History of Present Illness:

42 y/o F, with a history of hepatitis C, polysubstance abuse, asthma and seizures, who presents to the ED via EMS c/o abdominal pain for two weeks. Patient reports dull, intermittent suprapubic abdominal pain, with no alleviating or aggravating factors. She also reports multiple episodes of diarrhea per day for two weeks and yellow discoloration to her skin for one week. Patient reports to injecting heroin today and reports to drinking alcohol daily. She denies other drug use. She reports pruritus but denies fever, chills, chest pain, SOB, nausea, vomiting, hematemesis, blood in her stool, dysuria, hematuria, vaginal discharge or other symptoms at this time.

PMHx: Hepatitis C, polysubstance abuse, asthma, seizures

Medications: Levetiracetam (Keppra) 500 mg PO every 12 hours, folic acid 1 mg PO daily, Thiamine 100 mg PO daily, multivitamin 1 tablet PO daily

Allergies: NKDA

PSHx: none

PFHx: unknown 

Social history: Admits to IV heroin use daily, alcohol use daily and tobacco use daily. Occasional cocaine use. Patient is undomiciled.

Review of Systems:

General: Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever, chills or night sweats

Skin: Admits to color change and pruritus. Denies rash.

Eyes: Denies anyvisual disturbance, blurring, diplopia, photophobia

Mouth and throat: Denies bleeding gums, sore throat

Neck: Denieslocalized swelling/lumps, stiffness or decreased ROM

Pulm: Denies SOB, cough, wheezing, hemoptysis, cyanosis, sputum production

CV: Denies chest pain, palpitations, irregular heartbeat, edema, syncope, known heart murmur, hypertension

GI: Admits to suprapubic abdominal pain, diarrhea and jaundice. Denies change in appetite, nausea, vomiting, hematemesis, rectal bleeding, hematochezia.

GU: Denies frequency, urgency, oliguria, polyuria, dysuria, hematuria

Nervous System: Denies recentseizures, headache, loss of consciousness, sensory disturbances, change in mental status, weakness

Peripheral Vascular System: Denies claudication, coldness, edema, color change

Hematologic System: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE

Physical Exam:

Vitals: T 98.3, BP 108/57, RR 18, HR 90, O2 saturation 98%, Ht 5’5”, Wt 118 lbs, BMI

Gen: Alert and oriented, in no acute distress. Poorly groomed.  

Skin: multiple track marks on all extremities. Jaundice throughout. No erythema or warmth. Scabs to all extremities.

HEENT: Scleral icterus. Normocephalic, atraumatic, mucous membranes moist, EOMI, PERRLA.

Neck: Full ROM, supple

CV: Regular rate and rhythm

Pulm: Clear to auscultation bilaterally

Abd: Soft, flat and distended. Normoactive bowel sounds. Abdominal tenderness to suprapubic region.

Neuro: no focal deficit

Psych: Appears intoxicated  

Assessment:

42 y/o F, with a history of hepatitis C, polysubstance abuse, asthma and seizures, who presents to the ED via EMS with abdominal pain and non-bloody diarrhea for two weeks and jaundice for one week. Exam reveals patient is jaundiced with lower abdominal tenderness and distention.

Differentials:

Chronic hepatitis C, drug induced liver injury, hepatitis A/B, pancreatitis

Plan:

CBC

CMP

PT/PTT, T&S

Mg

Lipase

CK

Blood cultures

Ammonia level

Tylenol level

VBG

UA

US abdomen

CXR

Addendum:

WBC 3.18, RBC 3.35, H&H 9.7/29.3, PT/INR 21/1.8, K 2.5

Direct bilirubin 14.6, albumin 1.9, total protein 5.8, total bilirubin 20.1, Alk phos 97, ALT 122, AST 110

UTox positive for cocaine and methadone

Alcohol 22 mg/dL

Tylenol and ammonia levels WNL

Hepatitis A IgG and IgM reactive. Hepatitis B core antibody and surface antibody reactive. Hepatitis C antibody reactive.

Abdominal US with no cholelithiasis and no acute cholecystitis

Disposition:

Plan is to start Acetylcysteine [3,180 mg in dextrose 5% water 500 mL], potassium chloride 20 mEq in 100 mL and admit the patient. Will consult GI.

Education: You currently have an injury to your liver, as we can see on your blood tests and from your clinical picture. As of now, you are positive for hepatitis A and hepatitis C, both of which can be contributing to your current symptoms, such as the change in skin color you have noticed. A medication called acetylcysteine will be given to help restore some function to your liver. Also, while you are admitted, you will have a consult with gastroenterology. Labs will be drawn throughout the course of your admission to continue to monitor your liver function and to look for other potential abnormalities.