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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify signs and symptoms of cirrhosis and associated complications.

  • Provide pharmacotherapeutic and lifestyle recommendations for managing ascites due to portal hypertension and cirrhosis.

  • Develop a patient-specific regimen and monitoring parameters to meet the needs of a patient with ascites, esophageal varices, and hepatic encephalopathy.

  • Interpret laboratory values associated with ascites.

  • Provide appropriate patient education for the recommended pharmacologic and nonpharmacologic therapy to control complications of cirrhosis, as well as to prevent further complications.

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PATIENT PRESENTATION

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Chief Complaint

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“I look like I’m pregnant and it’s getting worse.”

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HPI

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Robert Smith is a 38-year-old man with a history of alcoholic cirrhosis who has been admitted to the hospital due to an unexplained 8-kg weight gain over the past 6 days, abdominal swelling and pain, shortness of breath, and mild confusion.

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PMH

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  • Alcoholic cirrhosis diagnosed 2 years ago, Child–Pugh Grade A on diagnosis

  • EGD performed at time of cirrhosis diagnosis showed no esophageal varices

  • Allergic rhinitis

  • Hypertension

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FH

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Father is alive and well at the age of 70 without significant disease. Mother died at age 47 due to complications of type 1 DM.

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SH

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Recently separated from wife of 10 years and lives alone. Works as a plumber. History of extreme alcohol abuse but had quit drinking on cirrhosis diagnosis. Admits to heavy alcohol use over the past 2 months since separating from his wife and went on a drinking binge about 1 week ago.

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Meds

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  • Fluticasone furoate two sprays per nostril once daily

  • Levocetirizine 5 mg once daily

  • Lisinopril 10 mg once daily

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All

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NKDA

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ROS

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Abdominal discomfort described as occurring throughout the abdomen, shortness of breath, and mild confusion. Patient denies chills or fevers.

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Physical Examination

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Gen
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Pleasant, chronically ill black man appearing to be in mild distress and fatigued

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VS
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BP 118/76, P 78, RR 27, T 37.2°C; Wt 94.2 kg, Ht 6′2″

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Skin
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(+) Palmar erythema, (+) spider angiomata, otherwise normal color

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HEENT
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PERRL, EOMI, clear sclerae, TMs normal, mucous membranes moist

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Neck/Lymph Nodes
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Supple, no thyroid nodules

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Lung/Thorax
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Mild bilateral crackles, decreased breath sounds in right lower lobe likely due to enlarged liver and ascites

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Breasts
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Nontender without masses

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CV
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RRR, S1 and S2...

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