CASE STUDY ON PORTAL HYPERTENSION

INTRODUCTION
Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver. If the vessels in the liver are blocked due to liver damage, blood cannot flow properly through the liver. As a result, high pressure in the portal system develops. This increased pressure in the portal vein may lead to the development of large, swollen veins (varices) within the esophagus, stomach, rectum, or umbilical area (belly button). Varices can rupture and bleed, resulting in potentially life-threatening complications. Portal hypertension develop when there is elevation of portal pressure greater than 12 mmHg, while normal portal pressure is 5 10mmHg. Causes of Portal Hypertension Pre Hepatic:

1- Congenital portal atresia 2- Portal vein thrombosis (Neonatal sepsis) 3- Phlebitis of portal vein (abdominal infection) 4- Trauma or thrombosed porto caval shunt. Hepatic:

1- Cirrhosis (alcoholic most frequently) 2- Chronic Active hepatitis 3- Parasitic diseases (Schistosomiasis) Post Hepatic:

1- Budd Chiari syndrome (Hepatic venous thrombosis) 2- Constrictive pericarditis 3- Tricuspid valve incompetence The onset of portal hypertension may not always be associated with specific symptoms that identify what is happening in the liver. But if you have liver disease that leads to cirrhosis, the chance of developing portal hypertension is high.

The main symptoms and complications of portal hypertension include:

Gastrointestinal bleeding; black, tarry stools or blood in the stools; or vomiting of blood due to the spontaneous rupture and hemorrhage from varices. Ascites, an accumulation of fluid in the abdomen. Encephalopathy, confusion and forgetfulness caused by poor liver function and the diversion of blood flow away from your liver. Reduced levels of platelets or decreased white blood cell count.

Diagnosis & Investigation Many investigations may be used at different time in portal hypertension such as: 1- FBC, Urea & electrolytes and clotting 2- Screening tests for the causes of the cirrhosis 3- CT & ultrasound scan to assess liver morphology, diagnose Portal hypertension and assess cause. 4- Transabdominal Doppler ultrasound to assess blood flow in the portal vein and hepatic artery. -Gastroscopy in acute variceal bleeding

Demographic Data
The name of the patient is MP, a 66-year-old widowed female. She presently resides at Brgy. Danaw, Taft Eastern Samar. She is a Filipina. Her religious orientation is Roman Catholic. She was not able to finish her primary education. She originally has 9 children but 3 died because of some illness. Her husband is also deceased. She was admitted on September 1, 2013. Her admitting diagnosis is T/C Portal Hypertension.

Chief Complaint
The patient was hospitalized because of complaint of pain when taking a deep breath due to abdominal enlargement.

History of Present Illness

This is the patients 7th time in the hospital because she said she comes back every now and then for extraction of fluid in her abdomen.

Past Medical History

She has a history of Schistosomiasis. She was diagnosed having the said disease in EVRMC on the year 2012 and received treatment. She had many medications which she cannot remember all but she remembers that she was taking omeprazole and co-amoxiclav. She has no immunizations because vaccines werent present during her childhood. She had an accident when she was a child. She fell off from a tree and had a back injury but didnt consult a physician. She was an alcoholic beverage drinker before but does not smoke but when she was having her 5th pregnancy, she smoked cigarette because she was craving for it. She has no known allergies.

Family History
The patient has family history of hypertension and DM from her fathers side and Hepatitis B from her mother.

Gordons Functional Health Pattern

Health Perception Prior to admission, the patient perceives her general health as poor. She does not do anything particular to maintain her health. She does not engage in exercise, but believes that her daily activities at home and in work cover her exercise regimen. She wakes up early in the morning to have her morning prayers then she sweeps on her front yard. She has been restricted of eating salty and fatty

foods and drinking a lot of fluids. She eats egg 3 times a day only the white, excluding the yolk because the doctor instructed her to do so and because the yolk is high in fat content. At the moment, she perceives her general health as poor. She says that she likes talking with someone. She enjoyed having this interview. She has trouble sleeping at night. She follows the recommendations and advices of Doctors and Nurses. Nutrition The patient eats egg with or without rice per meal. Her typical food intake is less than 1 cup of rice every meal. She has no food intolerance. She drinks less than a glass of water per day. She has good appetite and has no difficulty in eating and swallowing. She had diet restrictions eating salty and fatty foods and drinking a lot of fluids. She is taking multivitamins as a food supplement. She has missing teeth. Elimination Pattern Prior to hospitalization, she defecate everyday with no discomfort. Her feces are yellowish to brown in color, formed and with normal consistency. She also does not need to use laxatives or suppositories. She has no problem in controlling defecation but she frequently void. Her urine is clear. She does not perspire excessively. Activity-Exercise Pattern Prior to hospitalization, the patient was independent with activities of daily living. She perceives herself as weak and with insufficient energy to perform required activities. She wakes up early in the morning to have her morning prayers. Sometimes she experience headache and dizziness. Currently, she stays on bed, preferring to sit all the time she wants. Her blood pressure during examination was 110/80 mmHg. Her respiratory rate was 20, with regular rhythm. She had no wheezes, crackles or rales. No cough or sputum was noted. Sleep-Rest Pattern Prior to admission, the patient gets an average of 4-5 hours of sleep at night. She has problems sleeping. She doesnt take any sleeping medications. During hospitalization, she still cannot sleep at night because of shortness of breath when lying supine. She says she could not find a suitable position for sleep. She tries to take naps during the day to regain her energy. Cognitive-Perceptual Pattern Prior to admission the patient has no hearing. She doesnt wear hearing aids. She learns through observation and demonstration. But most of the time, she tries to learn things on her own. She has good memory and she sometimes has difficulty making important decisions but she does not like seeking advice from others.

Upon examination, the patient is oriented to time, place and person. She can hear a whisper and can distinguish sounds well. She has no problem distinguishing colors, sizes and shapes. She has good attention span, she can have long conversations.

Self-Perception and Self-Concept Pattern The patient describes herself as simple. She can easily get along well with others. Most of the time, she feels good about herself. She currently feels sad by her illness. The patient is able to maintain eye contact. She has good attention span. Her voice can be loud and full when she is talking. Role-Relationship Pattern The patient lives in her house often alone but sometimes her children alternates to accompany her. She has 6 children, originally 9 but 3 died. One died because of poisoning, the other one died because of typhoid fever and the other one they were not sure of the cause. All of her living children now have their own families. She has been widowed for several years now. Her husband died because of pneumonia. She has good relationship with her 6 children. Sexual-Reproductive Pattern The patient is not anymore active in sex since her husband died. She considers her age as not sexually active. She had her menopause at the age of 43. Coping Stress Tolerance Pattern The patient generally feels calm most of the time. There had been crisis in the last few years. There had been no change for her prior to the hospitalization because of her illness. Her children are very much helpful when problems arise. Value-Belief Pattern She generally does not get what she wants from life. She has no long term plans for the future. Her immediate goal is to get through with her disease. She is a Roman Catholic but does not go to religious activities regularly. She believes that there is a God and she is thankful and contented to her life and prays to give her long life.

PHYSICAL ASSESSMENT
VITAL SIGNS: T-36.5 C PR-92 bpm RR-20 cpm BP-110/80 mmHg General Survey:

Upon examination, patient appears alert, coherent, oriented (time, place, & person) Skin Head Configuration: normocephalic Facial movements: symmetrical Hair is black with minimal white hair strands Eyes Ears Nose Septum: midline External canal is clean No discharge noted Gross hearing: symmetrical Pinna recoils after it is folded Lids: symmetrical Visual acuity: grossly normal Peripheral vision: intact Hair: even distribution Scalp: No dandruff observed Color: Brown Texture: smooth Turgor: fair Moisture: dry skin is warm to touch

and calm, and looks according to age.

Mucosa; pinkish Patency: both patent Gross smell: symmetrical

No discharge seen

Mouth Neck Trachea: midline Thyroid: non palpable Normal range of motion Lips: pallor, dryness Tongue: midline Teeth: missing

Chest and Lungs HEART: Regular rhythm Breathing pattern: regular Lung expansion: symmetrical Breath sounds: clear

Abdomen Configuration: enlarged Bowel sounds: active

Back and Extremities Peripheral pulses: diminished Nail and beds: pallor

 Muscle tone and strength: equal strength Presence of edema on lower extremities