DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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A liver puzzle

55 year old man admitted to our service for ascites and anasarca (massive scrotal and leg edema.)  The patient had large volume paracentesis.  The SAAG (serum ascites albumin gradient) was 1.8 – consistent with portal hypertension.  He had no evidence for spontaneous bacterial peritonitis.  His serum ammonia was normal.

Later that evening he becomes hypoxic and is transferred to intensive care.  He is placed on a 50% rebreathing mask.

In reviewing his lab data we find:

 

Liver tests
Destruction Obstruction Factory
AST 34 alk phos 98 albumin 2.7
ALT 27 T. Bili. 0.8 INR 1.3

 

 

 

 

His ABG the next morning on 50% O2

 

Arterial Blood Gas – 50% oxygen
pH 7.115
pCO2 91
pO2 90

 

When he was admitted he had a serum bicarbonate of 31.

He has cardiomegaly on chest xray.

Questions:

1. What liver diseases might he have – what is your best guess?

2. What other tests would you order?

3. Why is his pCOso high?

I will provide some answers and a strong hypothesis.

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