PCL 2 - Case 7: CASE OF MICHAEL

PHILLIPS

Michal Zacharzewski. (2011). Last Man Standing [Online image]. Retrieved from http://www.sxc.hu/photo/1330435

Request Student Volunteer to interview patient Introduce the Standardized Patient Instructions for Student Volunteer:

During the interview you may take “time out” and ask questions

Student Leader/Tutor may interrupt to help facilitate the interview.

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INSTRUCTIONS

Case 7: Michael PhillipsPart 1: Interview (SP)

Go To Problem List

Go To Clinical Notes

What do you think?

Go to Problem List and Clinical Notes to begin the Differential Diagnosis

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INSTRUCTIONS

Case 7: Michael PhillipsPart 1:

Go To Problem List

Go To Clinical Notes

Problem List Learning ObjectivesDDx

Go to Clinical Notes

CC: (Chief Complaint/Concern):

HPI: (History of Present Illness):

PMH: (Past Medical History):

Clinical Notes:

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Past Surgical History:

Go To Problem List

FH: (Family History): Medications:

Allergies:

Clinical Notes:

SH: (Social History):

Go To Problem List

Clinical Notes:

Assessment & Plan:

Labs: Review of Systems:

Physical Exam:

Go To Problem List

*** Distribute Handout 1***

Background Information Physical Exam & Lab Results

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Case 7: Michael PhillipsPart 1: Background

Go To Problem List

Go To Clinical Notes

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Case 7: Michael PhillipsPart 2: Two Days Later

Go To Problem List

Go To Clinical Notes

Lab results show Michael Phillips has inflammation of the liver.

Doctor calls Michael Phillips and informs him he has hepatitis and recommends to “give the liver a rest” and asks Mr. Phillips to abstain from alcohol.

Michael schedules an appointment to follow up inone week.

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Case 7: Michael PhillipsPart 2: FRAMES Intervention

Go To Problem List

Go To Clinical Notes

One Week Later: Doctor meets with Michael Phillips to review his case.

FRAMES Intervention: Doctor (Student Leader) conducts “FRAMES” intervention using the AUDIT Questionnaire. (Script & Questionnaire on Blackboard)FRAMES Intervention:• Feedback• Responsibility• Advice• Menu of Options• Empathy• Support

AUDIT Questionnaire:• Alcohol Use Disorders

Identification Test (AUDIT)

*** Distribute Handout 2***

Handout 2: “Future Course of Patient’s Life”

Class review and discuss1) Pathway One2) Pathway Two

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Case 7: Michael PhillipsPart 2: Background

Go To Problem List

Go To Clinical Notes

(These Will Not Be Tested as Part of PCL)Clinical Problem Solving

List the differential diagnosis of abdominal pain in the setting of alcohol use

Basic and Clinical Sciences Review alcohol metabolism Review pathophysiology of alcohol related liver disease

(These Will Be Tested as Part of PCL)

Psychosocial, Behavioral, and Developmental Issues Recognize the role of standardized screening tools such as

AUDIT in evaluating alcohol usage Be familiar with validated brief intervention tools such as

FRAMES Recognize the impact of alcoholism to all the components in a

patient’s life.12

Case 7: Michael PhillipsLearning Objectives:

Go To Problem List

Go To Clinical Notes

NEXT WEEK: Readings

Required Reading: Mailliard M.E., Sorrell M.F. (2012). Chapter 307. Alcoholic Liver Disease. In D.L.

Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison's Principles of Internal Medicine, 18e. Retrieved January 26, 2012 from http://www.accessmedicine.com/content.aspx?aID=9134918.

Supplemental Readings: Fagbemi, K. (2011). QWhat

is the best questionnaire to screen for alcohol use disorder in an office practice? Cleveland Clinic Journal of Medicine, 78(10), 649-651.

Fiellin, D. A., Reid, M. C., & O'Connor, P. G. (2000). Screening for alcohol problems in primary care: A systematic review. Archives of Internal Medicine, 160(13), 1977-1989.

Webb, G., Shakeshaft, A., Sanson-Fisher, R., & Havard, A. (2009). A systematic review of work-place interventions for alcohol-related problems. Addiction, 104(3), 365-377.

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Case 7: Michael PhillipsSession 1: Wrap Up

Go To Problem List

Go To Clinical Notes

NEXT WEEK: Management of Session 2

Begin with an oral presentation of the case (Oral Presentation: See PowerPoint on Blackboard & Handout #4)

Student Presentations

Appoint a new scribe to keep track of the discussion

Review USMLE sample questions

Appoint a student leader for the next case

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Case 7: Michael PhillipsSession 1: Wrap Up

Go To Clinical Notes

Go To Problem List

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End of Session 1

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PCL 2 Case 7: Michael Phillips

Michal Zacharzewski. (2011). Last Man Standing [Online image]. Retrieved from http://www.sxc.hu/photo/1330435

MANAGEMENT OF SESSION 2:

Begin with an oral presentation of the case

Student Presentations

Appoint a new scribe to keep track of the discussion

Review USMLE sample questions

Solicit and provide Feedback on the session

Appoint a student leader for the next case

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Case 7: Michael PhillipsSession 2: Management

Go To Clinical Notes

Go To Problem List

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USMLE Questions

USMLE QUESTIONS

QUESTION 1: A 50-year-old male alcoholic presents with cirrhotic liver disease and chronic pancreatitis. He has been nauseated for the past several days, and not eating. Blood glucagon levels are elevated with which of the following results? A. Stimulation of glycogenolysis in muscleB. Inhibition of insulin secretionC. Stimulation of gluconeogenesis in the liverD. Inhibition of adenylate cyclaseE. Inhibition of phospholipase C

(All Practice questions were retrieved from USMLEasy Web site.) USMLEasy: Home Retrieved 1/25/2012, from http://www.usmleasy.com/

USMLE: 1

ANSWER:C

EXPLANATION: The primary action of glucagon is to increase blood glucose concentration, which it accomplishes by promoting gluconeogenesis and glycogenolysis in the liver but not in muscle. These effects are mediated by cyclic AMP, which is produced by hepatic adenylate cyclase following interaction of glucagon with its plasma membrane receptor. Interaction of glucagon with different hepatic plasma membrane receptors activates phospholipase C, which results in a rise in concentration of intra-cellular Ca2+, which further stimulates glycogenolysis. Although glucagon opposes the action of insulin, it does not directly affect insulin secretion.

USMLE QUESTIONS

USMLE:

(All Practice questions were retrieved from USMLEasy Web site.) USMLEasy: Home Retrieved 1/25/2012, from http://www.usmleasy.com/

USMLE QUESTIONS

QUESTION 2 : A 42-year-old woman presents with an acute onset of fever, jaundice, tender liver enlargement, and ascites. Liver biopsy reveals histological features of scattered foci hepatocytes undergoing swelling and necrosis, with neutrophilic infiltration around the affected cells, and sinusoidal and perivenular fibrosis. This is most suggestive of which of the following? A. Acetaminophen overdoseB. Acute fatty liver of pregnancyC. Alcoholic hepatitisD. Budd-Chiari syndromeE. Pyogenic liver abscess

King, M. W. (2008). Lange Q & A. USMLE step 1 / [edited by] Michael W. King. New York : McGraw-Hill Medical, c2008.

USMLE: 2

USMLE QUESTIONS

USMLE:

ANSWER:C

EXPLANATION: Alcoholic hepatitis (also called acute sclerosing hyaline necrosis of the liver) usually occurs acutely following an alcoholic binge superimposed on steatosis (fatty liver) or cirrhosis. Variable degrees of liver cell necrosis are present with corresponding clusters of neutrophils and frequent accompaniment of pericellular and perivenular fibrosis. Intracellular Mallory bodies are common. Alcoholic hepatitis may range from asymptomatic to fulminant hepatic failure. Symptoms, which may persist for weeks or months, include upper abdominal pain, anorexia, fever, tender hepatomegaly, and jaundice. Sever disease may cause encephalopathy and death.

King, M. W. (2008). Lange Q & A. USMLE step 1 / [edited by] Michael W. King. New York : McGraw-Hill Medical, c2008.