Case ConferenceCase Conference

Resident Name, MDResident Name, MD

SVCHSVCHApril 18, 2023April 18, 2023

CC: Epigastric pain x 2-3 daysCC: Epigastric pain x 2-3 days

51 yo AAM with PMH of DM, HTN, 51 yo AAM with PMH of DM, HTN, Smoker, HypercholesterolemiaSmoker, Hypercholesterolemia

Hx of Present IllnessHx of Present Illness

SSiteite epigastric epigastricOOnsetnset sudden, when he woke up sudden, when he woke upCCharacterharacter sharp, 7/10 sharp, 7/10RRadiationadiation to the chest to the chestAAlleviating factorslleviating factors none noneTTime courseime course still present still presentEExacerb.factorsxacerb.factors movement movementSSxx SOB, DOE SOB, DOE

PMHxPMHx

HTN – on ACEi – not controlledHTN – on ACEi – not controlled

DM – on InsulinDM – on Insulin

Hypercholesterolemia – on Lipitor, Hypercholesterolemia – on Lipitor, LDL 134, HDL 34LDL 134, HDL 34

MedicationsMedications

Insulin 70/30 – 30 U am, 10 U pmInsulin 70/30 – 30 U am, 10 U pm

Lipitor 10 qdLipitor 10 qd

Zestril 10 qdZestril 10 qd

Isoptin SR 120 qd (Verapamil)Isoptin SR 120 qd (Verapamil)

NKDANKDA

FMH, SHFMH, SH

Mother with HTNMother with HTN

Unemployed, lives aloneUnemployed, lives alone

Heavy drinking in the past, quit 10 yr agoHeavy drinking in the past, quit 10 yr ago

Smoker – ½ ppd x 30 yrsSmoker – ½ ppd x 30 yrs

Cocaine, Heroin IV user 12 yrs agoCocaine, Heroin IV user 12 yrs ago

Physical ExaminationPhysical Examination

Appearance:Appearance:

Thin man in Thin man in NADNAD

VitalsVitals

TemperatureTemperature 36.7 ºC36.7 ºC

PulsePulse 54/min54/min

RespirationsRespirations 18/min18/min

BPBP 167/79 mm Hg167/79 mm Hg

SpO2SpO2 100% on RA100% on RA

Physical ExaminationPhysical Examination

Skin: no rashSkin: no rashHEENT: NC/ATHEENT: NC/ATChest: CTA (B)Chest: CTA (B)Heart: Clear S1S2, regularHeart: Clear S1S2, regularAbdomen: Soft, epigastric tenderness, 4-5 cm Abdomen: Soft, epigastric tenderness, 4-5 cm hepatomegaly, hard liver edge, +BShepatomegaly, hard liver edge, +BSRectal: normalRectal: normalExtremities: no c/c/eExtremities: no c/c/eNeuro exam: AAO x 3, no focal deficitNeuro exam: AAO x 3, no focal deficit

LabsLabs

11

16

48178

134

5

99

26

16

0.959

PMN - 57 Bands – 17

Amylase 71, Lipase 235

Bil. – 1 AST - 158

Alb - 2.8 ALT - 238

INR - 1.11 AP – 364

CPP x 2 – negative

AG=9

Further testsFurther tests

What would you do in this What would you do in this situation?situation?

What do you think ?What do you think ?

Diagnosis?Diagnosis?

Differential diagnosis?Differential diagnosis?

What tests to order?What tests to order?

Empiric therapy?Empiric therapy?

What happened ?What happened ?

OutcomeOutcome

Treated with IVF, DopamineTreated with IVF, Dopamine

HyperK+ corrected with D50 + Insulin, HyperK+ corrected with D50 + Insulin, KayexalateKayexalate

Final DiagnosisFinal Diagnosis

Hepatocellular CAHepatocellular CA

Take home messageTake home message

Any questions ?Any questions ?

Literature DiscussionLiterature Discussion

Risk factorsRisk factors

EtiologyEtiology

SymptomsSymptoms

Physical Exam

DiagnosisDiagnosis

TreatmentTreatment

ScreeningScreening

EndEnd

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