1. Step 8
1.1. Diagnostic decision
1.1.1. alcoholic hepatitis (leads to liver cirrhosis)
1.2. Mechanism
1.2.1. chronic alcohol abuse lead to hepatic injury .. began with fatty liver and now it developed to hepatitis and complicated by cirrhosis
1.3. Presentation
1.3.1. jaundice
1.3.2. fatigue
1.3.3. RUQ pain
1.3.4. hot and colds
1.4. Supporting data
1.4.1. history and ohysical
1.4.2. CBC
1.4.3. serum biochem
1.4.4. US
1.4.5. CT
1.5. 10 minutes
2. Step 7
2.1. Inquiry plan and info gathering
2.1.1. History of presenting complaint
2.1.1.1. 5 yrs ago he saw a GP .. liver test were up
2.1.1.2. he drunk again and didn't come back to the doctor
2.1.1.3. 1st time for the pain
2.1.1.4. for the past month he was not able to focus in his work and was less energetic
2.1.1.5. decrease in libido over the last few weeks
2.1.1.6. others are negative
2.1.2. Previous medical / surgical history
2.1.2.1. negative
2.1.3. Drug history / allergy
2.1.3.1. no medication no allergy
2.1.4. Family history
2.1.4.1. negative
2.1.4.2. economic was down
2.1.5. Social / occupational history
2.1.5.1. no risk factors for hepatitis
2.1.5.2. travels to Europe twice a year
2.1.6. Systemic review
2.1.7. Physical examination
2.1.7.1. vitals
2.1.7.1.1. pulse 80/ min regular
2.1.7.1.2. BP130/70
2.1.7.1.3. temp 37.8
2.1.7.1.4. BMI 22
2.1.7.2. general inspection
2.1.7.2.1. looks tired
2.1.7.2.2. cutaneous jaundice
2.1.7.2.3. mild lower and upper muscle weakness
2.1.7.2.4. mild proximal muscle wasting
2.1.7.3. hands
2.1.7.3.1. palmar erythema
2.1.7.4. face
2.1.7.4.1. scleral icterus
2.1.7.4.2. spider neavie
2.1.7.5. neck
2.1.7.6. chest
2.1.7.6.1. no gyncomastia
2.1.7.7. abdomen
2.1.7.7.1. inspection
2.1.7.7.2. palpation
2.1.7.7.3. percussion
2.1.7.7.4. auscultation
2.1.7.8. lower limbs
2.1.7.9. cardiac
2.1.7.9.1. apex is normal
2.1.7.9.2. no heart sounds
2.1.7.9.3. prephral pulses is normal
2.1.7.10. respiratory
2.1.7.10.1. negative
2.1.7.11. mental
2.1.7.11.1. normal
2.1.7.12. neuro
2.1.7.12.1. normal
2.1.7.12.2. gait normal
2.1.8. tests results
2.1.8.1. cbc
2.1.8.1.1. heamoglobin is 10.9 g/dcl
2.1.8.1.2. mcv is 103 fL
2.1.8.1.3. TWC 13.8 x 10^9\ ltr
2.1.8.1.4. neutrophill 78%
2.1.8.1.5. lymphocyte 21 %
2.1.8.1.6. eaosinophill 1%
2.1.8.1.7. platlets 90 x 10^9
2.1.8.1.8. INR is 1.9
2.1.8.2. serum biochem
2.1.8.2.1. c reactive protein is increased
2.1.8.2.2. potassium is increased
2.1.8.2.3. AST is 290 .. increased
2.1.8.2.4. ALT 140
2.1.8.2.5. albumin is mild reduced .. is 30
2.1.8.2.6. total protein is reduced
2.1.8.2.7. GGT is increased
2.1.8.2.8. ALP is moderately increased
2.1.8.2.9. total billirubin is 120 .. increased
2.1.8.2.10. hepatitis is NEGATIVE
2.1.8.3. us
2.1.8.3.1. spleenomegaly
2.1.8.3.2. liver is enlarged
2.1.8.3.3. free perotoneal fluid
2.1.8.4. CT
2.1.8.4.1. macro nodular prynchemal pattern
2.2. 50 minutes
3. Step 6
3.1. Review session 1
3.2. Report new knowledge
3.3. 30 minutes
3.3.1. The scribe does not have to write in this step!