Case presentation

1
Case presentation

• 98/05/05
• Presented by Intern ???

2
Patient profile

• Name?O?
• Chart number 00555960
• Age 74-year-old
• Gender male
• Date of admission 98/4/23

3
Chief complaint

• Fever up to 39C with chills was noted in this
  morning.(4/23)

4
Present illness

• This 74 y/o male is a case of
• Diabetes mellitus was diagnosed 5 years ago,
  under oral anti-diabetic medication control.
• Last month, he was admitted for jaundice.
  Decreased appetite and loss of body weight (2kg
  within 2 weeks ) were noted then. The patient
  also complained of tea colored urine and clay
  colored stool.
• Associated symptoms and signs last month
  included
• fever (-), chills (-), fatigue()
• mental disturbance or behavior change (-),
• general weakness (), insomnia(-)
• RUQ tenderness(-),hunger pain (-), post prandial
  pain (), diarrhea (-), nausea (-), vomiting (-)
  ,tarry stool(-), bloody stool(-)
• Yellowing of the skin(), itching of the skin()

5
Present illness

• During last admission, a series of examinations
  were performed, and the laboratory data and image
  survey indicated the possibility of an
  obstructive leision involved his biliary tract.
• Under the impression of obstructive jaundice, she
  received ERBD insertion on 4/9 for symptom
  relief.

6
Clinical course
Jaundice. Decreased appetite. Loss of body
weight.
Bil (T/D) 7.50/4.01 ALP 1463 r-GT 1504
WBC 5290 CA199180.65
4/09
Arrange ERCP , ERBD was inserted Unasyn 1 vial
Q6H prophylatic for ascending cholangitis
Arrange abdominal echo, Lipase1837.9 Bil (T/D)
4.85/2.47 CRP 6.4
4/10
Fever up to 39.1, B/C x 2 ,
4/12
Arrange MRCP Unasyn used day 5
4/14
4/16
Discharged form our ward.
7
Present illness

• However, after discharged from our ward, fever up
  to 39C attacked him again with chills on 4/23,
  and his family brought him to our ER for help.
• Associated symptoms and signs included
• fever chills(), weakness (), fatigue(),
  rhinorrhea(-), sore throat(-), nasal
  obstruction(-), intermittent cough with mild
  sputum(-),
• abdominal pain(-), nausea(-), vomiting(-) ,bowel
  habit change(-), pain, tarry stool(-), bloody
  stool(-), clay color stool(-)
• urinary frequecny(-), burnning sensation(-),
  dysurea(-)
• Yellowing of the skin(-), itching of the skin(-)

8
Clinical course

• Under the impression of recurrent biliary tract
  infective episode, he was admitted again, and
  received antibiotic therapy.

9
Past history

• Diabetic mellitus diagnosed 5 years ago, under
  oral anti-diabetic medication control (Diamicron
  1 bid AC).
• Hypertension with medication control since ?? 94
  ?
• Olmetec 0.5 OM, Capoten 1 PRN
• Hepatitis non B, non C diagnosed on ??92?
• HBV/HCV HBsAg(-), Anti-HCV(-) (92.09.12)
• Alcohol/Smoking(/) now quit for 20 yrs
• Duodenal ulcer history()
• Gouty arthritis diagnosed on ??88?
• Hyperlipidemia ()
• Operation history denied
• Allergy history pyrine

10
Family history
Not contributory
11
Current medicine

• Diamicron MR(?) ?1 BID AC 28 D?
• Olmetec ?0.5 OM 28 D?
• Strocain(?????) ?1 TID PC 14 D?
• Nidolium ?1 TID PC 14 D?
• Suwell ?1 TID PC 14 D?
• Denied of Chinese herb use , medication for gouty
  atritis, and other drug exposure.

12
Physical examination on ER (4/23)

• Vital sign
• BP 100/55 mmHg, PR 94 bpm, RR 22 cpm, BT 39.1
  ?
• General Appearance
• Consciousness alert (E4V5M6)
• Conjunctivae not pale Sclera not icteric
• NeckSupple, no palpable mass
• no jugular vein engorgement
• no goiter
• No lymphadenopathy

13
Physical examination (4/23)

• ChestSymmetric expansion
• BS clear, no wheezing or crackles
• HeartRegular heart beats without audible murmur
• Abdomen
• Inspection mild distended
• Palpation
• Soft, Tender () RUQ, Guarding(-), Rebounding
  pain (/-)
• Liver / Spleen -/-
• Percussion tympanic(-), Shifting dullness(-)
  Auscultation Normoactive bowel sound
• Extremities and skin
• Pitting edema (-)
• Freely movable

14
Lab data on 4/23 (ER)
15
Lab data on 4/23 (ER)
16
Urine routine examination
17
Stool routine examination
18
Tentative diagnosis on 4/23

• Suspect recurrent biliary tract infection
• Obstructive Jaundice post endoscopic retrograde
  biliary drainage (98.4.9) ,
• Suspect early stage of ampulla vater tumor.
• Diabestes mellitus, type 2
• Hypertension
• Hepatitis

19
Clinical course

• Under the impression of recurrent biliary tract
  infective episode, he was admitted again, and
  received antibiotic therapy.
• We arranged abdominal echo on 4/25 in comparison
  of prior image on 4/10.
• For his condition is stable, and meet the
  indication of biliary surgery, he was discharged
  and went to KHCG for surgical intervention.

20
Hyperbilirubinemia
21
Hyperbilirubinemia

• The presence of scleral icterus indicates a serum
  bilirubin of at least 51 mol/L (3.0 mg/dL).
• The bilirubin present in serum represents a
  balance between input from production of
  bilirubin and hepatic/biliary removal of the
  pigment. Hyperbilirubinemia may result from
• (1) overproduction of bilirubin
• (2) impaired uptake, conjugation, or excretion of
  bilirubin
• (3) regurgitation of unconjugated or conjugated
  bilirubin from damaged hepatocytes or bile ducts.

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Bilirubin metabolism
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• Thank you very much!

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Lab data on 4/9
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Lab data on 4/9
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Blood culture on 4/12
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