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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the signs and symptoms of spontaneous bacterial peritonitis (SBP)

  • Identify the criteria for diagnosis of SBP

  • Develop a treatment plan for ascites and prophylaxis/treatment of SBP

  • List common adverse events caused by SBP and develop/identify an appropriate treatment regimen

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PATIENT PRESENTATION

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Chief Complaint

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"My stomach is killing me—I think I need to be tapped."

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History of Present Illness

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GE is a 48-year-old white female who presents to the emergency department (ED) with complaints of severe abdominal- pain and a feeling of fullness. She has a 4-year history of ascites, but is a bit vague about how long her abdomen has been distended; she says that the pain has gotten much worse recently. When questioned more closely about the time frame, she becomes angry and agitated. Although she was diagnosed with alcohol-induced cirrhosis 6 years ago, GE has continued to drink. GE reports subjective fever (she did not take her temperature) this morning and yesterday evening, but says she felt better after she took acetaminophen- and ibuprofen. GE says she is mostly compliant with her medications, but has been doubling up on her furosemide for the past few days since she assumed her belly pain was a result of fluid overload.

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Past Medical History

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Ethanol-induced cirrhosis × 6 years

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Esophageal varices 2 years ago, s/p banding

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HTN × 13 years

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Gravida 2, para 2

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OA of hands × 8 years

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Family History

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Father died at age 54 from alcoholic cirrhosis

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Mother alive with CAD

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Neither brother nor sister have a history of alcohol abuse; sister has type 2 DM

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Son with history of alcohol abuse, daughter healthy

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Social History

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Lives with husband and adult son

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Has worked in her family's restaurant since age 12

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Tobacco/Alcohol/Substance Use

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No tobacco, no illicit drugs, began drinking alcohol daily at age 13, currently drinks about seven to eight shots of liquor daily, but denies other forms of alcohol

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Allergies/Intolerances/Adverse Drug Events (ADEs)

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Severe hypotension when given IV morphine

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Medications (Current)

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Lactulose 15 mL PO twice daily

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Propranolol 10 mg PO q 12 h

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Furosemide 40 mg PO q am

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Spironolactone 100 mg PO q am

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Acetaminophen 1,000 mg PO PRN

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Ibuprofen 600 mg PO PRN

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Review of Systems

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(−) Nausea, vomiting, constipation

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Frequent diarrhea that she attributes to lactulose use

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Occasional ...

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