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MORNING REPORT – SEPT 6

MORNING REPORT – SEPT 6. Act 1 – First contact. CC: 77M Px as transfer from OSH HPI: Initially Px to OSH w/ cc Sharp, Epigastric Abdominal pain that woke him from sleep. Pain gradually worsened and he became increasingly ShoB, prompting call to EMS.

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MORNING REPORT – SEPT 6

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  1. MORNING REPORT – SEPT 6

  2. Act 1 – First contact • CC: 77M Px as transfer from OSH • HPI: • Initially Px to OSH w/ cc Sharp, Epigastric Abdominal pain that woke him from sleep. Pain gradually worsened and he became increasingly ShoB, prompting call to EMS. • Arrived @ OSH slightly hypoxemic on RA and was put on 2L NC and given Albuterol, Atrovent, & 1L NS.

  3. ROS • Const: Negative for chills, diaphoresis, fever • HEENT: Negative for sore throat • Card: Negative for chest pain/pressure, palpitations • Resp: Positive for ShoB, negative for cough. Endorsed Hx of COPD • GI: Positive for Abdominal pain, nausea. Negative for vomiting, Melena, Hematochezia, Hematemesis • GU: Negative for urinary symptoms, hematuria, stones • Musc: Endorses chronic back pain, denies acute worsening • Skin: Negative for Jaundice, wounds, rashes. • Neuro: negative for weakness, HA • Heme: Negative for bruising, bleeding

  4. History • PMHx– Minimal documentation. Pt notes COPD, Glaucoma, chronic back pain, • Past surgical history – Inguinal hernia repair • Medications – Latanoprost • Allergies – bee stings • Family history – Non-contributory • Social history – “Two shots of Bourbon per night”, 40 packyear smoking hx

  5. at OSH • Vitals • T 98.1 BP 84/58 HR 73 RR 19 SpO2 95% 2L BMI 17.7 • Physical exam • GEN: AAOx3, “No distress” • HEENT: NC/AT, MMM, oropharynx clear, PERRL, • CARD: RRR, no g/m/r, • RESP: Normal effort, No w/r/r • GI: BS+, TTP, no abd distention, • EXTR: Pulses equal and symmetric, no edema, cyanosis, clubbing • SKIN: Warm, dry, no rashes, no diaphoresis • NEURO: AAOx3

  6. Labs & Imaging Glu– 157 BUN – 20 Cr – 1.40 Na – 140 K – 4.1 Cl– 108 CO2 – 19 AG – 15.8 Ca– 10.9 T.bili – 1.7 AlkPhos – 63 AST – 1200 ALT – 619 Prot – 5.7 Alb – 2.9 Lactic acid – 5.1 • CXR – bibasilar opacities • CT abd/pelv: • diffuse colitis of uncertain etiology • colonic dilatation and non-obstructive stool throughout colon. • No evidence for high-grade obstruction • Periportal edema of liver • Mild ascites WBC – 6.4 Hb – 10.4 Plt – 140 pHv – 7.29 PT – 15.7 INR – 1.2 Trop (-) BNP 25 Labs Imaging

  7. Intermission • Differential diagnoses

  8. Act 2 – Arrival to ICU • Vitals • T 97.3 BP 76/53 HR 90 RR 31SpO2 63% on NRB • Physical exam • GEN: AAOx3, In distress, significant conversational dyspnea • HEENT: NC/AT, MM dry, PERRL, no scleral icterus • CARD: RRR, no g/m/r, • RESP: Slightly diminished throughout, no obvious w/r/r • GI: BS+, Markedly TTP, Tense, significant guarding • EXTR: Pulses equal and symmetric, no edema, cyanosis, clubbing. Extremities cool. • SKIN: dry, no rashes, no diaphoresis • NEURO: Lifts all extremities against gravity, speech normal, face symmetric, follows commands. • Psych: Oriented x3, Affect normal

  9. Labs & Imaging - ICU Glu – 189 BUN – 28 Cr – 2.01 Na – 138 K – 4.4 Cl – 111 CO2 – 17 AG – 12 T.bili – 1.7 AlkPhos – 159 AST – 4784 5185 ALT – 2618 3066 Lactic acid – 3.1  6.1 Procal – 38.94 RUQ US Doppler – negative for PVT WBC – 4.6 Hb – 10.3 Plt – 157 pH – 7.22 pCO2 – 40 pO2 – 72 O2% – 91% FiO2 – 100% PT – 17.620.3 INR – 1.5 1 .7 EtOH < 10 APAP < 1 Labs Imaging

  10. Intermission • Additional Dx?

  11. Acute Liver Failure • Failure – ALI with LFTs >10x UNL, Hepatic encephalopathy, Prolonged PT (INR >1.5) • Causes: Mnemonic (ABC’s) • A – Hep A, APAP, Autoimmune, A.phalloides, adenovir. • B – Hep B, Budd-chiari • C – Hep C, CMV • D– Hep D, Drugs/Toxins • E – Hep E, EBV • F – Fatty Infiltration (acute fatty liver of pregnancy) • G – Genetic (Wilson’s) • H – Hypoperfusion, HELLP, HSV, HLH, Heat stroke • I – Infiltration (by tumor)

  12. Acute Liver Failure • Clinical Manifestations: • S/S: Fever, Fatigue/Malaise, Lethargy, Jaundice, Nausea, Vomiting, RUQ pain, Pruritus, Ascites, Hepatic Encephalopathy, • Lab abnormalities: Anemia, Hypo- (-Glyc, -phos, -mag, -Kalemia), Acidosis/Alkalosis, elevated Ammonia, Elevated LDH • Treatment = Supportive measures + Treatment of Underlying cause

  13. Ischemic Hepatitis (“Shock Liver”) • Diffuse Hepatocellular injury following acute hypoperfusion • Shock, Arterial thrombus, Budd-Chiari, etc. • Hemodynamic insult typically declares itself early, but may be “sub-acute” in rare cases. • Will have massive LDH elevation with AST/ALT. • Nearly Almost Self-limited. • Treatment – Reverse Hemodynamic instability (limited Data) • IVF? • Pressors? Dopamine @ “renal” doses • N-Acetylcysteine? • Statin therapy prior to insult  Protective?

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