Richard C. Walls
Pharmacy 551—Case Presentation #1
General Patient Information:
KV is a 60 year old female admitted to UMHS on 2013-01-31.
Chief Complaint:
Abdominal pain accompanied by nausea, vomiting, skin discoloration, and abdominal
distension.
HPI:
The patient has not been feeling well for the past month and reported nausea, vomiting, and
skin discoloration. She had a hospital stay from 01-21 to 01-23 that identified ascites via
ultrasound, but no further diagnostics were performed and she was discharged. Her
symptoms continued to worsen over the following week and were not effectively managed
by a trip to the Grand Rapids ER and she was told to come to Ann Arbor. Her clinical
picture has stabilized with administration of IV fluids and the patient is preparing for
discharge to return to home care
PMH:
Non-alcoholic steatohepatitis cirrhosis (being evaluated for transplant and close to listing)
Gastric varices
Ascites
Myelodysplastic syndrome
s/p bone marrow transplant (1990) w/complications of GVHD and dry eyes
COPD
History of CMV infection
SH:
No tobacco, remote and inactive drinking, no illicit drugs, lives with husband
FH:
Cancer in father, mother, brother, and sisters (one with SCLC and one with sarcoma).
Medication History:
Cirrhosis:
MDS:
COPD:
Unknown:
Allergies:
Lasix
Spironolactone
Nadolol (prophylaxis of variceal bleeding)
Omeprazole
Lactulose
Short acting morphine 15 mg q4h (patient has stopped taking)
Zofran 4 mg PRN
Artificial Tears
Albuterol
Advair
Atrovent
Gabapentin 100 mg TID
Codeine, erythromycin, and morphine all cause nausea
ROS:
Negative excepting NV, abdominal pain and ascites
Physical Exam:
5’6” 77.6 kg obese female
Temp 36.7; HR 77; RR 20; BP 100/51; O2 Sat: 97%
General physical findings show no appreciable disease, and are markedly improved from
admission.
Regular rate and rhythm cardiac
Abdominal pain remains but does not show rebound or guarding.
Patient is alert and oriented x3 with no signs of hepatic encephalopathy.
Laboratory Findings:
Na
K
Cl
CO2
Ca++
Phos
Mg++
BUN
SCr
CrCl
Glucose
135
4.3
104
24
9.3
2.1 (low)
1.6
20
1.1
56.9
88
WBC
Plt
Hbg
HCT
MCV
RDW
7.8
107
10.7 (low)
28.5 (low)
95.6
20.3 (high)
TProtein
Albumin
AST
ALT
ALK
TBili
5.6 (low)
2.0 (low)
203 (high)
77 (high)
238 (high)
6.3 (high)
INR
1.6
Problem List:
1—Abdominal pain
Has improved markedly since admission but patient still complains of moderate
pressure-like pain in her abdomen. This pain has coincided with nausea, vomiting,
and gas. The origin of these symptoms is unclear and ascites are not severe enough
to perform diagnostics for possible SBP and an esophagastroduodenoscopy is
scheduled. Symptomatic treatment with ondansetron and prochlorperazine as needed
have been effective at managing these symptoms to date and I recommend
continuing them until a diagnosis can be made.
Goal: Resolution of nausea, vomiting, and abdominal pain
Recommendation: Continue prn use of ondansetron 4 mg IV q6h and
prochlorperazine 10 mg po q6hh until a cause of the symptoms can be identified.
Continue omeprazole 20 mg po daily. Switch patient to a bland diet. Continue IV
fluid replacement. Counsel patient to eat a low sodium diet and keep fluids <2 L as
outpatient to minimize fluid accumulation.
Monitoring: Worsening of ascites, frequency of nausea and vomiting, level and
frequency of abdominal pain
2—NASH Cirrhosis
Patient’s cirrhosis has decompensated and may be involved in patient’s chief
complaint. Liver enzymes are high as is total bilirubin, and total protein and albumin
are both low. Diagnostics have shown a new portal vein thrombus, but hepatic team
does not recommend systemic anti-coagulation. Patient is undergoing transplant
evaluation and is only waiting for clearance from her bone marrow transplant
physician to be listed for transplant.
Goal: Reduction of ascites, prevention of hepatic encephalopathy, prevention of
variceal bleeding
Recommendation: Continue nadolol 40 mg po daily and omeprazole 20 mg po daily.
Agree with physician’s recommendation to increase lactulose to 4x/day to achieve 2
bowel movements a day and that this dose should be continued outpatient.
Monitoring Parameters: Mental status changes, albumin, AST, ALT, ALK, bilirubin,
INR, ammonia, HR, frequency of bowel movements
3—Acute Kidney Injury
Patient’s creatinine was elevated on admission (1.6 compared to a baseline of 0.7) but
has been stabilizing with administration of IV fluids. Her SCr is currently 1.1 with a
CrCl of 56.9. Injury is likely pre-renal caused by hypovolemia secondary to vomiting
and third spacing of fluid.
Goal: Return of kidney function to normal, minimize the impact of currently poor
renal function on the patient
Recommendation: Continue IV fluids and consider albumin if kidney function does
not improve on fluids alone or ascites worsen. Continue to hold Lasix and
spironolactone until kidney injury resolves to ensure adequate perfusion. Doses of
current medications do not necessitate renal adjustment at this time.
Monitoring Parameters: BUN, SCr, Is/Os, Na+, K+, CO2, Ca++, Phos
4—Medications without Indication
Neither gabapentin nor morphine sulfate have a clear indication. Patient has stopped
taking morphine and this seems reasonable given that the pain she’s currently
experiencing is probably better suited by managing GI issues and actual causes and
morphine could exacerbate the patient’s nausea. Gabapentin has no clear indication
and is being prescribed at a very low dose. Given that common side effects of
gabapentin such as edema, NV, and mental status changes are all of special concern
in this cirrhotic patient, I recommend investigating the necessity of this agent and
likely discontinuing it.
Goal: Reduction of pill burden, reduction of exposure to unnecessary adverse events
Recommendation: Formally discontinue morphine sulfate and investigate the use of
gabapentin to see if it is necessary for the patient.
Summary: KV is a 60 yo F who presented to UMHS with abdominal pain along with nausea,
vomiting, abdominal distension and AKI all of which have improved markedly since admission.
Going forward, the patient’s cirrhosis is likely the patient’s biggest concern, and transplant seems
necessary at this stage.