NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Camila Deza Passias, M.D., PGY-3 2/14/2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient is a 62 year-old Asian man who presented to his primary care physician with abdominal discomfort for 1 month

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient has no known medical problems as he had not received regular medical care since he was a child • His abdominal discomfort occurs is diffuse, dull and non-radiating, without any relation to food • He also began to notice swelling of his abdomen over the last 2 weeks • He denies nausea, vomiting, or change in bowel habits • He does endorse decreased appetite and an unquantifiable weight loss

4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Denies • Past Surgical History: • Denies • Social History: • Denies any alcohol or tobacco use. No h/o IVDU. • The patient is from China, living in the United States for 15 years • Family History: • Denies • Allergies: • No Known Drug Allergies • Medications: • No prescription medications, vitamins, or herbal supplements

5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: The patient appeared cachectic and chronically ill but in no acute distress • Vital Signs: list T: 98.6 BP: 118/76 HR: 87 RR: 12 and O2 sat: 98% on room air • Abdomen was distended, diffusely tender with an appreciable fluid wave, and normal bowel sounds • Skin was mildly jaundice and sclera were icteric • Remainder of the physical exam was unremarkable

6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: Hemoglobin 11.8, MCV 97.6, platelets 178 • Remainder of CBC was within normal limits • Basic Metabolic panel: • Potassium 5.8, creatinine1.6 • Remainder of basic was within normal limits • Coagulation panel: INR 1.2, PTT 36 • Hepatic panel: • AST 66, ALT 134 • total bilirubin 2.7, conjugated bilirubin 0.3 • Remainder of hepatic panel was within normal limits

7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Hepatitis A, B, and C screening revealed a reactive hepatitis B surface antigen • Hepatitis B DNA viral load = 40,000 IU/mL • Hepatitis B e-antigen was reactive

8. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • No imaging studies were performed at this time

9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • The working diagnosis at this time was chronic hepatitis B infection with compensated cirrhosis

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • The patient was admitted to the hospital for large volume paracentesis which was negative for spontaneous bacterial peritonitis • Hospital Day 3: • Liver MRI with contrast was consistent with cirrhosis, and additionally revealed diffuse, infiltrating enhancing lesions throughout the liver with invasion into the portal vasculature

11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 5: • Palliative care was consulted • After ongoing discussion with the patient and family, the decision was made to discharge the patient to home hospice care

12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • The final diagnosis was chronic hepatitis B infection with compensated cirrhosis, complicated by metastatic hepatocellular carcinoma