Al Pate is a 52-year-old Caucasian male who is employed in a sales department of a major software company. He first presented to you 10 days ago at the urging of his wife, who said that he often is confused and that she thinks that his eyes look yellow.  She also noted that he “has terrible breath”.  Al admits that he drinks often, because “I have to show my clients a good time at lunch, dinner, and golfing”.  He states that he thinks he “should be okay” because he never feels heartburn nor gets a hangover from his drinking, he brags that he is his company’s top salesman every year.

His wife complains that he “actually drinks every single day.” Upon questioning he admits to drinking in the morning on occasion, “just to help me get going”.  He has also complained about fatigue and a couple of weeks of watery diarrhea. He feels tired and weak.  His wife says that he has gained some weight and that he has no interest in his children or her. “He barely touches me doctor” and she starts crying in your office while pointing at Al, “Doctor, I cannot live with him anymore.”  Upon questioning further, you decide to consult a social worker and refer him to a local support group.  You order some blood tests and decide to follow up in a couple of weeks.

Laboratory Studies:

BLOOD, PLASMA, SERUM Patient Lab Results NBME Lab Reference Values Remark
Alanine aminotransferase (ALT), serum 78 8 – 20 U/L
Amylase, serum 50 25 – 125 U/L
Aspartate aminotransferase (AST), serum 256 8 – 20 U/L
Bilirubin, serum (adult) Total // Direct 4 0.1 – 1.0 mg/dL // 0.0 – 0.3 mg/dL
Calcium, serum (Ca2+) 7.8 8.4 – 10.2 mg/dL
Alkaline Phosphate 215
Cholesterol, serum 100 Rec:<200 mg/dL
Cortisol, serum 14 0800 h: 5 – 23 ug/dL

1600 h: 3 – 15 ug/dL

2000 h: ≤50% of 0800h

Creatine kinase, serum 65 Male: 25 – 90 U/L

Female: 10 – 70 U/L

Creatinine, serum 1.4 0.6 – 1.2 mg/dL
Electrolytes, serum
Sodium (Na+) 130 136 – 145 mEq/L
Potassium (K+) 3.0 3.5 – 5.0 mEq/L
Chloride (Cl-) 98 95 – 105 mEq/L
Bicarbonate (HCO3-) 21 22 – 28 mEq/L
Magnesium (Mg2+) 1.4 1.5 – 2.0 mEq/L
Glucose, serum 200 Fasting: 70 – 110 mg/dL

2-h postprandial: <120 mg/dL

Lactate dehydrogenase, serum 100 45 – 90 U/L
Phosphorus (inorganic), serum 2.8 3.0 – 4.5 mg/dL
Proteins, serum
Total (recumbent) 5.0 6.0 – 7.8 g/dL
Albumin 2.0 3.5 – 5.5 g/dL
Globulin 3.0 2.3 – 3.5 g/dL
Thyroid-stimulating hormone, serum or plasma 0.8 0.5 – 5.0 U/mL
Triglycerides, serum 300 35 – 160 mg/dL
Urea nitrogen, serum 40 7 – 18 mg/dL
Uric acid, serum 7.8 3.0 – 8.2 mg/dL
Erythrocyte count 5.0 Male: 4.3 – 5.9 million/mm3

Female: 3.5 – 5.5 million/mm3

Erythrocyte sedimentation rate (Westergren) 12 Male: 0 – 15 mm/h

Female: 0 – 20 mm/h

Hematocrit 35 Male: 41% – 53%

Female: 36% – 46%

Hemoglobin A1C 7.6 ≤ 6%
Hemoglobin, blood 8.4 Male: 13.5 – 17.5 g/dL

Female: 12.0 -16.0 g/dL

Leukocyte count and differential
Leukocyte count 8500 4500 – 11,000/mm3
Segmented neutrophils 60 54% – 62%
Bands 3 3% – 5%
Eosinophils 1 1% – 3%
Basophils 0 0% – 0.75%
Lymphocytes 30 25% – 33%
Monocytes 8 3% – 7%
Mean corpuscular hemoglobin 24 25.4 – 34.6 pg/cell
Mean corpuscular hemoglobin concentration 29 31% – 36% Hb/cell
Mean corpuscle volume 77 80 – 100 mm3
Partial thromboplastin time (activated) 55 25 – 40 seconds
Platelet count 75,000 150,000 – 400,000/mm3
Prothrombin time 18 11 – 15 seconds
Reticulocyte count 0 0.5% – 1.5%
Ammonia Level 94
INR 1.8
GGT 86

ABDOMINAL ULTRASOUND: shows a diffusely enlarged fatty liver with a nodular contour, splenomegaly and moderate ascites. The portal vessels are prominent.

Surgical History: Inguinal hernia repair at 43 years old.

Medical History: History of diabetes mellitus and alcohol abuse.

Social History: Married to wife for almost 15 years.  Has 5 kids.  Ages 14, 12, 8, 6, and 2 months.   He has been working at the same company for almost 4 years. Wife does not work, stays at home with the kids.

Family History: His father died when he was 3 years old and says his mother never indicated why his father died.

Allergies: Penicillin

Medications: None

Review of Systems: Positive for diarrhea, weakness and impotence.

His vital signs are: Height 5’7’’ft (175cm), Weight 233 lbs (106kg), Temp; 97.5 F, Pulse: 110 bpm; RR: 22, BP 120/80, O2 95%.

HEENT: PEERL, EOMI, yellow discoloration of sclera, acanthosis nigricans on neck.

EARS: Normal TM and light reflex.

MOUTH: Strong alcohol odor, caries, otherwise mouth and pharynx normal.

NECK: No carotid bruits or jugular venous distention while sitting upright.  No cervical adenopathy noted.  Thyroid not palpated.

CHEST: Lungs with fine crackles on both bases, good air movement, no wheezing on inspiration/expiration.  Heart regular rate and rhythm, no murmurs heard.  Gynecomastia present bilaterally.

ABDOMEN: Obese and enlarged abdomen, reduced hair growth, varicocele umbilical vein present, telangiectasias, positive for shifting dullness, unable to palpate any visceromegaly’s due to distention.

GENITAL: Uncircumcised male, both testes descended bilaterally atrophy noticed.

EXTREMITIES: Thin appearance, poor muscle tone.  Lower extremity 2+ edema to the knees bilaterally; Strength 5/5, pulses present bilaterally, no other abnormalities.  Palmar erythema noted.

NEURO: Slurred speech, cranial nerves 2-12 normal; asterixis present.

Ten Days Later:

Today is the follow up visit.  Upon entering the room, you notice alcoholic odor and a large hematoma on his left arm which he indicates is the blood draw location from a couple of weeks ago.  He remarks that “sometimes I feel confused doc”, and says, “my energy is low, you gotta fix me.”  He mentions “my wife left with the kids to her mom’s house” and later, “I lost this year’s sales bonus at my company and I have started drinking more than usual.”

You decide to ask Al more details about his drinking.  He admits that he has gotten several DUIs over the past year.  Sometimes he forgets where he is at and when he tries to stop drinking, he feels bad, one time he had a seizure.  He has not tried to stop drinking because of that.

You ask Albert the following CAGE questions:

  1. Have you ever felt you should Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt bad or Guilty about your drinking?
  4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

Al answers in the affirmative for each of the CAGE questions and on examination, you notice that he has yellow discoloration of the sclera, some parts of his skin have bruises especially on his back and trunk.  You observe cherry red papules, lacy-looking patches and fragile skin.  Al complains about generalized itching “Doc I cannot sleep with this”. Upon examination of his abdomen, you realize that now he has markedly dilated abdominal wall veins, something that he did not have previously.  Diligently, you decide to auscultate the abdomen to evaluate his peristalsis.  To your surprise, you do not hear bowel sounds. You decide to do percussion and roll Al to his sides.  You can demonstrate “shifting dullness” and you are unable to palpate the liver or any other organ due to distension.  His extremities are thin and Al just tells you that he feels so tired and weak that, “I want to die doctor…”

Compassionately, you decide to take your time and listen to Al’s story.  Finalizing, you explain to him in plain terms that his liver is not functioning as it needs to.  Al asks, “What is wrong with it?”  You explain that the liver controls coagulation, protein synthesis to mention some.  Al remembers to tell you that his diarrhea has a “black color doc” and points out that this has been going on for the last couple of months.

With this information you decide to send Al to the hospital for inpatient admission for further management of his condition.  Your nurse just left since it is past 5pm and you had spent more than the allocated time with Al.  You decide to start the referral process and call the local ED yourself to present your patient. When asking Al about his preferred hospital, he tells you that he forgot to pay his insurance premium almost 2 months ago and now he is uninsured.  You send Al to the county hospital and you wonder if something else can be done.



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“Bad Breath”: An integrated case study of alcoholic liver disease for first year medical students. Copyright © 2020 by Omar Matuk-Villazon, MD, MBA and Kevin Rowland, PhD is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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