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Team D Morning Report

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by

Darien Wang

on 29 November 2013

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Transcript of Team D Morning Report

“Whiskey River, take my mind…”
CC: Abdominal Swelling
Young Cirrhotic(?):or “Why are these LFTs Jacked?”
Epic CareEverywhere

A Team D PSA
HPI
Mr. H (Night float admission)
40 y/o male with history of alcoholic cirrhosis, ascites, and banded varices presents with one week of increasing abdominal swelling, three days of abdominal pain, and a fever up to 102 for the past 24 hours. Also increasing sob, umbilical hernia, fatigue, diarrhea for 1 week

Labs/Imaging
H/H 9.0/25
WBC 16.1
Platelet 99
INR 2.1
LA 2.8
Ammonia 60
UA negative
Immediate Care
IVF boluses to 2 liters
Right IJ MML with norepi and vasopression
Diagnostic and therapeutic paracentesisw/albumin infusion
IV ceftriaxone 2 gram daily
ICU admission
Hepatology “Big Breakfast”
-HAV, HBV, HCV (reflexive viral load)
-Ferritin, Iron, Transferrin Saturation
-Ceruloplasmin
-ANA (reflexive ENA), AMA
-A1AT
-Immunoglobulins
-TTG, IgA
Lung Disease / Manifestations
Typically presents as unexplained Dyspnea/wheezing/recurrent-bronchitis in young, otherwise “healthy” patients

Patterning includes COPD and/or Bronchiectesis

Accelerated course with smoking or occupational exposure*

Liver Disease
Treatment (…or not)
Indications
High-risk phenotype
A1AT < 11umol/L
Obstructive pattern on PFT
Psychosocial stability
Never/former-smoker

Team D
Dr. James Franko
Zachary Stachura PGY-2
Travis Melin PGY-1
Darien Wang PGY-1
Dan Plessl VTCMS-3

Hospital Course
Day 2 – vasopressors stopped
Day 3 – gave Vit. K (UVa transplant service rec)
Day 4 – resumed home spirinolactone/lasix
Day 5 – stopped ceftriaxone, start norfloxicin
Day 6 - repeated paracentesis – PMN <250
Day 7 – discharged home w/ PCP and UVa follow up
Pooled A1AT
Aralast, Prolastin, Zemaira

-weekly dosing (60mg/kg) vs monthly (250mg/kg)

-Roughly $80k yearly

-Supportive Care: QUIT SMOKING, vigilance for lower respiratory-tract infections, VACCINATIONS

-accumulation and polymerization of deranged A1AT proteins as inclusion bodies*

-M and Z alleles confer risk (Null not implicated)**

-Male gender predisposition

-Ironically, Alcohol abuse and viral hepatitides do not increase risk of progression

On Basilar hypolucency…
Alpha-1 Antitrypsin Deficiency
A Brief Overview
Genotypic vs Phenotypic
A1AT – elastase inhibitor
Spectrum
“Normal”

Deficient: heterozygote (3% of caucasian Americans)

Null: homozygote deletion or mutation

Dysfunctional: inactive/inefficient protease inhibitors, albeit at detectable/sufficient levels
Detail 3
PMH/PSH
Cirrhosis w/ascites
- Diagnosed 1 year ago
- Paracentesis x2
- Portal hypertension with variceal bleed & banding x2
- Encephalopathy x1
- No episodes of SBP
Anemia
GERD
Appendectomy
Cleft lip repair
Vitals/PE
Temp: 102.7 BP: 80/42 HR: 74 Resp: 22 SpO2 100%
General: Appears ill, fatigued, but in NAD
HEENT: PERRL, EOMI, scleralicterus, MM dry
Neck: No JVD, no adenopathy
Heart: HRRR S1/S2 noted, no murmur, rub
Lungs: CTAB, no wheeze, rale , rhonchi, good air movement
Abdomen: Abdomen firm, distended, + fluid shift, diffusely tender, reducible umbilical hernia, bowel sounds present, prominent umbilical veins
Extremities: Trace pitting edema at ankle
Skin: Significant jaundice, multiple blanching angiomas to chest, no skin breakdown
Neuro: alert, oriented, good concentration, normal speech, no focal findings, no asterixsis, strength 5/5

Family History
- Non - contributory

Social History
- Non-smoker
- Alcohol - 2-3 mixed vodka drinks daily
- On disability
- Lives with parents

Medications
Propranolol – 20mg BID, Lasix – 40mg daily, Spirinolactone – 200mg Daily, Iron – 325mg BID, Citalopram – 20mg daily, Oxycodone – 5mg TID prn, Lactulose – 10mg TID
Na 120
K 5.1
Cl 87
CO2 23
BUN 16
Cr 1.24
Glucose 106
Albumin 2.9
Ca 8.3
Bili 8.1
AlkP 107
AST 55
ALT 25
CXR: Low lung volumes, bibasilar atelectasis, no effusion
Full transcript