Simple # 11 - 45-year-old man with abnormal LFTs - Mr.

Chapman

This case begins with Mr. Chapman, a 45-year-old male, with a PMHx of intravenous
drug use and alcohol abuse. He presents with fatigue and elevated liver
transaminase enzymes, alkaline phosphatase, and bilirubin levels. He has had
tattoos that were not done professionally so needle stick infection cannot be ruled
out. After thorough physical exam and diagnostic tests he is found to have active
hepatitis C infection. This case was very interesting because I did not know about
non-alcoholic steatohepatitis. This condition is similar to alcoholic hepatitis but in
the absence of alcohol and this is one of the most common causes of liver
inflammation. CAGE questions are important screening questions if one suspects
alcohol abuse. More than one positive response on CAGE questions is considered a
risk for alcohol abuse and dependence. I did not know that there were medications
to treat hepatitis C. Usually interferon and ribavirin is given, sometimes a protease
inhibitor is also added for certain genotypes of virus. Overall a great case that
reviews the basics of elevated liver enzymes.

fM # 19 - 39-year-old male with epigastric pain - Mr. Rodriguez

This case begins with Mr. Rodriguez, a 39-year-old Hispanic male, who presents
with pain in his upper abdomen over the last year, now occurring daily. His
symptoms sometimes improve with meals but ay other times the pain is worse with
food so there is no relationship to food intake and pain. Mr. Rodriguez does not have
health insurance and therefore he did not have timely access to preventative care.
Mr. Rodriguez is given a trial of omeprazole to see if his pain improves. In this case, I
learned that non-specific abdominal pain that is not worsening without associated
symptoms can be treated in clinic without referring to GI specialist. Mr. Rodriguez
returned after a month and said that omeprazole did not improve his symptoms. So
H. pylori test was done and the IgG was positive. He was given PPI triple therapy. 2
months later, Mr. Rodriguez reports no improvement. Another H. Pylori test was
performed and was positive so he was given the salvage treatment for resistant H.
Pylori which eventually resolved Mr. Rodriguez’s complaint. This case was great in
highlighting the use of interpreters when providing care for minorities as we see a
lot of use of interpreters in clinic. Also, culture sensitivity is very important as I did
not know that latino culture place a great emphasis on masculinity which may
prevent men from seeking timely medical care. I learned that a “test and treat”
approach to GERD and PUD is the most accepted initial treatment. Referral is only
after 8 weeks of test and treat, if there are extra GI symptoms, or any acute alarming
symptoms. Overall a great case for the medicine rotation because it is very relevant.