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A 50-year-old man with complaints of fatigue for 2 mon

50 years old | Male

Vignette:

A 50-year-old man presents to his primary-care clinic physician with complaints of fatigue for 2 months. The patient also notes distention of his abdomen and shortness of breath beginning 2 weeks ago. His wife reports that the patient has been having episodes of confusion lately. The patient has a significant medical history of chronic heavy alcohol consumption of about a half pint of vodka daily for around 20 years. On physical exam the patient is noted to have scleral icterus, tremors of both hands, and spider angiomata on the chest. There is abdominal distention with presence of shifting dullness, fluid waves, and splenomegaly. Laboratory examination shows low hemoglobin, low platelets, low sodium, aspartate aminotransferase (AST) elevation > alanine aminotransferase (ALT) elevation, and high prothrombin time (PT) and international normalized ratio (INR). Ultrasound of the abdomen shows liver hyperechogenicity, portal hypertension, splenomegaly, and ascites.

Summary:

fatigue | 2 months | abdominal distention | shortness of breath | confusion | heavy alcohol consumption | scleral icterus | tremors of hands | spider angiomata on the chest | shifting dullness | fluid waves | splenomegaly | low hemoglobin | low platelets | low sodium | AST greater than ALT | elevated prothrombin time | elevated INR | liver hyperechogenicity | portal hypertension | ascites

Dx:

Alcoholic liver disease Alcoholic Hepatitis Alcoholic Fatty Liver

Ref:

https://online.epocrates.com/diseases/111622/Alcoholic-liver-disease/Common-Vignette

Rank

Disease

Weight

1 Alcoholic Liver Cirrhosis 804.0
2 Alcoholic hepatitis 798.0
3 Alcoholic Liver Disease 778.0
4 Liver Cirrhosis 777.0
5 Biliary cirrhosis 776.0
6 Primary biliary cirrhosis 774.0
7 Autoimmune hepatitis 697.0
8 Alcoholic Fatty Liver 668.0
9 Primary sclerosing cholangitis 646.0
10 Acute Liver Failure 635.0
11 Budd Chiari Syndrome 607.0
12 Hepatocellular carcinoma 581.0
13 Acute Lymphoblastic leukemia in children 579.0
14 Cholangiocarcinoma 534.0
15 Hereditary hemochromatosis 534.0
16 Hepatic Encephalopathy 506.0
17 Primary Myelofibrosis 490.0
18 Chronic heart failure 486.0
19 Gastritis 484.0
20 Short bowel syndrome 467.0
21 Pyogenic Liver Abscess 466.0
22 Acute Lymphocytic Leukemia in Adults 458.0
23 Non-alcoholic Fatty Liver Disease 446.0
24 Cystic Fibrosis 437.0
25 Rocky Mountain spotted fever 437.0
26 Common cutaneous drug reactions 428.0
27 Klebsiella pneumoniae liver abscess 417.0
28 Tuberculous Peritonitis 409.0
29 Acute Myeloid Leukemia in adults 400.0
30 Sarcoidosis 398.0
31 Acute Hepatitis 391.0
32 Systemic sclerosis 385.0
33 Hepatorenal Syndrome 384.0
34 pancreatic cancer 379.0
35 Wilson disease 367.0
36 Systemic lupus erythematosus 351.0
37 Acute fatty liver of pregnancy 348.0
38 Toxic Megacolon 346.0
39 Ovarian Hyperstimulation Syndrome 344.0
40 Acute Pancreatitis 340.0
41 Pneumonia 337.0
42 Eclampsia 336.0
43 Chronic Hepatitis 335.0
44 Addison Disease 335.0
45 Hemolytic uremic syndrome 325.0
46 Acute Myeloid Leukemia in children 322.0
47 Chronic liver disease 319.0
48 Celiac Disease 318.0
49 Liver disease 315.0
50 Adrenal crisis 314.0
51 Amebic Liver Abscess 313.0
52 Thrombotic thrombocytopenic purpura 313.0
53 Gallstone pancreatitis 313.0
54 Graves Disease 311.0
55 Autosomal Recessive Polycystic Kidney Disease 301.0
56 Brucellosis 298.0
57 Malaria 293.0
58 Multiple Myeloma 293.0
59 mucosal Eosinophilic gastroenteritis 289.0
60 Non-small cell lung cancer 287.0
61 Crohn Disease 286.0
62 Acetaminophen overdose 284.0
63 Ascites 282.0
64 Infectious mononucleosis 281.0
65 Hypothyroidism 278.0
66 Mitral Stenosis 278.0
67 Heparin-induced thrombocytopenia 278.0
68 Hypertriglyceridemia 276.0
69 Disseminated intravascular coagulation 274.0
70 Acute intermittent porphyria 268.0
71 Hypogammaglobulinemia 266.0
72 Anthrax 264.0
73 Chronic Myeloid Leukemia 263.0
74 Food poisoning 263.0
75 Colorectal cancer 260.0
76 Abnormal uterine bleeding 258.0
77 Preeclampsia 251.0
78 Ovarian Cancer 250.0
79 Foreign body ingestion 242.0
80 Spontaneous bacterial peritonitis 240.0
81 Ulcerative Colitis 239.0
82 Acute bacterial meningitis in adults 239.0
83 Chronic Lymphocytic Leukemia 235.0
84 Anemia of chronic disease 234.0
85 Hereditary Angioedema 233.0
86 Hyperprolactinemia 227.0
87 Shigellosis 226.0
88 Mesenteric ischemia 221.0
89 Kawasaki disease 220.0
90 Lung Cancer 216.0
91 Diabetic Ketoacidosis 215.0
92 Extraintestinal Entamoeba histolytica amebiasis 213.0
93 Rheumatoid Arthritis 212.0
94 Acute bacterial meningitis in children 212.0
95 Granulomatosis with polyangiitis 207.0
96 Chronic Mitral regurgitation 206.0
97 Chronic Pancreatitis 205.0
98 Choledocholithiasis 205.0
99 Amyloidosis 203.0
100 Muscle Layer Eosinophilic gastroenteritis 200.0
101 Premenstrual syndrome 200.0
102 Intestinal Obstruction 197.0
103 Hyperosmolar Hyperglycemic state 195.0
104 Subdural hematoma 194.0
105 Stable ischemic heart disease 191.0
106 Acute bacterial meningitis in neonates 191.0
107 Chronic atrial fibrillation 190.0
108 Portal hypertension 189.0
109 Cryptococcosis 189.0
110 Typhoid infection 188.0
111 Adrenocortical carcinoma 187.0
112 Non-cholera Vibrio infections 187.0
113 Acute Cholangitis 186.0
114 Autoimmune Pancreatitis 182.0
115 subserosal eosinophilic gastroenteritis 182.0
116 Drowning 182.0
117 Pulmonary Embolism 180.0
118 Abdominal compartment syndrome 178.0
119 Hyperthyroidism 177.0
120 Acute respiratory failure 176.0
121 Aortic stenosis 170.0
122 Inflammatory Bowel Diseases 169.0
123 Laryngeal Cancer 169.0
124 Viral pharyngitis 168.0
125 Non-diabetic hypoglycemia 168.0
126 Non-ST-elevation myocardial infarction 168.0
127 Peutz-Jeghers Syndrome 167.0
128 Acromegaly 166.0
129 Liver Abscess 165.0
130 Acute disseminated encephalomyelitis 163.0
131 Gastric cancer 158.0
132 Fungal meningitis 158.0
133 Bacterial pharyngitis 157.0
134 Familial adenomatous polyposis syndrome 157.0
135 Polyarteritis nodosa 155.0
136 Osteoporosis 155.0
137 Fibromyalgia 155.0
138 Obstructive Sleep Apnea 154.0
139 Acute peptic ulcer 154.0
140 Anaphylaxis 154.0
141 Ankylosing spondylitis 152.0
142 Deep venous thrombosis 150.0
143 Foodborne E coli infection 149.0
144 Ruptured ectopic pregnancy 149.0
145 chronic biliary obstruction 149.0
146 Renal Cell Carcinoma 145.0
147 Familial Mediterranean fever 143.0
148 Aortic coarctation 142.0
149 Chronic Clonorchiasis 140.0
150 Acute peritonitis 139.0
151 Chronic Kidney Diseases 139.0
152 anterior ischemic optic neuropathy 138.0
153 Clostridium difficile infection 138.0
154 Chronic bacterial prostatitis 137.0
155 Leiomyomas 137.0
156 Giardiasis 136.0
157 Amphetamine use disorder 136.0
158 Gastric Outlet Obstruction 135.0
159 Von willebrand disease 135.0
160 Acute viral meningitis 134.0
161 Oropharyngeal cancer 132.0
162 Gallbladder cancer 131.0
163 Hypercalcemia 130.0
164 COPD Exacerbation 129.0
165 Stevens-Johnson syndrome 129.0
166 Sigmoid volvulus 129.0
167 Prinzmetal angina 129.0
168 End Stage Renal Disease 128.0
169 Hiatus hernia 124.0
170 Umbilical hernia 124.0
171 Analgesic nephropathy 123.0
172 Renal and perinephric abscess 123.0
173 Multiple Sclerosis 123.0
174 Glomerulonephritis 123.0
175 Cushing syndrome 123.0
176 Meckel diverticulum 122.0
177 Clonorchiasis 120.0
178 Influenza 119.0
179 Aseptic meningitis 119.0
180 Hemorrhagic stroke 117.0
181 Ischemic stroke 117.0
182 Lactose intolerance 115.0
183 Pheochromocytoma 115.0
184 Painless thyroiditis 115.0
185 Acute heart failure 115.0
186 Eosinophilic gastroenteritis 114.0
187 Diverticulitis 114.0
188 Mallory-Weiss syndrome 112.0
189 Primary hypogonadism 111.0
190 Diabetic Kidney Disease 108.0
191 Acute Cholecystitis 107.0
192 Acute Clonorchiasis 106.0
193 COVID19 105.0
194 Salmonella infection 105.0
195 Prolactinoma 104.0
196 Endometrial cancer 104.0
197 Gastroparesis 104.0
198 Biliary cyst 104.0
199 Emphysematous cholecystitis 103.0
200 Candidal intertrigo 102.0
201 Candida Balanitis 102.0
202 Oropharyngeal and esophageal candidiasis 102.0
203 Vulvovaginal candidiasis 102.0
204 Oral candidiasis 102.0
205 Angiodysplasia of the colon 101.0
206 Bruxism 101.0
207 Autoimmune hemolytic anemia 100.0
208 Type 1 Diabetes mellitus 100.0
209 Insomnia in adults 100.0
210 Toxic thyroid adenoma 100.0
211 Breast Cancer 100.0
212 Acute Appendicitis 99.0
213 Intrahepatic cholestasis of pregnancy 99.0
214 Osteoarthritis 98.0
215 posteriorischemic optic neuropathy 98.0
216 Graves ophthalmopathy 98.0
217 Irritable Bowel Syndrome 97.0
218 Kartagener syndrome 96.0
219 Psoas Abscess 96.0
220 Chronic pyelonephritis 95.0
221 Acute perforated appendicitis 94.0
222 Acne fulminans 94.0
223 Campylobacter infection 94.0
224 Abetalipoproteinemia 93.0
225 Rotor syndrome 92.0
226 Intrahepatic Cholestasis 92.0
227 Gastrointestinal Hemorrhage 91.0
228 Lower gastrointestinal hemorrhage 91.0
229 Upper gastrointestinal hemorrhage 91.0
230 ST-elevation myocardial infarction 91.0
231 Pancreatic Pseudocyst 90.0
232 Parkinson disease 90.0
233 Asthma 90.0
234 Gastric Volvulus 90.0
235 Intussusception 87.0
236 Stable angina 86.0
237 Multiple endocrine neoplasia 2A 86.0
238 Dyspepsia 86.0
239 Chronic fatigue syndrome 85.0
240 Cholera 85.0
241 biliary SOD 85.0
242 Stroke 84.0
243 Splenic Rupture 84.0
244 Duodenal Ulcer 83.0
245 Gastric Ulcer 83.0
246 Gallstones 83.0
247 Autosomal Dominant Polycystic Kidney Disease 82.0
248 Bullous pemphigoid 82.0
249 Alzheimer disease 81.0
250 Immune thrombocytopenia 81.0
251 Limited cutaneous systemic sclerosis 81.0
252 Transient ischemic attack 80.0
253 Recurrent aphthous stomatitis 80.0
254 Hyperparathyroidism 79.0
255 chronic acalculous cholecystitis 79.0
256 Travelers diarrhea 78.0
257 Motion Sickness 78.0
258 Ileus 78.0
259 Hypoparathyroidism 76.0
260 Gilbert syndrome 76.0
261 Atopic dermatitis 76.0
262 Primary ciliary dyskinesia 75.0
263 Intestinal Pseudo Obstruction 75.0
264 Pharyngitis 74.0
265 STI HIV Pharyngitis 74.0
266 Herpes pharyngitis 74.0
267 Insect bites and stings 74.0
268 Empyema 73.0
269 Allergic rhinitis 73.0
270 Chronic pelvic pain in women 73.0
271 Secondary hypogonadism 73.0
272 Goiter 72.0
273 Diffuse nontoxic goiter 72.0
274 Toxic multinodular goiter 72.0
275 Obstructive cervical goiters 72.0
276 Cervical goiter 72.0
277 Gestational diabetes mellitus 72.0
278 Hyperaldosteronism 71.0
279 Migraine 70.0
280 Epilepsy 70.0
281 Ovarian Torsion 67.0
282 Annular pancreas 66.0
283 Anaplastic thyroid cancer 66.0
284 Multiple endocrine neoplasia 2B 66.0
285 Psoriasis 65.0
286 Extrahepatic Cholestasis 65.0
287 Premature labor 65.0
288 Splenic abscess 64.0
289 Psychogenic polydipsia 63.0
290 Acute bacterial rhinosinusitis 62.0
291 Unstable angina 61.0
292 Intestinal Entamoeba histolytica amebiasis 61.0
293 Acute pyelonephritis in adults 61.0
294 Migraine headache in adults 61.0
295 Ruptured ovarian cyst 61.0
296 Inguinal hernia 60.0
297 Aortic Dissection 59.0
298 Type 2 Diabetes mellitus 59.0
299 Esophagitis 59.0
300 Guillain-Barre syndrome 59.0
301 Adrenal Suppression 57.0
302 Central hypothyroidism 56.0
303 Central diabetes insipidus 54.0
304 Milk-alkali syndrome 54.0
305 Acute Milk-alkali syndrome 54.0
306 Chronic Milk-alkali syndrome 54.0
307 Menopause 54.0
308 Splenic Infarction 54.0
309 Priapism 54.0
310 Systemic vasculitis 53.0
311 Intraperitoneal bleeding 53.0
312 Intestinal malrotation 52.0
313 Balanitis 51.0
314 Acute Rhinosinusitis 50.0
315 Acute viral rhinosinusitis 50.0
316 Cataract 50.0
317 Infertility in women 50.0
318 Mirizzi Syndrome 50.0
319 Cholestasis 50.0
320 Acalculous Cholecystitis 49.0
321 Croup 49.0
322 Endometriosis 48.0
323 Herpes zoster 48.0
324 Acute pericarditis 48.0
325 Acute Mitral regurgitation 48.0
326 Ischemic optic neuropathy 48.0
327 Gastroesophageal reflux disease 48.0
328 Chlamydia pneumoniae infection 48.0
329 Atypical pneumonia 48.0
330 Gout 48.0
331 Optic neuritis 47.0
332 Neuropapillitis 47.0
333 Erectile dysfunction 47.0
334 Amebiasis 47.0
335 Urinary Tract Obstruction 46.0
336 Pseudohypoparathyroidism 46.0
337 Thyroid lymphoma 46.0
338 Varicose veins 46.0
339 cholestatic liver disease 45.0
340 Male factor infertility 45.0
341 Endometritis 44.0
342 Sunburn 44.0
343 Malt lymphoma 44.0
344 Viral Gastroenteritis 43.0
345 Ruptured Tuboovarian abscess 43.0
346 Churg-Strauss Syndrome 43.0
347 Achalasia 43.0
348 Bed bugs 42.0
349 Dubin-Johnson syndrome 42.0
350 Phenylketonuria 41.0
351 Choledochal Cyst 41.0
352 Bladder Cancer 40.0
353 Penis Carcinoma 40.0
354 Gallbladder Dyskinesia 40.0
355 pancreatic SOD 40.0
356 Essential Tremor 36.0
357 Acute atrial fibrillation 35.0
358 Henoch-Schonlein purpura 35.0
359 Nasal polyps 34.0
360 Exocrine pancreatic insufficiency 34.0
361 Rosacea 34.0
362 Animal bites 34.0
363 Tinnitus 34.0
364 chronic cholestatic liver disease 33.0
365 Gingivitis 33.0
366 Substernal goiter 33.0
367 Labyrinthitis 33.0
368 Peptic Ulcer 32.0
369 Intra-abdominal abscess 32.0
370 Peritoneal dialysis associated peritonitis 30.0
371 Common cold(adults) 29.0
372 Renal Artery Stenosis 29.0
373 Cellulitis 29.0
374 Miliaria 29.0
375 Listerial gastroenteritis 27.0
376 Acute otitis media 27.0
377 Ovarian and fallopian tube torsion 27.0
378 Paraneoplastic Syndromes 26.0
379 Testicular cancer 26.0
380 Chronic Renal vein thrombosis 26.0
381 Pelvic inflammatory disease 25.0
382 Acute pelvic inflammatory disease 25.0
383 Kidney stones 25.0
384 Diabetes Mellitus 25.0
385 Osteomyelitis 24.0
386 Periorbital and orbital cellulitis 24.0
387 Mitral Valve Prolapse 24.0
388 Acute Bacterial Prostatitis 23.0
389 Bacterial gastroenteritis 22.0
390 biliary obstruction 22.0
391 Hemorrhoids 21.0
392 Gallbladder Empyema 21.0
393 Genital herpes 20.0
394 Charcot-Marie-Tooth Disease 20.0
395 Zollinger-Ellison Syndrome 20.0
396 Sphincter of Oddi Dysfunction 20.0
397 Papilledema 20.0
398 Chronic meningitis 20.0
399 biliary colic 19.0
400 Pyelonephritis 19.0
401 Secondary hyperparathyroidism 18.0
402 Musculoskeletal sprains and strains 18.0
403 Medullary thyroid cancer 18.0
404 Barrett esophagus 18.0
405 Panic disorder in adults 18.0
406 Ichthyosis 18.0
407 Chronic Cholecystitis 18.0
408 Meniere disease 18.0
409 Angle Closure Glaucoma 17.0
410 Bacterial conjunctivitis 15.0
411 Viral conjunctivitis 15.0
412 Diabetic Neuropathy 15.0
413 Sexual abuse and assault 15.0
414 Dystonia 15.0
415 Secondary Peritonitis 14.0
416 Rotator Cuff Tears 14.0
417 Nephrogenic diabetes insipidus 14.0
418 Acute cervical spine trauma 14.0
419 Discogenic low back pain 11.0
420 Benign Prostatic Hyperplasia 11.0
421 Acute Bronchitis 9.0
422 Sialadenitis 9.0
423 Psoriatic arthritis 8.0
424 Gastroenteritis 7.0
425 Common cold(children) 6.0
426 Epiploic appendagitis 6.0
427 Pityriasis rosea 5.0
428 Alopecia areata 4.0
429 Diabetic Amyotrophy 3.0
430 endocarditis 2.0
431 Acute Cystitis(Men) 0.0
432 Carpal Tunnel Syndrome 0.0
433 Bell palsy 0.0
434 Orthostatic hypotension 0.0
435 Pulmonary regurgitation 0.0
436 Tetanus 0.0
437 Congenital Myasthenic Syndromes 0.0
438 Neonatal Myasthenia Gravis 0.0
439 Myasthenia Gravis 0.0
440 Hodgkin lymphoma 0.0
441 Measles 0.0
442 Visceral leishmaniasis 0.0
443 Acute epididymitis 0.0
444 Musculoskeletal lower back pain 0.0