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

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

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

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

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

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

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

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

Labs PMN - 57 Bands – 17 Amylase 71, Lipase 235 Bil. – 1 AST Alb ALT INR AP – 364 CPP x 2 – negative AG=9

Further tests

What would you do in this situation?

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

What happened ?

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

Final Diagnosis Hepatocellular CA

Take home message

Any questions ?

Literature Discussion

Risk factors

Etiology

Symptoms Symptoms

Physical Exam

Diagnosis

Treatment

Screening

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