Eldra W.

Daniels
March 4, 2009
Introduction to Physical Diagnosis
Patients Initials: FT
Medical Record Number: N!
Date of Admission: 022409
Date of Interview: 022"09
Attending Physician: T. #$esisan
Dictating Physician: E. Daniels
Chief Complaint
Patient co%&lains o' &ain on her le't and right sides 'or three (ee)s duration
istory of Present Illness
! *4 year old 'e%ale !'rican !%erican 'e%ale in no distress is &resented in her
hos&ital roo% (ith co%&laints o' &ain on her le't and right sides 'or three (ee)s duration.
When as)ed a$out the &ain, she stated that she initially had nu%$ing &ain in her 'eet
(hich radiated u& the legs and %ade her 'eet 'eel cold. +y &ro&&ing her 'eet u& on a
&illo(, she (as a$le to relie,e this &ain. -ater she had started 'eeling a thro$$ing &ain in
her sides that radiates do(n her legs. #n a scale 'ro% . to .0, Mrs. T descri$es the &ain
as 9. +y ta)ing Tylenol and lying on her le't side hel&s alle,iate the &ain. /he stated t(o
(ee)s ago that a relati,e noticed that her eyes (ere yello(. /he has states that she has
lost a signi'icant a%ount o' (eight 01*l$s2 in the last year due to not eating. /he only
drin)s alcohol and %ost days she does not ha,e an a&&etite. /he has no associated
sy%&to%s and states that other than this &ain she 'eels 'ine.
Review !f "ystems:
3ead4 3as occasional headaches
Eyes4 3as cataracts and ,ision has $een decreasing
Ears4 Feels stu''ed u& (hen coughs
Nose4 5ontains %ucus
Mouth4 3as $een losing teeth o,er the &ast years
Nec)4 No s(ollen ly%&h nodes or glands
5hest4 Denies any tightness
!$do%en4 Thro$$ing &ain on the sides
6&&er E7tre%ities4 No a$do%inal &ain
-o(er E7tre%ities4 Pain in the legs and &ain in the right hi& 0arthritis2
Past Medical istory
.2 !lcoholic 8elated /ei9ure
22 Dia$etes Mellitus
:2 !rthritis right hi&
42 5ar&al Tunnel /yndro%e
Past "urgical istory
.2 No /urgeries
Current Medications
.2 Tylenol E7tra /trength *00%g ; 4h
Allergies
.2 Penicillin
abits
.2 Et#34 40 years duration, currently a &int &er day E and < +randy
22 /%o)ing4 20 &ac) year history
:2 Illict Drugs4 Mari=uana teenage years
"ocial istory
.2 -i,es (ith sister in Washington D.5.
22 Is a (ido( 7 " years
:2 5urrently une%&loyed 7 " years
42 Pre,iously (or)ed as a certi'ied nursing assistant 7 .0 years
#amily istory
.2 Dia$etes Mellitus
22 Prostate 5ancer
:2 -ung 5ancer
Physical $%amination
>EN4 &atient is cal% in no o$,ious distress
5N/4 alert and oriented (ith no 'ocal neurological de'icits
3EENT4 scleral icterus is e,ident in $oth eyes
53E/T4 sy%%etrical $ilaterally (ith e;ual e7&ansion
5?/4 regular heart sounds (ere heard. No <?D, $ruits, or %ur%urs (ere &resent. No /:
or /4 gallo&s (ere &resent
!+D4 distended sy%%etrically due to $ulging 'lan)s. No scars, hernias or color changes
are &resent. 6&on auscultation, nor%al $o(el sounds (ith no $ory$ory%i or $ruits (ere
heard. 6&on su&er'icial &al&itation, no tenderness is o$ser,ed. With dee& &al&ation, the
in'erior $order o' li,er and sur'ace o' the li,er are &al&a$le. The sur'ace o' the li,er 'elt
rough, and nodular. The length o' the li,er s&an (as uno$taina$le due to lac) o' a ruler.
6&on su&ine &ercussion, the &atient de%onstrated 'lan) dullness in (hich ty%&any (as
heard o,er the &eriu%$ilical region and dullness o,er the lateral a$do%en. When the
&atient (as rolled to her le't side, the region that (as &re,iously dull to &ercussion
de%onstrated ty%&any indicating shi'ting dullness.
E@T4 No ede%a or lesions
Assessment
.& Alcoholic epatitis4 The &atients continued alcoholic usage &laces her at great ris) 'or
de,elo&ing this disease. !lcoholic he&atitis is a stage in alcoholic li,er disease (hich is
re,ersi$le u&on a$stinence o' alcohol inta)e. The sy%&to%s o' this disease include
=aundice, and ascities (hich the &atient de%onstrates. The %eta$olis% o' alcohol causes a
rise in the N!D3 N!D ratio. This increased ratio re&laces 'atty acids as a 'uel, lo(ers
'atty acid o7idation, and allo(s triglycerides to accu%ulate, causing 'atty li,er and
hy&erli&ide%ia. !lcohol %eta$olis% %ay also %a)e the li,er hy&er%eta$olic, causing
hy&o7ia and 'ree radicalAinduced li&id &ero7idati,e da%age. !lcohol and undernutrition
de&lete antio7idants, such as glutathione and ,ita%ins ! and E, (hich &redis&ose to such
da%age
.
. /ince our &atient has $een constantly drin)ing alcohol and is not eating, she is
&utting her li,er in great ris) o' de,elo&ing alcoholic he&atitis.
22 r'o Alcoholic Cirrhosis4 It is &ossi$le that this &atients drin)ing ha$its has caused her
li,er to &rogress to ad,anced li,er disease. !lcoholic cirrhosis is an irre,ersi$le lesion
due to the 'or%ation o' 'i$rosis, scarring and &arenchy%al necrosis. reat%ent includes
li,er trans&lantation. The &atient has already e7&erienced a alcoholic sei9ure se,en to
eight years ago. !lso she has $een drin)ing at least a &int &er day o' E B < +randy (hich
is 40C alcohol $y ,olu%e 0D0 &roo'2
2
. 3o(e,er, the &atientEs sy%&to%s %a)e this
diagnosis less li)ely. Patients (ith alcoholic cirrhosis %ay not ha,e a$used alcohol 'or
%any years &rior to &resentation (hile &atients (ith alcoholic he&atitis ha,e $een a$using
alcohol till the ti%e o' &resentation
:
. Further tests need to $e conducted such as a li,er
'unction test 0-FT2 and a co%&lete $lood count 05+52 to di''erentiate $et(een alcoholic
he&atitis and alcoholic cirrhosis.
:2 Primary (iliary Cirrhosis )P(C&4 The disease is characteri9ed $y in'la%%atory
destruction o' the s%all $ile ducts (ithin the li,er. P+/ e,entually leads to cirrhosis o'
the li,er and usually &resents (ith itching and =aundice. E,en though our &atient is a
'e%ale, (hich is a signi'icant ris) 'actor 'or P+5, her history o' alcohol a$use &oints
to(ards alcoholic he&atitis as the %ost li)ely diagnosis.
42 *iral epatitis: %ost li)ely are not the cause o' her illness $ecause o' history
&resentation and sy%&to%s.
*2 Drug usage: %ost li)ely are not the cause o' her illness $ecause o' history
&resentation and sy%&to%s.
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