1. Case Conference Resident Name, MD SVCH May 15, 2015May 15, 2015May 15, 2015

2. CC: Epigastric pain x 2-3 days 51 yo AAM with PMH of DM, HTN, Smoker, Hypercholesterolemia

3. Hx of Present Illness Site  epigastric Onset  sudden, when he woke up Character  sharp, 7/10 Radiation  to the chest Alleviating factors  none Time course  still present Exacerb.factors  movement Sx  SOB, DOE

4. PMHx HTN – on ACEi – not controlled DM – on Insulin Hypercholesterolemia – on Lipitor, LDL 134, HDL 34

5. Medications Insulin 70/30 – 30 U am, 10 U pm Lipitor 10 qd Zestril 10 qd Isoptin SR 120 qd (Verapamil) NKDA

6. FMH, SH Mother with HTN Unemployed, lives alone Heavy drinking in the past, quit 10 yr ago Smoker – ½ ppd x 30 yrs Cocaine, Heroin IV user 12 yrs ago

7. Physical Examination Appearance: Thin man in NAD Vitals Temperature 36.7 ºC Pulse54/min Respirations18/min BP 167/79 mm Hg SpO2 100% on RA

8. Physical Examination Skin: no rash HEENT: NC/AT Chest: CTA (B) Heart: Clear S1S2, regular Abdomen: Soft, epigastric tenderness, 4-5 cm hepatomegaly, hard liver edge, +BS Rectal: normal Extremities: no c/c/e Neuro exam: AAO x 3, no focal deficit

9. Labs 11 16 48 178 134 5 99 26 16 0.9 59 PMN - 57 Bands – 17 Amylase 71, Lipase 235 Bil. – 1 AST - 158 Alb - 2.8 ALT - 238 INR - 1.11 AP – 364 CPP x 2 – negative AG=9

10. Further tests

11. What would you do in this situation?

12. What do you think ? Diagnosis? Differential diagnosis? What tests to order? Empiric therapy?

13. What happened ?

14. Outcome Treated with IVF, Dopamine HyperK+ corrected with D50 + Insulin, Kayexalate

15. Final Diagnosis Hepatocellular CA

16. Take home message

17. Any questions ?

18. Literature Discussion

19. Risk factors

20. Etiology

21. Symptoms Symptoms

22. Physical Exam

23. Diagnosis

24. Treatment

25. Screening

26. End Click to go back to SVCH home page svch.blogspot.com svch.blogspot.com