A CLINICAL CASE STUDY: SPONTANEOUS BACTERIAL PERITONITIS
Here is my
case study. The article is Spontaneous Bacterial Peritonitis by Steven
Bandy, MD and Alan Tuttle, MD from emedicine
Admission: Mr. M is a 49 year old. Hispanic male who presented with chills, rigors and SOB after he was deboarded by the flight crew d/t these symptoms. He is a homeless man from Jacksonville, Fla., where he was recently released from jail and was traveling to NY to live with his sister. He denied any illicit drug use, but admitted to drinking a 6-pack of beer per day and smokes cigarettes with a 45 pack-year history. PMH includes a rt. inguinal hernia, which presented 3 months ago and pt. was advised to have this surgically repair, but he has not done so. NKA. Pt. is on no chronic medication. Family history is + for ETOH abuse & + for liver disease. ROS is negative except for his presenting symptoms and diarrhea. PE: Pt is an AAO Hispanic male w/ mild dyspnea. T=102.9, HR=116, RR=24 & BP=121/67. O2 sat on RA was 86%, improving to 91% on O2 @ 3 lpm via n/c. No sclera icterus noted. On lt. forehead noted dilated varicose veins & pulsatile artery. Positive JVD. No lymphadenopathy noted. EBBSH and clear throughout. Heart with RRR, without m/r/g. Abdomen distended, but non-tender with hepatomegaly noted. Large rt. non-tender, non-reducible inguinal hernia noted. Extremities are without edema, cyanosis or clubbing. CNs II-XII are intact. No focal neurological or muscular deficits noted. Laboratory data includes Na=139, K=3.9, Cl=109, HCO3= 21, BUN=7, Creat=0.9, glu=127, t bili=2.2, AST=205, ALT=133, alk phos=147, alb=2.7, WBC=7.1with 80.4% PMNs, Hgb=15.5, Hct=43.8, Plt=111. ABGs on 100% NRM are pH=7.53, pCO2=24, pO2=139, HCO3=20, O2 sat=99%. CXR shows mildly increased interstitial markings, with no focal infiltrates or effusions. Chest CT is – for PE or pulmonary infiltrates. Normal lung parenchyma with significant ascites noted around the liver. Impression: #1 fever and chills probably r/t SBP, but possibly pneumonia; #2 Hypoxemia probably r/t hepatopulmaonary syndrome, but possibly r/t pneumonia or pulmonary HTN; #3 Alcohol abuse with probable cirrhosis, cannot exclude hepatitis; #4 ascites r/t cirrhosis; and #5 rt. inguinal hernia. Plan: US guided paracentesis to evaluate peritoneal fluid, blood cultures X 2, HIV, Hepatitis panel ordered. IV Ceftriaxone and Tequin to cover SBP or pneumonia given. Thiamin, folate, multivitamin, and Ativan ordered for ETOH withdrawal. GI consult to evaluate cirrhosis & surgery consult to evaluate inguinal hernia and forehead varicosity. Coags checked and with PT of 18.8 and INR of 1.79 and PTT of 35.4.
Day 2: Chemistries reveal Na=138, K=4, Cl=111, BUN=7, Creat=0.8, glu=82, AST= 168, ALT= 116, Alk Phos=126, t bili=2.4, Ca=8.3, alb=2.4, t protein=6.1 & glob=3.7. CBC with WBC =5.8 with 69.8% PMNs, Hgb =14.6, Hct =43.5 and Plts =81. Received 4u of FFP with Lasix in preparation for paracentesis. Repeat CXR still no infiltrate or effusion, mild increase in pulmonary vasculature. Stool for O&P ordered. Iron studies were wnl.
Day 3: Repeat PT was 19.7 with INR of 1.45. Paracentesis under US guidance performed with cloudy yellow fluid and WBCs=1020 and a differential of 50% PMNs, RBCs=2540 and no bacteria seen.
Day 4: CBC revealed WBC=3.6 with 63% PMNs, Hgb=14.1 AND Plts=92. HIV neg &
Hepatitis C + (all other hepatitis tests negative) results return. Pt. counseled. Pt. hungry,
dietary consult and double portions ordered.
Day 5: Ionized Ca=1.25 & Mg=1.9. Paracentesis fluid culture revealed no growth. Stool O&P were negative. Blood cultures revealed no growth. ABGs evaluated to determine if pt would need or qualify for home O2. Results were Ph=7.43, pCO2=29, pO2=61, HCO3=19 and O2 sat=92%. Anticipate discharge on Sunday after receiving IV antibiotics. Pt. has located a PCP in NY for follow-up. SW to get consent signed & fax records, help with changing flights if needed, provide transportation to the airport and to obtain Vantin & Levaquin tablets, which pt will need to continue for 3 days. Pt. aware he will need a follow-up paracentesis to document resolution and that he is at increased risk for recurrence and may want to discuss prophylaxis with his MD in NY.
Day 6: Pt. doing well. All plans are in place for discharge early Sunday is. Discharge summary dictated. Discussed need for continued abstinence from ETOH and need for hepatitis A and B vaccinations as well as pneumovax. Discussed smoking cessation, but pt. totally uninterested. Pt. received annual flu vaccination.