PCL 2 - Case 7: CASE OF MICHAEL PHILLIPS Michal Zacharzewski. (2011). Last Man Standing [Online image]. Retrieved from

 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 I NSTRUCTIONS

 What do you think?  Go to Problem List and Clinical Notes to begin the Differential Diagnosis 3 I NSTRUCTIONS

Learning Objectives DDx Go to Clinical Notes

CC: (Chief Complaint/Concern): HPI: (History of Present Illness): PMH: (Past Medical History): 5 Past Surgical History:

FH: (Family History):Medications: Allergies: SH: (Social History):

Assessment & Plan: Labs: Review of Systems: Physical Exam:

*** Distribute Handout 1***  Background Information  Physical Exam & Lab Results 8

9  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.

10  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: Feedback Responsibility Advice Menu of Options Empathy Support AUDIT Questionnaire: Alcohol Use Disorders Identification Test (AUDIT)

*** 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 Alcoholic Liver Disease 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), 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),  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), 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),  Webb, G., Shakeshaft, A., Sanson-Fisher, R., & Havard, A. (2009). A systematic review of work-place interventions for alcohol-related problems. Addiction, 104(3), Webb, G., Shakeshaft, A., Sanson-Fisher, R., & Havard, A. (2009). A systematic review of work-place interventions for alcohol-related problems. Addiction, 104(3),

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

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16 PCL 2 Case 7: Michael Phillips Michal Zacharzewski. (2011). Last Man Standing [Online image]. Retrieved from

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

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USMLE Q UESTIONS 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.Stimulation of glycogenolysis in muscle B.Inhibition of insulin secretion C.Stimulation of gluconeogenesis in the liver D.Inhibition of adenylate cyclase E.Inhibition of phospholipase C (All Practice questions were retrieved from USMLEasy Web site.) USMLEasy: Home Retrieved 1/25/2012, from

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 Ca 2+, which further stimulates glycogenolysis. Although glucagon opposes the action of insulin, it does not directly affect insulin secretion. USMLE Q UESTIONS (All Practice questions were retrieved from USMLEasy Web site.) USMLEasy: Home Retrieved 1/25/2012, from

USMLE Q UESTIONS 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.Acetaminophen overdose B.Acute fatty liver of pregnancy C.Alcoholic hepatitis D.Budd-Chiari syndrome E.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 Q UESTIONS 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.