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(Solved) Chief complaint. X is a 62-year-old white female who was brought to the emergency department (ED) by her daughter for hematemesis and an altered...

I need a concept map to question 37 only, I have answered the other question. I have downloaded the whole scenario

1. Chief complaint. Ms. X is a 62-year-old white
female who was brought to the emergency
department (ED) by her daughter for hematemesis
and an altered mental status for the last three days. History of present illness. Ms. X is a 62-year-old
white female who was brought to the ED by her
daughter for confusion and hematemesis. The
daughter is not currently at the bedside and the
patient is unable to give any historical information
secondary to her altered mental status. The ED
notes document that she has a history of cirrhosis,
that the daughter reported one bout of
hematemesis and had noticed a progressive
increase in abdominal girth. According to
previous medical records she is followed by
hepatology as an outpatient. She has had three
other hospitalizations this year for hepatic
encephalopathy and one hospitalization for an
upper gastrointestinal bleed. One year ago she had
an esophagogastroduodenoscopy (EGD) which
showed grade 0-1 esophageal varices. Three
attempts have been made to contact the daughter
via telephone without success. A computerized
tomography (CT) scan of the head was completed
in the ED and was negative for any acute
intracranial changes. The ammonia level was
noted to be 195 (mcg/dl) in the ED, and she is
now being admitted with a diagnosis of hepatic
encephalopathy. All historical information is
obtained from the review of previous medical
records. Past medical history. Insomnia, cirrhosis,
hepatitis C, cerebral vascular accident, and
hypertension. She is post-menopausal as of age
50. Past surgical history. None Family history. Father died of natural causes at
age 80. Her mother had a history of diabetes
mellitus type 2 and died at the age of 80 secondary
to heart failure. She is a widow and has one
daughter whose prior medical history is negative.
She has not had any gainful employment outside
the house. Social history. Lives with her daughter who is her
primary caregiver. Prior documentation reveals no
history of smoking, alcohol use, or recreational
drug use. Review of systems. Practitioner is unable to
perform review of systems secondary to the altered
mental status; however, as noted in the history of
present illness, the daughter has noticed a threeday history of confusion and one bout of
hematemesis. Allergies. NKDA Home medications. Propranolol 10 milligrams by
mouth twice a day, lactulose 30 grams by mouth
three times a day, furosemide 40mg by mouth twice
a day, and spironolactone 100mg by mouth daily. Physical Examination Data
Vital signs. Temperature: 97.5, heart rate:
62, respiratory rate: 20, blood pressure: 90/58. O2
saturation: 99%, height: 56 inches, weight: 87
pounds, body mass index: 19.5. General. 62-year-old white female who
appears documented age. She is well nourished,
obtunded, calm, and in no acute distress.
Skin. Her skin is warm, dry, and intact.
Color is appropriate for race. There is no evidence
of jaundice, bruising, or petechiae. There are three
spider angiomas present on the thorax.
Hair. Normal texture and distribution on
head. No nits or lice noted.
Nails. No clubbing noted in fingers or toes
bilaterally. Capillary refill is < 3 seconds in all finger
and toe nail beds bilaterally. Nail beds are pink
Head. Normocephalic. Temporal arteries
are +2/4 bilaterally and without tenderness. No
lesions noted.
Eyes. Sclera are anicteric bilaterally.
Corneas are clear bilaterally. No drainage from
either eye noted. Pupils are round and reactive to
light bilaterally. Fundoscopic exam with sharp
discs, no AV nicking, no papilledema bilaterally.
Corneal reflex is absent bilaterally.
Ears. Canals are clear bilaterally. Tympanic
membranes are pearly grey and intact bilaterally.
Nose. Septum is midline and intact. Nasal
mucosa is pink and moist.
Throat. Oral mucosa is pink and moist.
Pharynx is without exudates and tonsils are +1. No
lesions noted. There are various dental caries
noted. Tongue is midline, moist and pink.
Neck. Supple with full range of motion. No
jugular vein distension or cervical
lymphadenopathy. Trachea is midline. Thyroid is
without masses. Carotids are without bruits
bilaterally. Heart. Regular rate and rhythm. S1 and S2
without murmur, gallop or click. No lifts or heaves
noted. PMI at 5th intercostal space at the left
midclavicular line. No jugular vein distention noted.
Lungs. Respirations regular and even.
Lungs fields are resonant bilaterally. Breath sounds
are clear in anterior, posterior, and lateral fields
Abdomen. Round and distended. Active
bowel sounds. No renal or aortic bruits noted
bilaterally. Splenomegaly. Shifting dullness
present. Dullness to percussion in the lateral,
lower quadrants noted. Fluid wave is present.
Genitourinary. External genitalia normal.
Foley catheter in place. Rectum without masses.
Stool brown with negative guaiac.
Extremities. Extremities are warm, pink,
and without lesions. Radial, brachial, femoral,
popliteal, posterior tibial, and dorsalis pedis pulses
are +2/4 bilaterally. There is +2 edema of the
bilateral lower extremities.
Neurological. She is obtunded, opens
eyes to vigorous stimuli, and is calm. Unable to
assess cranial nerves, strength testing, or
sensation testing. The following is a listing of the significant diagnostic
test results obtained at the time of admission:
White Blood Cell (WBC) 3.0
Hemoglobin (Hgb) was 8.0g/dl.
Hematocrit (Hct) was 25%.
Mean Corpuscular Volume was 90 mm3.
Platelets (Plts) were 75,000 mm3.
Sodium (Na) was 136 mEq/L.
Potassium (K) was 4.7 mEq/L.
Blood urea nitrogen (BUN) was 12 mg/dl.
Creatinine was 1.04 mg/dl.
Glucose was 110 mg/dl. Calcium (Ca) was 9.1 mg/dl.
Phosphorus was 3.2 mg/dl.
Magnesium (Mg) was 1.7 mEq/L.
Albumin was 2.0 g/dl.
Aspartate aminotransferase (AST) was 35 units/L.
Alanine aminotransferase (ALT) was 22 units/L.
Total bilirubin was 0.5 mg/dl.
Direct bilirubin was 0.2 mg/dl.
International normalized ratio (INR) was 2.3.
Ammonia was 195 mcg/dl.
Urinalysis was negative for blood, ketones, WBC,
red blood cells, leukoesterase, and nitrates.
CT of head was significant for only atherosclerotic
calcifications. No acute intracranial changes were
Abdominal ultrasound findings were significant for
cirrhosis of the liver, with moderate to large
amount of ascites in the abdominal and pelvic
cavities. Mild splenomegaly is also noted.
Gallbladder wall thickening is present which is likely
secondary to hypoalbuminemia. Kidneys are
consistent with medical renal disease and are
without hydronephrosis.
Ascitic fluid analysis: number of cells 100,
nucleated cells 36 and polymorphonuclear
neutrophilic leukocyte (PMN) 1 and ascitic fluid
cultures were negative.
Serum Ascites Albumin Gradient (SAAG): 2
Urine culture was negative.
Blood cultures were negative. Answer the following questions. Based on the information available, what is the
most likely cause of Ms. X’s cirrhosis?
What risk factors can contribute to the development
of the etiology of Ms. X’s cirrhosis which you
identified in question 1?
What is a SAAG and how is it used in the clinical
management of a person with cirrhosis?
What does the hematemesis indicate and what
differentials need to be considered? What complication is an individual with cirrhosis
and ascites who is having an active GI bleed at
high risk for acquiring?
What is the purpose of giving propranolol, a nonselective beta blocker, to a person with cirrhosis
and how does it benefit them?
What is the purpose of giving spironolactone to a
person with cirrhosis and describe its mechanism
of action?
What is the most likely etiology of her hepatic
encephalopathy and why?
What treatment guidelines are available to help
guide the treatment of a GI bleed and ascites (there
are two separate guidelines) in a patient with
cirrhosis? Who writes the guidelines?
Using a computer program such as Microsoft word,
power point or Visio draw a concept map which
shows the pathogenesis that explains all of the
bolded clinical manifestations above. The concept
map must be your own work. A copy of a picture
pasted into your case-study is not allowed and 50
points will be deducted if this occurs. If the concept
map is not completed, 50 points will be deducted
from the case-study.


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Sep 05, 2019





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