1. Step (6): Review of Learning Objectives
1.1. 1- To list the main differential diagnosis for jaundice
1.1.1. prehepatic
1.1.1.1. hemolysis
1.1.1.2. gilbert syndrome
1.1.1.3. crigler najjar
1.1.1.4. uncongugated
1.1.2. intrahepatic
1.1.2.1. congugated and uncongugated
1.1.2.2. primary billiary cirrhosis
1.1.2.3. viral
1.1.2.4. toxic
1.1.3. posthepatic
1.1.3.1. congugated
1.1.3.2. obstructive jaundice
1.1.3.3. cancer
1.1.3.3.1. pancreas
1.1.4. charcot triade
1.2. 2- To identify alcoholic liver diseases, and how to differentiate from other liver diseases
1.2.1. definition
1.2.1.1. toxic effect of alcohol on hepatocytes
1.2.2. diseases
1.2.2.1. alcoholic fatty liver
1.2.2.1.1. usually asymptomatic
1.2.2.2. steatohepatitis
1.2.2.2.1. symptomatic
1.2.2.3. cirrhosis
1.2.2.3.1. portal hypertension
1.2.2.3.2. hematemesis
1.2.2.3.3. edema
1.2.2.3.4. SOB
1.2.3. pathophisiology
1.2.3.1. it is an effect of liver metabolism
1.2.3.2. acetaldehyde
1.2.3.2.1. hepatitis
1.2.3.3. elevation of NADH
1.2.3.4. intestinal flora
1.2.3.4.1. lipopoly sacharides
1.3. 3- How to approach an alcoholic patient
1.3.1. how much he drinks
1.3.1.1. for how long?
1.3.2. physical exam
1.4. 4-To identify causes of liver cirrhosis
1.4.1. common
1.4.1.1. chronic viral hepatitis
1.4.1.2. alcoholic liver diseases
1.4.1.3. non alcoholic fatty liver
1.4.2. less common
1.4.2.1. wilson
1.4.2.2. alpha 1 antitrypsin deficiency
1.4.2.3. portal fibrosis
2. Third Session
2.1. 2nd trigger
2.1.1. 1-18months after first time
2.1.2. 2-hematemesis
2.1.3. 3-confused
2.1.4. 4-increasingly forgettful
2.1.5. 5-mixing things over the last 3months
2.1.6. 6-increasing abdominal destention
2.2. Step (10): Management
2.2.1. Goal
2.2.1.1. prevent or slow progression
2.2.1.1.1. abstenence of alcohol
2.2.1.2. prevent having a superimposed liver insult
2.2.1.2.1. vaccinations
2.2.1.3. managing associated symptoms
2.2.1.3.1. nutritional managment
2.2.1.3.2. clostramine or anti histamine
2.2.1.3.3. plasmapheresis
2.2.1.3.4. anemia
2.2.1.3.5. stress management and support
2.2.1.3.6. withdrwal symptoms
2.2.1.4. managing the case
2.2.1.4.1. prognosis
2.2.1.5. liver transplant
2.2.1.5.1. 6 months of alcoholic abstinence
2.2.1.5.2. decompensated
2.2.2. hepatitis
2.2.2.1. start with steroid
2.2.2.1.1. 2wks
2.2.2.2. pentxifylline
2.2.2.2.1. 4wk
2.2.2.3. liver transplant
2.2.3. patient managment
2.2.3.1. bleeding
2.2.3.1.1. endoscopic
2.2.3.1.2. stabilization
2.2.3.1.3. beta blocker
2.2.3.1.4. shunting
2.2.3.2. hepatic encephalopathy
2.2.3.2.1. rifaximin
2.3. Step (11): Feedback & Resources
3. Second Session
3.1. Step (7): Gathering Information & Inquiry Plan
3.1.1. History
3.1.1.1. CAGE
3.1.1.2. RUQ pain
3.1.1.2.1. first time
3.1.1.3. alcohol
3.1.1.4. difficulty focusing
3.1.1.5. ywo weeks
3.1.1.5.1. yellowish eye
3.1.1.6. never had black stool
3.1.1.7. never vomited blood
3.1.1.8. married
3.1.1.8.1. 2 children
3.1.1.8.2. all in good health
3.1.1.8.3. his wife has interest in wine, not more than 2 glasses
3.1.1.9. no rectal bleeding
3.1.1.10. past history
3.1.1.10.1. no surgeries
3.1.1.10.2. HBV,HCV NO
3.1.1.10.3. no medication
3.1.1.10.4. non smoker
3.1.1.10.5. no drugs
3.1.1.10.6. decreased libido
3.1.1.10.7. 5yrs ago
3.1.1.11. antique business
3.1.1.12. downturn of economic status
3.1.2. Physical Examination
3.1.2.1. vital signs
3.1.2.2. general appearance
3.1.2.2.1. not distressed
3.1.2.2.2. BMI=22
3.1.2.2.3. tired
3.1.2.3. STIGMATA of liver diseases
3.1.2.3.1. hand
3.1.2.3.2. head
3.1.2.3.3. neck
3.1.2.3.4. chest
3.1.2.3.5. abdomen
3.1.2.4. neurological
3.1.2.4.1. mild muscle weakness
3.1.2.4.2. no tremor
3.1.2.4.3. no sensory impairment
3.1.2.4.4. no cerebellar dysfunction
3.1.2.5. cardiovascular
3.1.2.5.1. normal
3.1.2.6. respiratory
3.1.2.6.1. normal
3.1.2.7. GI
3.1.2.7.1. liver
3.1.2.7.2. no other abdominal mases
3.1.2.7.3. spleen
3.1.3. Investigation
3.1.3.1. Blood test
3.1.3.1.1. Hgb=109
3.1.3.1.2. WBC=
3.1.3.1.3. MCV=103
3.1.3.1.4. PLATALETE =90
3.1.3.2. BIOCHEMISTRY
3.1.3.2.1. na=134
3.1.3.2.2. k=1.2
3.1.3.2.3. creatinen
3.1.3.2.4. cl
3.1.3.3. LFT
3.1.3.3.1. liver enzymes
3.1.3.3.2. COAGULATION
3.1.3.3.3. ALBUMIN
3.1.3.3.4. BILLIRUBIN
3.1.3.4. SEROLOGY
3.1.3.4.1. -VE
3.1.3.5. US
3.1.3.5.1. liver =15cm
3.1.3.6. CT
3.1.3.6.1. macronodular parynchymal pattern consistent with cirrhosis
3.2. Step (8): Diagnostic Decision
3.2.1. Mechanism
3.2.1.1. toxic effect of chronic alcohol drinking on the liver cell, impairing its function
3.2.2. Presentation
3.2.2.1. jaundice
3.2.2.2. RUQ pain
3.2.3. Supporting Data
4. First Session
4.1. Step (1): Identifying Difficult Words & Cues
4.1.1. Difficult Words
4.1.1.1. cognac
4.1.1.1.1. french brand of alcohol
4.1.1.2. single malt whiskey
4.1.1.3. downturn
4.1.2. Cues
4.1.2.1. male 52yo
4.1.2.2. feeling unwell and tired for the last two weeks
4.1.2.3. eyes turned yellow
4.1.2.4. hot and cold
4.1.2.5. RUQ discomfort
4.1.2.6. loss of appetite
4.1.2.7. long standing interest in alcohol
4.1.2.7.1. 15 years
4.1.2.7.2. increased in last 6 weeks
4.1.2.7.3. whiskey , wine, and cognac
4.1.2.8. increased anxiety
4.1.2.8.1. due to business downturn
4.2. Step (2): Problem Formulation
4.2.1. a 52 yo male,persistent alcohol drinker, presenting with yellow eyes, fatigue, and RUQ discomfort for the last 2 weeks.
4.3. Step (3): Hypotheses Generation
4.3.1. liver pathology
4.3.1.1. alcohol
4.3.1.2. jaundice
4.3.1.3. the pathology
4.3.1.3.1. fatty liver
4.3.1.3.2. alcohol metabolized in the liver
4.3.2. downturn business
4.3.2.1. anxiety
4.3.2.1.1. increased drinking
4.3.3. jaundice
4.3.3.1. prehepatic
4.3.3.1.1. blood hemolysis
4.3.3.1.2. genetic
4.3.3.2. hepatic
4.3.3.2.1. toxic
4.3.3.2.2. infections
4.3.3.2.3. genetic
4.3.3.3. posthepatic
4.3.3.3.1. biliary duct stone
4.3.3.3.2. pancreatic cancer
4.3.4. loss of appetite
4.3.4.1. may indicate liver problem
4.3.5. alcohol risk
4.3.5.1. 60g/day is the cut point
4.3.5.2. our patient is having 105g/day for 15yrs
4.3.6. hot and cold
4.4. Step (4): Hypotheses Organization
4.4.1. prehepatic
4.4.2. hepatic
4.4.3. posthepatic
4.5. Step (5): Learning Objectives
4.5.1. 1- To list the main differential diagnosis for jaundice
4.5.2. 2- To identify alcoholic liver diseases, and how to differentiate from other liver diseases
4.5.2.1. definition
4.5.2.2. pathophysiology
4.5.2.3. work-up
4.5.3. 3- How to approach an alcoholic patient
4.5.4. 4-To identify causes of liver cirrhosis