Explain how this symptom relates to her cirrhosis.

Peggy Fender is well known to the emergency department (ED) staff. She’s a 59-year-old woman whose visit today is similar to her frequent visits in the past. She arrives in the afternoon, appearing intoxicated and complaining of abdominal pain, particularly in the right upper quadrant (RUQ) of her abdominopelvic cavity. “Another Fender bender,” a nearby nurse whispers to Tim, the new physician assistant (PA) who is due to examine Mrs. Fender.
Tim proceeds with his physical examination. Mrs. Fender appears emaciated with bruising of various ages on her arms, legs, and face. She is jaundiced (yellow-skinned) and has the strong smell of alcohol on her breath. Tim palpates the inferior border of her liver, which is hard and enlarged; Mrs. Fender moans with pain. Mrs. Fender is not entirely coherent; she knows where she is and who she is, but is unable to relate anything about her present illness except a slurred, “My stomach hurts; quit poking it, you idiot!” Her coordination is poor when she attempts to sit or stand. She becomes annoyed and indignant when Tim asks her how much alcohol she’s had to drink today even though she is obviously inebriated.
Questions
1. Tim reviews the patient’s blood tests, which reveal hyperglycemia, prolonged prothrombin time, and elevated blood transaminases. Explain what is being is measured in each of these three tests. (3 pts)
2. What is the cause of Mrs. Fender’s jaundice? Explain how this symptom relates to her cirrhosis. (3 pts)
3. Mrs. Fender’s symptoms of prolonged clotting times and excessive bruising are related. Considering the normal physiological function of the liver, why do these two things happen when alcohol damages hepatocytes? (2 pts)
4. Blood enters the liver through the hepatic artery and also through the hepatic portal vein. The portal vein contains unique exchange blood vessels called sinusoids. How do the specialized characteristics of these capillaries relate to the function of the liver? (2 pts)
Based on her history, and present findings, Tim diagnoses Mrs. Fender with alcoholic cirrhosis, which is the result of chronic inflammation of the liver from heavy, consistent alcohol ingestion. If alcohol abuse continues long-term, it leads to fat accumulation in the liver, followed by fibrosis and severe liver dysfunction.
5. Along with her other symptoms, Tim notices that Mrs. Fender is suffering from ascites of the abdomen. Define the term ascites. (1 pt)
6. Cirrhosis leads to scarring which can narrow or obstruct the hepatic portal vein. Considering that the portal vein brings blood from capillaries surrounding the intestines to the sinusoids of the liver, why would scarring contribute to ascites? (4 pts)
7. The cirrhotic liver is unable to produce normal amounts of albumin. What is the main function of this plasma protein? How would low levels of plasma albumin also contribute to ascites? (4 pts)
Tim admits Mrs. Fender to the hospital and the attending physician, Dr. Davis, orders paracentesis to remove some of the extra fluid from Mrs. Fender’s abdomen. However, without continued treatment, the fluid will accumulate again.
8. There are two types of diuretic drugs that are commonly prescribed to treat this problem. Define the term diuresis. (1 pt)
9. Those two medications are ACE inhibitor drugs and aldosterone receptor antagonists. Define the term antagonist. (1 pt)
10. Explain the direct effect of ACE inhibitors and explain the direct effect of aldosterone antagonists. How would each of these drugs help reduce edema? (6 pts)
Dr. Davis prescribes spironolactone, an aldosterone receptor antagonist, and counsels the patient on lifestyle changes. He also refers her to a liver specialist before discharging her. However, Mrs. Fender’s parting remarks suggest she will not be changing her habits or visiting a more expensive medical professional any time soon.
11. One possible side effect of spironolactone is hyperkalemia. Define the term hyperkalemia and explain why blocking the effects of aldosterone in the kidney would cause hyperkalemia. (3 pts)
12. Another side effect of the treatment includes increased retention of H+ ions by the kidney that can lead to a plasma pH of