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Kingdom of Saudi Kingdom of SaudiArabiaArabia
King Fahd HospitalKing Fahd Hospital
JeddahJeddah
Internal MedicalInternal Medical DepartmentDepartment
Mortality MeetingMortality Meeting
:By:By
Gastro. teamGastro. team
Dr. Wail Ali BajhmoomDr. Wail Ali Bajhmoom
A.D 23.4.1426 A.H 31.5.2005A.D 23.4.1426 A.H 31.5.2005
History.History.Physical examination. Physical examination. DDx.DDx.Investigations. Investigations.
Diagnosis .Diagnosis .Treatment.Treatment.Hospital Course.Hospital Course .Discussion.Discussion.
:History:History
25-year-old , Lady, 25-year-old , Lady,
.Somalia.Somalia E.RE.R 16.2.1426 A.H (9:10 a.m). 16.2.1426 A.H (9:10 a.m).
C/O : yellow discoloration of her C/O : yellow discoloration of her
eyes 1/12 eyes 1/12
She was not known to have any She was not known to have any Medical ilness .Medical ilness . 1 mth prior to admission she had1 mth prior to admission she had jaundice associated fever & rigor . jaundice associated fever & rigor . No clear localizing symptomsNo clear localizing symptoms
for the fever.for the fever.
Just 2 wk prior to the episode of Just 2 wk prior to the episode of
jaundice she went to a polyclinic jaundice she went to a polyclinic
& was given drugs ? for neck& was given drugs ? for neck
problem ??problem ??
“ “ not a swelling “ not a swelling “
She also had a mild epigastric She also had a mild epigastric
abdominal pain for which sheabdominal pain for which she
had a cautery.had a cautery. Loss of appetite but no loss Wt. Loss of appetite but no loss Wt. She had been in KSA for 4 y She had been in KSA for 4 y
& never traveled anywhere& never traveled anywhere . .
Se denied any drugs use or abuse.Se denied any drugs use or abuse.
including herbals .including herbals . No Hx contact w/ No Hx contact w/
- jaundice pt.- jaundice pt.
-T.B pt .-T.B pt .
-animals. -animals. No family Hx of T.BNo family Hx of T.B
She had benign past HxShe had benign past Hx
-no blood transfusion.-no blood transfusion.
-no hospital admission.-no hospital admission.
-Hx malaria treated in-Hx malaria treated in
Somalia >5ySomalia >5y
-not D.M , HTN -not D.M , HTN
-not asthmatic -not asthmatic
No Hx allergy.No Hx allergy. Non smoker or alcohol drinker .Non smoker or alcohol drinker . She was divorced , came to KSA She was divorced , came to KSA
for Omrah 4 years ago .for Omrah 4 years ago . Socioeconomic life. Socioeconomic life.
:Summary:Summary
25 years Somali lady w/ benign 25 years Somali lady w/ benign
past Hx presented w/ past Hx presented w/
11stst episode of jaundice for 1 mth episode of jaundice for 1 mth
ass. wl fever & rigor w/ no Hx of ass. wl fever & rigor w/ no Hx of
T.B ;travel ;blood Tx ;herbal or T.B ;travel ;blood Tx ;herbal or
drugs use …drugs use …
General appearance: General appearance:
-well looking.-well looking.
-deeply jaundiced.-deeply jaundiced.
-not pale.-not pale.
-no L.N enlargement.-no L.N enlargement.
-no L.L edema. -no L.L edema.
Physical ExaminationPhysical Examination::
-No stigmata of C.L.D .-No stigmata of C.L.D .
- conscious & oriented.- conscious & oriented.
Vitals: Vitals:
B.P 103/55 R.R 18B.P 103/55 R.R 18
Temp. 36.6 P.R 65 reg.Temp. 36.6 P.R 65 reg.
Abdomen : Abdomen :
-no distention. -no distention.
-soft &lax.-soft &lax.
- no tenderness. - no tenderness.
-hepatomegaly of 4cm b.c.m. -hepatomegaly of 4cm b.c.m.
-tip of spleen was palpable. -tip of spleen was palpable.
Chest : clear Chest : clear
C.V.S : normalC.V.S : normal
C.N.S : intact C.N.S : intact
Acute hepatitis “ viral “ Acute hepatitis “ viral “ Exacerbation of ch. hepatitis.Exacerbation of ch. hepatitis. Drug or herbal meds. Induced .Drug or herbal meds. Induced . Autoimmune .Autoimmune . Or Budd-Chiari.Or Budd-Chiari.
:DDx:DDx
Investigations :Investigations : C.B.C : Hb 15.2C.B.C : Hb 15.2
WBC 11.8WBC 11.8
Plt 172Plt 172 BUN 8 ; Cr. 0.6BUN 8 ; Cr. 0.6
Na 139 ; K 3.2Na 139 ; K 3.2
glucose 200 ; Alb 2.4glucose 200 ; Alb 2.4
AST 413 ; ALT 1256AST 413 ; ALT 1256
LDH 620 ; AlP 148LDH 620 ; AlP 148
T.bili 32.1 ; D.bili 22.9T.bili 32.1 ; D.bili 22.9
PT 39.4/12 ; PTT 82.5/35.6PT 39.4/12 ; PTT 82.5/35.6
E.C.G : Sinus bradycardia.E.C.G : Sinus bradycardia.
Urinalysis: Bile pigment ,few cast ,Urinalysis: Bile pigment ,few cast ,
WBC 3-5 ,RBC 1-2 HPFWBC 3-5 ,RBC 1-2 HPF
Upper GI endoscopy : Normal Upper GI endoscopy : Normal
Abdominal US: Abdominal US:
- Thick wall G.B- Thick wall G.B
- C.B.D 6 mm- C.B.D 6 mm
- portal vein 11.3 mm- portal vein 11.3 mm
- Homogeneous liver wl- Homogeneous liver wl
hepatomegaly 15.4 cmhepatomegaly 15.4 cm
- no focal lesion - no focal lesion
- normal pancreas - normal pancreas
- mild spleenomegaly 13.8 cm- mild spleenomegaly 13.8 cm C.T scan of Abdomen :C.T scan of Abdomen :
- hepatomegaly, intrahepatic biliary - hepatomegaly, intrahepatic biliary duct dilatation, course texture of the liver duct dilatation, course texture of the liver finding suggest of CLD.finding suggest of CLD.
- otherwise normal . - otherwise normal .
Treatment & Hospital Treatment & Hospital:Course:Course
Patient spent about 12 daysPatient spent about 12 days
at hospital .at hospital .
IVF D5NS 2 L / day .IVF D5NS 2 L / day . Serology tests were requested.Serology tests were requested. Metoclpramide , Ranitidine . Metoclpramide , Ranitidine .
Pat. Was clinically showing some Pat. Was clinically showing some improvement.improvement.
Serology were neg. : Serology were neg. :
- HIV- HIV
- HBsAg- HBsAg
- HCV- HCV Hepatitis markers were requested. Hepatitis markers were requested.
HA IgM , HBcIgM , HCV-RNA were all HA IgM , HBcIgM , HCV-RNA were all requested. “20.2.1426 AH”.requested. “20.2.1426 AH”.
ANA , AMA & immunoglobulin level ANA , AMA & immunoglobulin level as well at 23.2.1426 AH.as well at 23.2.1426 AH.
Meanwhile patient was managed Meanwhile patient was managed as sever acute hepatitis as sever acute hepatitis “ “ ? Etiology “ ? Etiology “
Day 9 : - awake & a wearDay 9 : - awake & a wear Vitals - BP 123/82 RR 24Vitals - BP 123/82 RR 24
- PR 95 Temp. 37- PR 95 Temp. 37 c/o eigastric pain & vomiting c/o eigastric pain & vomiting CBC -WBC 19CBC -WBC 19
-Hb 14.2-Hb 14.2
-Plt 300-Plt 300
AST 1126 ALT 1336AST 1126 ALT 1336 PT 40.6/12.5 PTT 106/35PT 40.6/12.5 PTT 106/35 INR 3.3 ALP 1000INR 3.3 ALP 1000
F/U of all requested Investigations F/U of all requested Investigations Still NO RESULT ?? “ ~7 days” Still NO RESULT ?? “ ~7 days”
Day 10 - Normal vitals Day 10 - Normal vitals
- drowsy & confused - drowsy & confused
- H. Encephalopathy II.- H. Encephalopathy II. Ammonia 153Ammonia 153 ICU consultation “ NO BED “ICU consultation “ NO BED “ VARBALLY VARBALLY : high IgG >34.73: high IgG >34.73 Other result ((NOT YET)) .Other result ((NOT YET)) .
Pat. Was started on :Pat. Was started on :
-Prednisolone 30 mg orally-Prednisolone 30 mg orally
-Azathioprne 50 mg orally -Azathioprne 50 mg orally
- lactulose - lactulose
- zero protein , 2gm salt diet.- zero protein , 2gm salt diet.
- IVF D5NS Q6h.- IVF D5NS Q6h.
DAY 11 : -DAY 11 : - Still encephalopathy. Still encephalopathy. Clinically deteriorating .Clinically deteriorating . Responding to painful stimuli. Responding to painful stimuli. Late night – low BP.Late night – low BP. 22ndnd ICU consultation ICU consultation
-“ same answer ??”-“ same answer ??”
HBcIgM negative. 28.2.1426 AHHBcIgM negative. 28.2.1426 AH HAIgM negative. “ 10 days “ HAIgM negative. “ 10 days “ Other results “ NOT YET ??? ”Other results “ NOT YET ??? ” CBC WBC 15CBC WBC 15
Hb 14.5Hb 14.5
Plt 240 Plt 240
Na 134 , K 2.8 Na 134 , K 2.8 AST 800 , ALT 807AST 800 , ALT 807 Alb 2.4 , T.bili 45.2Alb 2.4 , T.bili 45.2 Cr 1.1 , BUN 23Cr 1.1 , BUN 23 Glucose 226 Glucose 226
Day 12 “ Day 12 “ last daylast day “ : - “ : -
- early morning 7:00 a.m she - early morning 7:00 a.m she
became irrecordable BP despite became irrecordable BP despite
all Rx “ fluid, dopamine ,…”all Rx “ fluid, dopamine ,…”
At 11:55 a.m 29.2.1426 AH She At 11:55 a.m 29.2.1426 AH She
had cardiorespiratory arrest .had cardiorespiratory arrest .
Code blue @ 12:00 p.mCode blue @ 12:00 p.m
Active CPR was initiated .Active CPR was initiated .
She was announced dead @ 12:15 p.mShe was announced dead @ 12:15 p.m Investigation results :Investigation results :
“ “ after patient expired ?? “ after patient expired ?? “ ANA –positive ANA –positive AMA –no reagent AMA –no reagent HCV-RNA “PCR” negative.HCV-RNA “PCR” negative.
THANK YOUTHANK YOU
Dr.Wail Bajhmoom Dr.Wail Bajhmoom