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You are an Fy1 working in the Gastroenterology ward in your hospital. Ms Ann Emia is a 51 year old lady who has just been admitted to the ward via GP referral, complaining of a ‘swollen tummy’. This is not the first time Ann has presented in this way: indeed she was just discharged from the acute medical unit at your hospital last week. Ann has arrived with a handwritten medication list. The GP’s handwriting is difficult to interpret, but you can make out the following medications:

Furosemide 40mg OD Spironolactone 150mg OD Thiamine Salbutamol inhaler PRN GTN spray PRN Rivaroxaban

Please take a history from Ann and perform the appropriate examination. Ensure you assess the impact this condition has had on Ann’s life. This will be followed by a discussion about Ann’s presentation.

You are Ann Emia, a 51 year old lady who enjoys time with your family. You have been very unwell recently, however, and you put all of this down to your drinking. You don’t like to admit this, however, as you are quite ashamed of your drinking and feel the staff will judge you. You have been told that your liver is very damaged and has been unable to repair itself, and believe this to be the cause of your frequent admissions to hospital. HPC: Your tummy has become incredibly swollen over the last week or so, only one week after leaving hospital the last time. It is so swollen it is affecting your breathing and it is really painful from time to time.

The pain comes and goes in waves, and is down both flanks. It is usually when you are lying flat or when you are changing positions. It is not associated with eating and nothing really makes it better. The shortness of breath is also worst when you are lying flat. You think this is down to how big your tummy has got, but you did have a blood clot in your lung a few years ago. The swelling in your tummy started gradually but has been worse the last couple of days. Nowhere else appears to be swollen.

This is how you felt when you were last admitted to this hospital a few weeks ago. They told you then that one of your salts was low as well. They put a needle in and took some water from your tummy. At first it was such a relief, but now it is back to the way it originally was. It’s very frustrating!

ICE: You are concerned that you haven’t got any better the last few times you have been in hospital. You are worried that you have done so much damage already to your liver due to the alcohol, that you won’t get better. You are expecting another needle into your tummy to remove all the fluid in there.

PMH: You know you have a long term problem with your liver. You had a blood clot in your lung a few years ago and take a tablet for that. You used to take warfarin but this new tablet means you don’t need to get your blood taken all the time – which is a big relief! You used to have chest pain due to angina but you haven’t had that for a long time. You don’t use that inhaler. You sometimes use a blue inhaler when you’re breathless. It doesn’t really help. SH: You used to drink a lot of alcohol, but you don’t any more. You last drank 6 months ago and haven’t drunk a drop since. On an average day, you could drink 2 bottles of wine. This was over a period of 30 years. You broke up with your partner as he would not stop drinking at the same time as you. This has made you feel so much more free to do your own thing and to become more healthy. You don’t smoke and you live in a terraced house, with your family nearby. Your mum comes to see you sometimes as you can’t get around the house as well as you used to. FH: No one in your family has had any long term conditions that you are aware of. No one else in your family drinks alcohol.

The student should demonstrate a clear history of the patient’s alcohol intake, alongside a good history of presenting complaint of the abdominal distension, including risk factors. In terms of examination, an abdominal exam would be appropriate.

The student’s differential diagnosis should sound something like:

My differential diagnosis would include an abdominal cause, more specifically alcoholic liver disease, presenting with ascites. I would want to identify the extent of her liver disease to assess for cirrhosis. It would be important to rule out any signs of malignancy in this patient which is known to be a cause for ascites, in addition to cardiac failure. Finally it would be important to include gynaecological malignancy, particularly ovarian cancer, in my differential diagnosis. Example for discussion may include:

  • How would you investigate this patient in the acute setting?
  • How would you manage this patient acutely?
  • How would you classify ascites?
  • How can you tell the difference between exudate and transudate in ascites?
  • Do you know any ways to classify cirrhosis?
  • What would the prognosis be for this patient?
  • If this patient presented with confusion, how would you explain that?