PCL 2 - Case 7:
CASE OF MICHAEL PHILLIPS
Michal Zacharzewski. (2011). Last Man Standing [Online image]. Retrieved
from http://www.sxc.hu/photo/1330435
INSTRUCTIONS



Request Student Volunteer to interview patient
Introduce the Standardized Patient
Instructions for Student Volunteer:
During the interview you may take “time out” and
ask questions
Student Leader/Tutor may interrupt to help
facilitate the interview.
2
INSTRUCTIONS
 What do you think?
Go to Problem List and Clinical Notes
to begin the Differential Diagnosis
3
Go to Clinical Notes
DDx
Learning Objectives
CC: (Chief Complaint/Concern):
PMH: (Past Medical History):
HPI: (History of Present Illness):
Past Surgical History:
5
FH: (Family History):
Medications:
Allergies:
SH: (Social History):
Labs:
Review of Systems:
Physical Exam:
Assessment & Plan:
*** Distribute Handout 1***
Background Information
 Physical Exam & Lab Results
8
 Lab results show Michael Phillips has inflammation
of the liver.
 Doctor calls Michael Phillips and informs him he has
hepatitis and recommends to “give the liver a rest”
and asks Mr. Phillips to abstain from alcohol.
 Michael schedules an appointment to follow up in
one week.
9
 One Week Later: Doctor meets with Michael Phillips
to review his case.
 FRAMES Intervention: Doctor (Student Leader)
conducts “FRAMES” intervention using the AUDIT
Questionnaire. (Script & Questionnaire on Blackboard)
FRAMES Intervention:
AUDIT Questionnaire:
•
•
•
•
•
•
•
Feedback
Responsibility
Advice
Menu of Options
Empathy
Support
Alcohol Use Disorders
Identification Test (AUDIT)
10
*** Distribute Handout 2***
Handout 2: “Future Course of Patient’s Life”
Class review and discuss
1) Pathway One
2) Pathway Two
11
(These Will Not Be Tested as Part of PCL)
Clinical Problem Solving
 List the differential diagnosis of abdominal pain in the setting of alcohol use
Basic and Clinical Sciences
 Review alcohol metabolism
 Review pathophysiology of alcohol related liver disease
(These Will Be Tested as Part of PCL)
Psychosocial, Behavioral, and Developmental Issues
 Recognize the role of standardized screening tools such as AUDIT in evaluating
alcohol usage
 Be familiar with validated brief intervention tools such as FRAMES
 Recognize the impact of alcoholism to all the components in a patient’s life.
12
NEXT WEEK: Readings
Required Reading:

Mailliard M.E., Sorrell M.F. (2012). Chapter 307. Alcoholic Liver Disease. In D.L. Longo, A.S. Fauci,
D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison's Principles of Internal Medicine,
18e. Retrieved January 26, 2012 from http://www.accessmedicine.com/content.aspx?aID=9134918.
Supplemental Readings:
 Fagbemi, K. (2011). QWhat is the best questionnaire to screen for alcohol use disorder in an office
practice? Cleveland Clinic Journal of Medicine, 78(10), 649-651.
 Fiellin, D. A., Reid, M. C., & O'Connor, P. G. (2000). Screening for alcohol problems in primary care: A
systematic review. Archives of Internal Medicine, 160(13), 1977-1989.
 Webb, G., Shakeshaft, A., Sanson-Fisher, R., & Havard, A. (2009). A systematic review of work-place
interventions for alcohol-related problems. Addiction, 104(3), 365-377.
13
NEXT WEEK: Management of Session 2

Begin with an oral presentation of the case
(Oral Presentation: See PowerPoint on Blackboard & Handout #4)

Student Presentations

Appoint a new scribe to keep track of the discussion

Review USMLE sample questions

Appoint a student leader for the next case
14
15
PCL 2 Case 7: Michael Phillips
Michal Zacharzewski. (2011). Last Man Standing [Online image]. Retrieved
from http://www.sxc.hu/photo/1330435
16
MANAGEMENT OF SESSION 2:

Begin with an oral presentation of the case

Student Presentations

Appoint a new scribe to keep track of the discussion

Review USMLE sample questions

Solicit and provide Feedback on the session

Appoint a student leader for the next case
17
18
USMLE QUESTIONS
QUESTION 1: A 50-year-old male alcoholic presents with cirrhotic liver
disease and chronic pancreatitis. He has been nauseated for the past several
days, and not eating. Blood glucagon levels are elevated with which of the
following results?
A.
B.
C.
D.
E.
Stimulation of glycogenolysis in muscle
Inhibition of insulin secretion
Stimulation of gluconeogenesis in the liver
Inhibition of adenylate cyclase
Inhibition of phospholipase C
(All Practice questions were retrieved from USMLEasy Web site.)
USMLEasy: Home Retrieved 1/25/2012, from http://www.usmleasy.com/
USMLE QUESTIONS
ANSWER:C

EXPLANATION: The primary action of glucagon is to increase blood glucose
concentration, which it accomplishes by promoting gluconeogenesis and
glycogenolysis in the liver but not in muscle. These effects are mediated by
cyclic AMP, which is produced by hepatic adenylate cyclase following
interaction of glucagon with its plasma membrane receptor. Interaction of
glucagon with different hepatic plasma membrane receptors activates
phospholipase C, which results in a rise in concentration of intra-cellular Ca2+,
which further stimulates glycogenolysis. Although glucagon opposes the
action of insulin, it does not directly affect insulin secretion.
(All Practice questions were retrieved from USMLEasy Web site.)
USMLEasy: Home Retrieved 1/25/2012, from http://www.usmleasy.com/
USMLE QUESTIONS
QUESTION 2 : A 42-year-old woman presents with an acute onset of fever,
jaundice, tender liver enlargement, and ascites. Liver biopsy reveals
histological features of scattered foci hepatocytes undergoing swelling and
necrosis, with neutrophilic infiltration around the affected cells, and sinusoidal
and perivenular fibrosis. This is most suggestive of which of the following?
A.
B.
C.
D.
E.
Acetaminophen overdose
Acute fatty liver of pregnancy
Alcoholic hepatitis
Budd-Chiari syndrome
Pyogenic liver abscess
King, M. W. (2008). Lange Q & A. USMLE step 1 / [edited by] Michael W.
King. New York : McGraw-Hill Medical, c2008.
USMLE QUESTIONS
ANSWER:C

EXPLANATION: Alcoholic hepatitis (also called acute sclerosing hyaline
necrosis of the liver) usually occurs acutely following an alcoholic binge
superimposed on steatosis (fatty liver) or cirrhosis. Variable degrees of liver
cell necrosis are present with corresponding clusters of neutrophils and
frequent accompaniment of pericellular and perivenular fibrosis.
Intracellular Mallory bodies are common. Alcoholic hepatitis may range from
asymptomatic to fulminant hepatic failure. Symptoms, which may persist for
weeks or months, include upper abdominal pain, anorexia, fever, tender
hepatomegaly, and jaundice. Sever disease may cause encephalopathy and
death.
King, M. W. (2008). Lange Q & A. USMLE step 1 / [edited by] Michael W.
King. New York : McGraw-Hill Medical, c2008.