- What is PBL and PBeL ?
- Traditional medical education --- Lectures in the classroom by a teacher.
- Integration of basic and clinical medical knowledge.
- Problem-based or Practice-based Learning (e: electronic).
- Best method of learning medical knowledge technique and in bedside teaching.
- Problem of the patient's physical condition (character, mechanism, etiology, diagnosis, treatment)
- Small group teaching and an instructor.
- Search and study of resources for solving problems from journals, references, and Internet contents by students themselves.
- What is a liver ?
- Liver is the largest and the most complex organ in the body, located in the right upper part of the abdomen, and it is usually not palpable from the abdominal wall.
- Under the liver, there is a gall bladder, the liver and gallbladder are connected by ducts known as the biliary tract.
- Refer to:
- What is a liver disease?
- Most of the liver disease is a condition in which the normal structure and physiological function of the liver is damaged.
- The other two conditions are congenital and new growth of the liver.
- And the most of the new growths of the liver are derived from the damages of the liver.
- Refer to:
- What is the main symptoms and signs of the liver disease ?
- Jaundice (sclera, skin).
- Pruritus.
- Hepatomegaly.
- Flu-like symptoms, headache, muscle pain, fever.
- Malaise, fatigue, weakness.
- Nausea, vomiting.
- Fever.
- RUQ Pain.
- Deep discoloration of urine.
- Clay color stool.
- Portal hypertension (splenomegaly, esophageal varices, ascites, edema of the lower legs)
- Spider angiomata (nevi), palmer erythema, engorgement of superficial veins of the abdomen and thorax, gynecomastia.
- Bleeding tendency (Purpura: ecchymosis, petechiae, suggilation)
- Hemopoiesis: anemia, leukopenia, throbocytopenia
- Encephalopathy (drowsiness, tremor, asterixis, dysarthrias, delirium, coma)
- No any symptoms and signs.
- Refer to:
- Laboratory data of liver diseases
- Transaminase (ALT -- GPT, AST -- GOT).
- Bilirubin.
- Biliary enzymes (Al-P, GGTP).
- Albumin.
- Globulin.
- Ammonia.
- Amylase.
- Ceruloplasmin, serum copper, urine copper
- Serum ferritin, transferrin saturation, iron
- Alpha-1-antitrypsin
- Hepatitis marker (anti-HAV, HBsAg, anti-HBs, anti-HBc, HBeAg, anti-HBe, anti-HCV, anti-HEV).
- Tumor marker (AFP, AFP-L3, CEA, Isoenzymes, PIVKA-II, CA19-9 )
- PIIIP, IV Collagen, TGF-£]
- Refer to:
- Image diagnosis of liver diseases
- Simple X-ray film
- Ultrasonography
- Endoscopic ultrasonography
- CT
- Angiography
- MRI
- How to proceed the diagnosis of liver diseases
- SOAP (Subjective, Objective, Analysis, Planning)
- PBL (Problem based learning), PBeL (Problem based e-learning)
- Neighboring organs of the liver
- Lung, diaphragm, gall bladder, bile duct, duodenum, stomach, pancreas and transverse colon.
- Pain and tumor.
Practical application
- SOAP = PBL
- Basic data:
- Name, age, sex
- Residence history:
- past, present, and duration.
- Travelling.
- What is the endemic diseases of the indwelling or travel place. (i.e: HAV, HEV, Dengue fever, Schistosomiasis)
- Past history: (alcoholics, drug intake, IVDA, infection)
Case 1:Da-Ming Yang. 72 yrs old, male
- S: (subjective)Chief complaint:
- Fever, epigastralgia, vomiting, jaundice for 3 days.
- Residence and travelling
- Living in Taipei city for 50 yrs.
- Came from mainland China at the age of 22.
- Analysis
- Epigastralgia:position neighboring organ:
- Nausea, vomiting:G-I tract dis.,acute & chronic hepatitis, biliary tract dis., pancreatitis, and other diseases.
- Jaundice: Bilirubin
- Liver: infection, cirrhosis, neoplasm.
- biliary tract: stone. infection, neoplasm.
- Hemolysis.
- Fever:
- Infections: Bacteria, Rickettsia, Chlamydiae, Mycoplasma, Virus, Parasite,
- Refer to:
- Malignant neoplastic disease:
- Hematologic disease:
- CNS diseases:
- Factitious :
- Diseases of other systems:
- Residence history in China: Kala azar (Leishmaniasis), Schistosomiasis, Clonorchiasis (intake of raw fresh water fish)
- Past history
- Alcohol intake for more than 30 yrs. (chronic alcoholics).
- History of jaundice 5 yrs. ago, but no further study at that time.
- Occasional eigastralgia.
- No history of any drug intake (Drug-induced liver disease)
- Analysis
- Lliver disease: (alcoholic, infection)
- Biliary tract disease:
- Pancreatitis:
- (G-I tract)
- Physical examination
- Skin: slightly icteric.
- Sclera: mod. icteric.
- Spider angiomata on upper chest.
- Hepatomegaly (3 cm below right costal margin)
- Margin: dull
- Consistency: firm.
- Surface: irregular, no mass.
- Portal hypertension:
- Ascites:
- Abdomen: slight frog belly.
- Superficial venous engorgement on abdominal wall.
- Shifting dullness (+).
- Splenomegaly: (3 cm below left costal margin)
- Lower leg pitting edema (+).
- Analysis
- Chronic liver disease (chronic hepatitis, cirrhosis, HCC) -- (alcoholic, viral)
- Chronic biliary tract diseases (stone, PBC)
- Pancreatitis (alcoholic)
- (G-I tract disease)
- Laboratory data:
- RBC: 334 x 104
- WBC: 8,200
- Platelet: 70,000
- Bilirubin: Direct: 3.2, Total: 4.6
- AlP: 112 U; GGTP: 340 U.
- ALT: 62 IU; AST: 176 IU.
- Amylase: 310
- HBsAg (+), anti-HBc (+), anti-HBs (-), anti-HCV (-), HBeAg (+) (HBV)
- AFP: 5.3 ng.(Hepatitis virus and hepatocellular carcinoma.)
- Image & endoscopic study:
- Final Diagnosis:
