6/17/2023 0 Comments Positive scleral icterusB is 56 y/o female patient c/o “yellow skin and eyes” x 2 weeks. Her ANA, hepatitis A IgM antibody, HBsAg hepatitis B IgM core antibody, and hepatitis C antibody are all negative. B has an abdominal CT scan, which shows an enlarged, nodular liver, moderate ascites, and a normal pancreas. B because of her history of a blood transfusion. Tests for hepatitis are necessary in all patients with liver disease and are especially important in Ms. However, in this patient, pancreatic cancer or other malignancies are more likely causes of extrabiliary obstruction than stones therefore, an abdominal CT scan or MRCP would be a better first test. As discussed in Chapter 3, Abdominal Pain, ultrasound is the best first test to look for stones in the gallbladder, although the sensitivity is less for common bile duct stones. An imaging study is necessary not to rule in ALD but rather to exclude alternative diagnoses. B’s transaminases are consistent with, but not diagnostic of, ALD. Her past medical history is notable only for Helicobacter pylori–positive gastric and duodenal ulcers 6 years ago, treated with eradication therapy. She has no history of injection drug use, tattoos, or smoking, but she has consumed between 2 glasses and 1 bottle of wine daily for years. B had a blood transfusion in Latvia in 1996. You obtain the following initial tests: total bilirubin, 13 mg/dL direct bilirubin, 9.6 mg/dL AST, 250 units/L ALT, 113 units/L alkaline phosphatase, 503 units/L albumin, 2.8 g/dL prothrombin time (PT), 15.4 s (control 11.1 s) WBC = 22,000 cells/mcL with 80% PMNs, 16% lymphocytes, and 4% monocytes. B has hyperbilirubinemia and suspect that it will be primarily conjugated. Given the pivotal historical points (dark urine and light colored stools) and the physical exam findings of jaundice, hepatomegaly, and splenomegaly, you are confident that Ms. There is no peripheral edema, and the rest of her exam is normal. There is no abdominal tenderness or distention. The liver extends across the midline, and the spleen tip is palpable. B’s physical exam shows scleral icterus and jaundice as well as hepatomegaly, with her liver edge palpable 7 cm below the costal margin. She has no nausea, vomiting, abdominal pain, or fever. B also tells you she has dark urine, light-colored stools, anorexia, and fatigue. B is a 56-year-old woman who comes to your office because her skin and eyes have been yellow for the past 2 weeks. (Above image from Medcomics by Jorge Muniz, PA-C) Jaundice Case Study and SOAP Note Exercise
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