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O God, that men should put an enemy in their mouths to steal away their brains! That we should with joy, pleasance, revel, and applause transform ourselves into beasts!
William Shakespeare (1564-1616) British poet and playwright.
48 year old Caucasian female
"My stomach is really hurting"
HPI
Past Medical History
Past Surgical History
Rhinoplasty
Allergies
Acetaminophen (rash)
Oxycodone (nausea)
Medications
Propanolol 10 mg po BID
Pantoprazole 40 mg po BID
Lactulose 15 mg po Qday
Spironolactone 25 mg po Qday
Sertraline 100 mg po Qday
Clonazepam 1 mg po BID
Review of Systems
Physical Exam
99.0 T 76 P 18 RR 115/60 BP 97% on 2L nasal cannula
Weight: 70.307 kg
General: Middle aged lady, in obvious pain but no acute respiratory distress, alert and oriented to person, place, and time.
HEENT: Scalp normal, pupils equally round and reactive to light and accomodation. Fundoscopic exam reveals normal vessels, tympanic membranes are normal, oral pharynx is normal, neck is supple, no abnormal adenopathy in cervical or supraclavicular areas, thyroid is normal without any masses.
Cardio: No murmurs/rubs, heart sounds S1 and S2 are present.
Resp: Decreased air entry over the rt lower lung field, some expiratory wheezing bilaterally.
GI: The abdomen is distended and bulging at the flanks but not tense, diffuse tenderness to palpation exquisitely over the epigastrium, Murphy's sign not present, bowel sounds are present, positive for shifting dullness, liver palpable 2 fingers below the subcostal margin, unable to appreciate exact size of liver or any splenomegaly
MS: No cyanosis, clubbing, or edema noted. Peripheal pulses in the dorsalis pedis, and radial arms are normal.
Skin: Multiple spider angiomas over subclavicular region, face and shoulders
Neuro: Alert, oriented x3, CN II-XII intact, power 5/5 all extremities.
March 10: Hypoxic requiring 100%FIO2 and PEEP of 12.
March 11: Breathing improving requiring PEEP of 5 and FiO2 of 40%. Renal function improving with the CVVHD
March 12: Breathing treatment the same, worsening encephalopathy, sedated but arousable, does not follow commands this am, eye opening present. CT of abdmn showed mild ascites, possible ascending colitis. Displaying multiorgan failure.
March 13: Family decides to change code to DNI/DNR and request pt to be extubated with pastoral services present.
March 14: Pt displays agonal breathing, no longer arousable. On morphine drip for pain.
March 15: Worsening agonal breathing, no longer arousable. On morphine drip for pain.
March 16: Pt passes away at 6:21pm.
SBP
SBP
Fever and chills occur in as many as 80% of patients. Abdominal pain or discomfort is found in as many as 70% of patients.
Other signs and symptoms may include the following:
Treatment for SBP
References
Runyon, Bruce A. Spontaneous bacterial peritonitis variants. www.uptodate.com
Harrisons Internal Medicine Online
Conn Harold O. Spontaneous Bacterial Peritonitis: The Disease, Pathogenesis and treatment. 2000.
Social History
Past Family History
Father 79 years old has heart disease. No liver dx in the family. A brother with diabetes that was on dialysis but had a kidney and pancreas transplant and doing well.
Our Patient Work Up:
Summary
A 48 year old Caucasian female with recent diagnosis of cirrhosis of the liver presented with abdominal distention, cough, sob, low grade fever who on Abdmn US showed moderate ascites, low voltage EKG, chest x ray suggestive of right lower lobe infiltrates and recent hospital admission for upper GI bleeding.
SBP Work Up
Blood and urine cultures should be obtained in all patients suspected of having spontaneous bacterial peritonitis and undergo peritoneal fluid analysis.
Serum-ascites albumin gradient
SAAG = (albumin concentration of serum) - (albumin concentration of ascitic fluid).
A high gradient (> 1.1 g/dL) indicates the ascites is due to portal hypertension (HVPG >5mmHG) with 97% accuracy.
A low gradient (< 1.1 g/dL ) indicates ascites is associated with nephrotic syndrome, tuberculosis, and various types of cancer.
Our patient: 2.4-0.6=1.8 confirms portal HTN
Differential Diagnosis
Spontaneous Bacterial Peritonitis (SBP)
Tense Ascites
Cholecystitis
March 8: Pt was hypotensive (MAP 50-60s). Elevated wbc's continue. Getting albumin infusion 25 gm q12. Peritoneal fluid-> no evidence of SBP. SAAG >1.1. Hold on propanolol and spironolactone. Creatine getting worse, 3.5. Hepatorenal syndrome? Start on octreotide. CXR showed fluid congestion this am. Hepatic hydrothorax? Continue antibiotics and nebs. Edema present in LLE. Get venous doppler.
At night, patient was found dyspneic and was intubated.
March 9: In the ICU intubated, DVT found in LLE, continue heparin. Lactate elevated. AG metabolic acidosis. Required continuous Veno-Venous Hemodialysis . Had a 2D echo done, moderate pul. hyptertension.
Hospital Management
March 5: Start on Zosyn and Vanco for possible HAP. Aldactone 25mg po Qday, Propanolol 25 mg, lactulose 10 mg po qday.
March 6: Pt has fevers w elevated wbc's. Continue meds.
March 7: Pts creatinine bumped up to 2, could be dehydration. Also slightly hypotensive. Will monitor. Continue meds.
Paracentesis (therapeutic/diagnosic) 2 L removed.