I. Chief complaint
“ My abdomen is bloated”
II. History of present illness
RF is a 55-year-old African American woman referred to the hepatology clinic by her primary
care physician because of an increase in abdominal girth over the past month in association
with abnormal liver tests.
RF reports progressive increase in abdominal girth, and leg swelling for the past month,
associated with symptoms of abdominal discomfort, early satiety and nausea, without vomiting.
She has had no change in bowel habits. She has no fever, chills or weight loss. She has no
prior known history of liver disease and no family history of liver disease. She drinks 2-3 glasses
of wine daily with dinner but she has not had any since she developed her symptoms. She has
no history of drug use and does not recall having had blood transfusions, tattoos or body
piercing. She noted increased itching in the evening for the past year; she is taking Benadryl
OTC which is controlling her symptoms.
III. Past medical history
 Hypertension dx 5 years ago
 Hysterectomy for vaginal bleeding in 1999
 Splenectomy after a motor vehicle accident at age 6
 Screening colonoscopy at age 53 with no polyps detected
IV. Family history
 Mother with hypertension
 Father with hypertension, diabetes and CAD
 Sister with hypertension and cervical cancer
 No liver disease
V. Social history
 Never smoked
 Never used drugs
 Drinks wine with dinner regularly (as in HPI)
 Works as a teller at a bank. Married, lives with her husband and has 2 adult children.
VI. Medications
 Atenolol 50 mg daily
 Ibuprofen 400 mg po tid as needed for back pain
 Calcium and vitamin D twice a day
 Multivitamin once daily
 Benadryl 25 mg QHS for itching
VII. Review of systems
 Increased fatigue and difficulty sleeping at night: has been on medical leave from her
work for the past 3 weeks.
 Chronic back pain relieved with ibuprofen
VIII. Physical examination
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Vital signs: P: 68, BP: 122/76, R: 10, T: 98.9, 98% sat on room air
Wt 220 lbs, Ht 5’7”
General: Evidence of temporal wasting
HEENT: Slightly icteric
Neck: supple without adenopathy or jugular venous distention
Cardiovascular: normal rate, regular rhythm, no murmurs
Chest and lungs: symmetrical expansion, clear to auscultation and percussion
Abdomen: LUQ scar of prior splenectomy. Distended abdomen, tense, mild diffuse
tenderness to palpation. Dull to percussion at the flanks with evidence of shifting
dullness. No fluid wave detected.
Extremities: without clubbing or cyanosis; 1+ lower extremity edema appreciated
bilaterally.
Neurologic examination: normal exam. Fully alert and oriented. No asterixis.
IX. Laboratory evaluation
Component
WBC
Hgb
MCV
Platelets
INR
Na
K
BUN
Creatinine
Albumin
Total bilirubin
Alkaline Phosphatase
AST
ALT
Ferritin
HAV serologies
HBV serologies
HCV antibody
AFP
ASMA
ANA
Ig Quant
Reference range
(4.5-13.5 THO/μL)
(13-16 g/dL)
(83 – 93)
(150-400 THO/μL)
(0.9-1.1)
(134-142)
(3.6 – 5.0)
(10-20)
(0.6-1.35 mg/dL)
(3.6-5.0 g/dL)
(0.3-1.2 mg/dL)
(38-120 U/L)
(10-40 U/L)
(9-60 U/L)
(0-5 IU/mL)
(Less than 1:20)
(Less than 1:40)
Value
12 THO/μL
10.9 g/dL
96
140 THO/μL
1.7
134
4.0
8
1.0 mg/dL
3.2 g/dL
4.4 mg/dL
187 U/L
128 U/L
78 U/L
12
Negative
Negative
Positive
8 IU/mL
1:40
1:160
IgG 1.6 g/mL (ULN
1.2)
IgA, IgM within normal
Table 1
X. Medical imaging:
Ultrasound of the abdomen was obtained. The liver had a heterogeneous echotexture, but did
not appear nodular. No focal liver lesions. The hepatic and portal veins appeared patent by
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Doppler. Large amount of ascites noted. Gallbladder is normal. Spleen is absent. Kidneys are of
normal size and echogenicity, no hydronephrosis.
XI. Follow up
Visit A- Initial intervention
The patient underwent an 8.1 L paracentesis with albumin replacement. Ascitic fluid analysis
revealed an ascitic fluid protein of 1.0, albumin < 1.0, WBC 35. Ibuprofen was stopped, she
received diet counseling for a 2 gram Na restricted diet. Spironolactone 100 mg daily and
furosemide 40 mg daily were started.
Visit B- Two months follow up
She presents for follow up 2 months later. She has been abstinent of alcohol. Ascites is
controlled on diuretics. The following laboratory tests are obtained on follow up.
Component
WBC
Hgb
Platelets
INR
Na
K
BUN
Creatinine
Albumin
Total bilirubin
Alkaline Phosphatase
AST
ALT
HCV RNA
HCV genotype
Reference range
(4.5-13.5 THO/μL)
(13-16 g/dL)
(150-400 THO/μL)
(0.9-1.1)
(0.6-1.35 mg/dL)
(3.6-5.0 g/dL)
(0.3-1.2 mg/dL)
(38-120 U/L)
(10-40 U/L)
(9-60 U/L)
Value
4.3 THO/μL
12.0 g/dL
182 THO/μL
1.2
132
4.3
23
1.2 mg/dL
3.5 g/dL
2.9 mg/dL
198 U/L
58 U/L
38 U/L
1,200,000 units
1b
Table 2
Visit C- One month later
RF continued to be well until about 1 month after her follow up visit when she started developing
leg swelling, followed by increased abdominal distention and confusion progressing over 5 days
prior to presentation. She is brought to the ED by her husband who reported that she has not
been drinking alcohol and has been taking all of her medication as instructed. She has not had
fever or chills. No cough or shortness of breath or headache. No urinary symptoms. She has
been complaining of a mild abdominal discomfort and nausea and has a reduced oral intake
over the past 48 hours.
Vitals BP110/65, Pulse 88, RR 14, Temp 99.2
She is icteric, has a distended abdomen with flank dullness, +2 LE edema, she opens her eyes
when her name is called. She responds to questions with an incomprehensible mumbling. Milk
maid sign is positive.
Component
Reference range
Value
3
WBC
Hgb
Platelets
INR
Na
K
Creatinine
Albumin
Total bilirubin
Alkaline Phosphatase
AST
ALT
(4.5-13.5 THO/μL)
(13-16 g/dL)
(150-400 THO/μL)
(0.9-1.1)
(0.6-1.35 mg/dL)
(3.6-5.0 g/dL)
(0.3-1.2 mg/dL)
(38-120 U/L)
(10-40 U/L)
(9-60 U/L)
8.8 THO/μL
10.3 g/dL
96 THO/μL
2.1
130
5.1
2.72 mg/dL
2.9 g/dL
7.0 mg/dL
113 U/L
48 U/L
44 U/L
Table 3
Issues for contemplation
A. Initial Presentation
 Discuss the finding of a distended abdomen on exam in our patient and the
diagnostic accuracy of physical exam maneuvers in identifying ascites as a
cause of abdominal distention.
 What other physical exam findings would you look for that would help you with
the differential diagnosis?
 What is your assessment of the patient’s alcohol intake? What other elements of
history would you like to obtain to ascertain whether the patient has signs of
alcohol dependence?
 Discuss the abnormalities in liver associated enzymes, markers of liver synthetic
function, and CBC on presentation in our patient and how this helps you in
formulating a differential diagnosis for the cause of her symptoms.
 Discuss the finding of a low Ferritin level on initial evaluation.
 What was the significance of a positive hepatitis C antibody? What are the
sensitivity and specificity of this finding in detecting a chronic hepatitis C
infection?
 What are the risk factors for chronic hepatitis C? Who should be screened for this
infection in the general population?
 What is the likely mode of transmission of HCV to our patient?
 What are the factors associated with a severe liver injury due to hepatitis C?
 Discuss the clinical significance of a positive ANA and elevated IgG fraction in
our patient.
 Are there additional tests that you like to obtain at the time of the initial evaluation
of our patient?
 Are there additional management interventions that you would recommend after
initial evaluation?
B. Hepatitis C management
 What is the current standard of care in treatment of hepatitis C infection and
the expected outcome of treatment in the general population of infected
patients?
 What are the potential adverse effects of the standard of care treatment?
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
What are the risks and benefits of HCV treatment in the case of our patient at
initial presentation and at the time of the first follow up visit.
C. Presentation to the ED
 What is your interpretation of the patient’s history and physical exam findings at
presentation to the ED?
 What is your interpretation of her laboratory tests on presentation?
 What is your differential diagnosis for this acute illness? Are there findings on her
initial evaluation and testing that suggest that she is a risk for a specific
complication?
 What would you initial steps in management be?
 Assuming that, after an initial diagnostic evaluation and treatment, three days
after the initial presentation, her mental status is improved, bilirubin is reduced to
4.0 and INR to 1.7, but Creatinine continues to rise and is now 3.6. She is
making about 80 cc of urine per day. How would you evaluate the renal further?
What are the next steps in management?
 What is her long term prognosis, and how does this affect your management
decisions?
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