History of Present Illness
Mr McGrath is a 46-year-old university lecturer with a 25-year history of heavy drinking; 5 years ago he was diagnosed with alcoholic cirrhosis of the liver. He stopped drinking after his diagnosis.
Mr. McGrath went to his GP with his wife complaining of fatigue, weakness, and pain under his right rib cage. He had been complaining to his wife for a couple of months but has refused to see anyone about it until now. He has been self-medicating with panadol for the pain. According to Mr. McGrath’s wife he has been more difficult than usual for the past week “very confused and acting strangely”. His wife was concerned this morning as he didn’t seem to understand her. His wife also thinks his stomach is swelling up again and is worried his cirrhosis is getting worse.
He has recently gained 10kg, and his abdomen has become significantly swollen. Mr. McGrath has had difficulty sleeping, remembering things, and has according to his wife been more grumpy than usual. Over the week, Mr. McGrath has become increasingly lethargic and disoriented. Based on his presentation, Mr. G was admitted to the hospital with abdominal swelling and confusion for investigation.
Past Medical/Surgical History
Regular bouts of Pneumonia over the last 6 years, alcoholic cirrhosis 5 years ago, anemia, an admission for upper GI hemorrhage secondary to oesophageal varices 3 years ago. Admitted for abdominal paracentesis 18 months ago. He has had a laparoscopic cholcystectomy 15 years ago. Appendectomy at 16, fractured arm at 13years old.
Family History
Mother died of liver disease at age 64, father died of a heart attack at age 58.
Social History
MrMcGrath has been married for 20 years with 3 daughters and a son. Previously a heavy drinker (6 slabs of VB /week x 20 years) stopped drinking 5 ago. Smokes 1 pack per day has been smoking for 30 years.
Medications
•??Propranolol 10 mg orally 8/24 ?
•??Spironolactone 50 mg orally BD ?
•??Furosemide 20 mg orally BD ?
•??OTC drugs – Panadol – for his pain not prescribed ?On examination ?Mr. McGrath is restless and disoriented to person, place, and time. He responds to questions slowly, and his answers are often inappropriate. ?Mr. McGrath’s skin and sclera have a yellowish colour, and he has several ecchymoses to the lower extremities. PERRL. Lungs clear to auscultation. Abdomen distended, firm, and tender with prominent veins at the umbilicus. Bowel sounds normal. Enlarged liver. Haemorrhoids present. Slight metabolic flap observed. Confused and disoriented. ?BP 118/70, P 82 and regular, RR 22, T 37.7°C, weight 95Kg, height 185, SaO2 91% (room air) ?Biochemistry: ?
Serum albumin 25g/l
AST 120 U/L
Total bilirubin 55umol/l ALT 80 U/L
Prothrombin time 20 seconds ALP 170 U/L
GGT 110 U/L
Review the presentation and management of Mr McGrath ensuring you address the following questions:
•??Explain the cause of his presenting symptoms particularly in relation to his confusion ?
•??Describe the pathophysiology of the development of oesophageal varices and discuss ?potential management strategies for bleeding varices. ?
•??Discuss the role and potential complications of abdominal paracentesis in the ?management of ascites. ?
•??Discuss the educational requirements for Mr McGrath following his current ?admission. ?
•??Analyze the drug regimen Mr McGrath is currently prescribed and identify the ?rational / reason he has been prescribed these drugs. ?
