.)
2) I would advise the patient that the edema and splenomegaly were caused by portal hypertension and that the cause of the portal hypertension was liver cirrhosis, which explains the hepatomegaly and the jaundice. I would then draw the following diagram for the patient to aid in my explanation of the problem:
Finally, I would explain the importance of following the advice I gave while explaining the treatment of the liver cirrhosis and the edema. I would also inform the patient of the possibility that she might have hepatitis, in which case she should take extra care with hygiene as to avoid spreading it to other people. Also, perhaps those close to her should consider getting vaccinated for hepatitis to avoid having this happen to them.
ROJ@11dec18