Second Nature--Nancy Claussen

Nancy Claussen

University of Nebraska Medical Center - College of Medicine
Omaha, Nebraska
Instructor(s): Von Essen, Susanna; Roy, H.
Subject area: Health / Medicine
Department: Medicine
Level: Undergraduate Medical
Learning objective: Develop Group Skills, Develop Individual Skills, Provide Information
Teaching style: Group Activity, In-class Activity

Please note that the copyright for this course project is retained by the instructor.

This Problem Based Learning Case is presented to first and second year medical students at the University of Nebraska College of Medicine. The students work through an actual case presentation of an environmental health problem. The instructor guides the discussion as the students work through the case. In an interactive question/discussion format, needed information is provided to the students to work through the differential diagnosis and arrive at the appropriate conclusion. This case focuses on exposures that can lead to acute liver failure.

FACILITATOR'S GUIDE

Learning Objectives

1. To study environmental and occupational exposures that can lead to acute liver failure.
2. To learn the differential diagnosis of nausea, vomiting and abdominal pain.
3. To learn about the effects of diabetes mellitus on the gastrointestinal tract.
4. To learn about the manifestations of acetaminophen poisoning.
5. To learn about the diagnosis and management of hepatic failure.
6. To learn about the pathologic manifestations of liver failure.
7. To discuss the differential diagnosis of coma.
8. To discuss the differential diagnosis and management of hypoglycemia.
9. To learn about the clinical indications for liver transplantation.
10. To learn about therapeutic immunosuppression in the setting of liver transplantation.

SESSION 1

Initial Presentation

Nancy Claussen is a 45 year old woman who presents to your primary care clinic with a 48 hour history of nausea, vomiting and abdominal pain. She and her husband returned last evening from a camping trip. Her husband is very concerned because she was too weak to walk unassisted from the car to the clinic. She went to an emergency room in rural Illinois yesterday and was told she had viral gastroenteritis.

STOP
DISCUSS THIS SECTION BEFORE CONTINUING

What additional history should be obtained?
What is the differential diagnosis of vomiting and abdominal pain?
What diagnostic tests should be ordered?
What findings would lead you to admit this patient to the hospital?
What are the physiologic mechanisms associated with symptoms of nausea? Vomiting? Abdominal pain?

Additional Information

This patient has been seen once before in your clinic. Her other medical problems include osteoarthritis for which she occasionally takes acetaminophen. She has Type II diabetes mellitus which is diet controlled.

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DISCUSS THIS SECTION BEFORE CONTINUING

How could acetaminophen cause this clinical picture?
How can diabetes affect the gastrointestinal tract?
What disorders that cause nausea, vomiting and abdominal pain are more common in patients with diabetes?

Additional Information

The patient's husband developed non-bloody diarrhea at the time when she began to complain about her symptoms.

The patient works as a secretary in an elementary school. She has never smoked and admits to drinking 2 alcoholic beverages per day.

She and her husband were on their way home from a vacation in the Blue Ridge Mountains when she became ill.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

What illnesses like this can be contracted from exposure to infectious agents or other substances to which one might be exposed while camping in the woods in the Blue Ridge Mountains?
How does the information that the patient's husband is also ill with a gastrointestinal complaint change the differential diagnosis?
Is her alcohol consumption likely to contribute to this illness?
Does her alcohol consumption place her risk or protect her from any other disorders?

Physical Examination

On physical examination, she is a mildly obese (body mass index = 28) female who appears weak and uncomfortable. She is somewhat confused.

Vital signs: T = 99.0, P = 116, R = 28, BP = 96/70
HEENT exam: mild icterus, dry mucous membranes
Lungs: clear to auscultation
Heart: S4 gallop
Abdomen: obese, mildly distended, right upper quadrant tenderness without rebound tenderness, liver span approximately 14 cm, few bowel sounds
Neurologic exam: She is lethargic. The exam is otherwise notable for the presence of asterixis.
Laboratory studies:

Hemoglobin 15.1 g/dl
White blood count 10.7 x 103/mm3
- 68% segmented neutrophils
- 19% band forms
Serum creatinine 1.6 mg/dL
Direct bilirubin 3.1 mg/dl
SGPT 5,110
Alkalinephosphatase 181 IU
LDH 5,170 IU.

You refer this patient to the gastroenterologist on call, who decides to admit her directly to the Adult Intensive Care Unit of University Hospital.

How do you explain her neurologic findings?
How does the laboratory information change the differential diagnosis?
What complications can be anticipated from her acute illness?
How would you rule out acetaminophen poisoning?
How is the body mass index calculated and what is the normal range?

Wrap-Up

1. Hand out summary of this session.
2. Have a student summarize the case.
3. Review and prioritize learning issues; discuss possible resources.

Tasks For Next Session

1. Summarize/review case.
2. Review and discuss Beaming issues.
3. List and critique resources used.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.

SESSION 2

Additional Information

The patient developed severe watery diarrhea and became comatose soon after admission to the intensive care unit. She was responsive only to painful stimuli and developed decerebrate posturing. Her neurologic examination was notable for positive doll's eyes, positive corneal reflex and gag reflex. Babinski's sign was present.

CT scan of the head showed diffuse cerebral edema. See exhibit A.

She was intubated and mechanically ventilated to protect her airway from aspiration and to hyperventilate her. She was given intravenous penicillin.

Laboratory values obtained at the time of admission:

Prothrombin time: 38 seconds reference range 11-13.8, critical value >30
Artenal blood gases:
- pH = 7.30
- paC02 = 26 mm Hg
- paO2 = 96 mm Hg
- HC03 = 13 mmol/L(room air)
Serum glucose: 42 mg/dl, reference range 60-110 mg/dL, critical value <45

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What additional diagnoses do the laboratory and radiographic information suggest?
How should the neurologic information be interpreted?
How do you interpret the arterial blood gases?
What is the most likely mechanism for the low serum glucose?
Why are the coagulation studies markedly abnormal? What are possible adverse outcomes from abnormal coagulation studies?
What is the differential diagnosis of elevated amylase and lipase?
What is in the differential diagnosis of acute, fulminate hepatitis in this patient?
What is the most likely mechanism for the patient's hypoglycemia and how should it be treated?
How should the hepatitis be managed?
Why is hyperventilation helpful in this seeing?
What electrolyte abnormalities are to be expected from severe watery diarrhea?

Laboratory values obtained 12 hours after admission:

WBC: 4 - 11 x 103/mm3, 33% band forms
Platelet count 250,000
Total bilirubin 9.8 mg/dl (0-1.2 mg/dL)
SGOT 1,806 IU (0-56 mg/dL)
Amylase 157 IU/L (0-130 IU/L)
Lipase 1,710 IU (23-208 IU/L)
Prothrombin time >100 seconds
PTT 63.8 seconds
Venous ammonia 348 ug/L normal 11-35 (mol/L)
Acetominophen level negative
Abdominal ultrasound showed ascites and an enlarged liver.
Hepatitis A antibody negative
Hepatitis B surface antibody negative
Hepatitis B core antibody negative
Hepatitis C antibody negative

STOP
END OF SESSION

Wrap-Up

1. Hand out summary of this session.
2. Have a student summarize the case.
3. Review and prioritize learning issues; discuss possible resources.

Tasks For Next Session

1. Summarize/review case.
2. Review and discuss learning issues.
3. List and critique resources used.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.

SESSION 3

Additional Information

The patient was evaluated for orthotopic liver transplantation and placed on a waiting list.

She continued to be mechanically ventilated, and was given fresh frozen plasma.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

What is the protocol involved in being placed on a waiting list for a liver transplant?

Nine days after admission the patient underwent liver transplantation.

The explant was shrunken (915 g) and on sectioning showed markedly softened hepatic parenchyma with an exaggerated red-brown to yellow lobular (nutmeg) architecture.

Microscopic examination showed collapse of the reticulum framework with severe hepatocellular loss and necrosis greatest in pericentral zones

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

What is your differential diagnosis for the pathology findings?

Post Operative Course

The patient was discharged from the hospital 1 month after transplantation with a functioning liver on an immunosuppressive regimen of cyclosporin A, azathioprine and prednisone. Her condition 8 months after transplantation was good.

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END OF CASE

What is the mechanism of action of cyclosporin A, azathioprine and prednisone?

This document was last modified on 06/14/2000 03:07:53 PM

This resource was acquired by CEEM (Consortium for Environmental Education in Medicine), a program of Second Nature, under the auspices of a NIEHS grant to gather and disseminate environmental health educational resources over the internet in order to help medical and allied health sciences faculty identify, locate and use resources for incorporating environment and health perspectives into their curricula. CEEM has authorized the use of these materials on this website for archival purposes. Please note that the copyright for this material is retained by the instructor and/or contributing institution.