Download Case Study of End-Stage Liver Cirrhosis with Complications and more Study notes Agricultural Mathematics in PDF only on Docsity!
Comprehensive Management of
End-Stage Liver Cirrhosis: A Case
Study of Mr. Scoaline
Case Study #2: Mr. Scoaline
History of Presenting Illness (HPI)
Mr. Scoaline is a 58-year-old male who was brought to the emergency department by EMS. His neighbor called EMS because Mr. Scoaline looked generally unwell, jaundiced, lethargic, and was behaving in a confused manner.
Health History
Alcohol Use Disorder (AUD) Non-smoker Known Liver Cirrhosis with portal hypertension Depression Unremarkable family history
Home Medications
Carvedilol 6.25mg PO daily Folic Acid 5 mg PO daily Multivitamins 1 Tab PO daily Paroxene 40 mg PO daily Spironolactone 25 mg PO daily Thiamine 100 mg PO daily
Physical Assessment on Admission Day 1
General Appearance: disheveled, slow and unsteady gait Neurological: lethargic, oriented to person, inconsistent with date and time Respiratory: clear air entry to all lung fields, no SOB, no cyanosis, respirations unlaboured Cardiovascular: S1 S2 heard, no murmur, pulses moderate, regular and palpable, skin warm, dry. Cap refill <3 seconds, +2 edema to lower legs bilaterally Gastrointestinal: Abdomen large, softly distended, mild diffuse tenderness, BS x4, loose BM x2 today Genitourinary: Voiding without difficulty, urine clear yellow. No bladder distension noted
Integumentary/Musculoskeletal: Skin intact, jaundiced skin & sclera, a few scattered bruises to arms and legs. Motor power moderate and equal x4. Psychosocial: Lives alone, no kids, divorced. Retired factory worker. Poor management of cirrhosis and portal hypertension. Currently has ETOH consumption ~8 beers/day.
Vital Signs
T. 37.8, HR 96 regular, RR 18, 96% RA, BP 94/
Diagnostics
CT scan demonstrates worsening liver cirrhosis Abdominal U/S demonstrates significant Ascites Ascites fluid diagnostics demonstrate spontaneous bacterial peritonitis Endoscopy demonstrates increased portal hypertension
Blood Work on Admission
CBC: Hemoglobin 130 g/L (120-160), Platelets 90 (130-380), WBC 13. (3.5-10.5) Electrolytes: Sodium 136 mEq/L (135-145), Potassium 3.8 mEq/L (3.5-5.0), Chloride 100 mEq/L (98-107), Magnesium 0.82mmol/L (0.74-1.07) Renal panel: Creatine 187 (53-106mcmol/L), eGFR 26 ml/min (>60 ml/ min) Liver panel: AST 68 U/L (0-35), ALT 55 (4-36), ALP 225 (35-120 U/L), Total Bilirubin 32 mcmol/L(5.1-17) Miscellaneous: Ammonia 77 mcmol/L (6-47 mcmol/L), Albumin 22 g/L (35-50 g/L), INR 1.9 (0.9-1.1)
Working Diagnosis
Hepatic encephalopathy Spontaneous bacterial peritonitis (SPB) Query onset of Hepatorenal syndrome Significant progression of liver cirrhosis and portal hypertension Alcohol withdrawal
In-Hospital Treatment & Orders
Paracentesis drained 3L fluid CIWA protocol Delirium and CAM (confused assessment method) monitoring Monitoring and replacement of electrolytes Monitoring of refeeding syndrome
In-Hospital Medication Orders
Albumin IV 25% x3 doses
Case Analysis Questions
Choose three questions from the case analysis list below that correlate to your learning needs. Ensure that you are adequately integrating the case of Mr. Scoaline into your discussion. Answers for each question are limited to 250 - 400 words (per question) and you are expected to use credible and current sources of evidence to support your discussion.
Describe one effect of late-stage cirrhosis on each of the following systems: central nervous system, hematologic, integumentary, hepatic, and renal. Explain the pharmacokinetics and pharmacodynamics of the medications rifaximin and baclofen. Why was Mr. Scoaline prescribed these? Discuss the pathophysiology of edema in Mr. Scoaline's lower extremities and three nursing interventions. Why was Mr. Scoaline prescribed thiamine, folic acid, and multivitamins? Describe the relationship between AUD, hepatic encephalopathy, ascites and SPB. What are three priority nursing interventions? Explain the use of albumin in this case scenario. Mr. Scoaline is experiencing frequent diarrhea. Explain the importance of monitoring alcohol withdrawal symptoms. Why are benzodiazepines used to treat withdrawal symptoms? Explain electrolyte imbalances and refeeding syndrome in this case study.
Health Promotion and Discharge Planning
You are planning to engage with Mr. Scoaline regarding health promotion strategies and addressing barriers to discharge. Discuss three health promotion teaching focuses for Mr. Scoaline. Which allied members of the health care team you would consult in preparation for discharge?
Resources Used
Alberta Health Services. Alcohol withdrawal protocol- adult inpatients; self-directed learning module and self-quiz. American Association for the Study of Liver Diseases. Practice guidelines. Civan, J. M. (2019). Cirrhosis. Merck Manuals. Crabb, D.W., Im, G.Y., Szabo, G., Melliger, J.L., Lucey, M.R. (2019). Diagnosis and treatment of alcohol-associated liver diseases: 2019 Practice guidance from the American Association for the Study of Liver Diseases. Pagana, K. D., Pagana, T.J, Pike-MacDonald, S.A. (2013). Mosby's manual of diagnostic and laboratory tests. 1st Canadian Ed. Elsevier Toy, E., Patland, J., & Warner, M. (2017). Case files internal medicine 5th ed. McGraw-Hill Education Tholey, D. (2012). Portal hypertension. Merck Manuals. Tholey, D. (2021). Ascites. Merck Manuals.
