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Case presentationCase presentation
98/05/05Presented by Intern :吳勝騰
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Patient profile
Name: 辜 O雄 Chart number: 00555960 Age : 74-year-old Gender: male Date of admission: 98/4/23
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Chief complaint
Fever up to 39’C with chills was noted in this morning.(4/23)
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Present illnessPresent illness This 74 y/o male is a case of This 74 y/o male is a case of
– Diabetes mellitus was diagnosed 5 years ago, under Diabetes mellitus was diagnosed 5 years ago, under oral anti-diabetic medication control. oral anti-diabetic medication control.
Last month, he was admitted for jaundice. Decreased Last month, he was admitted for jaundice. Decreased appetite and loss of body weight (2kg within 2 weeks ) appetite and loss of body weight (2kg within 2 weeks ) were noted then. The patient also complained of tea were noted then. The patient also complained of tea colored urine and clay colored stool. colored urine and clay colored stool.
Associated symptoms and signs last month included: Associated symptoms and signs last month included: – fever (-), chills (-), fever (-), chills (-), fatigue(+)fatigue(+) – mental disturbance or behavior change (-), mental disturbance or behavior change (-), general weakness (+),general weakness (+), insomnia(-) insomnia(-) – RUQ tenderness(-),hunger pain (-), RUQ tenderness(-),hunger pain (-), post prandial pain (+),post prandial pain (+), diarrhea diarrhea
(-), nausea (-), vomiting (-) ,tarry stool(-), bloody stool(-)(-), nausea (-), vomiting (-) ,tarry stool(-), bloody stool(-)– Yellowing of the skin(+), itching of the skin(+)Yellowing of the skin(+), itching of the skin(+)
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Present illness
During last admission, a series of During last admission, a series of examinations were performed, and the examinations were performed, and the laboratory data and image survey and image survey indicated the possibility of an obstructive indicated the possibility of an obstructive leision involved his biliary tract.leision involved his biliary tract.
Under the impression of obstructive Under the impression of obstructive jaundice, she received ERBD insertion on jaundice, she received ERBD insertion on 4/9 for symptom relief.4/9 for symptom relief.
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Clinical courseJaundice. Jaundice. Decreased appetite. Decreased appetite. Loss of body weight.Loss of body weight.
Arrange ERCP , ERBD was insertedERBD was inserted
Unasyn 1 vial Q6H prophylatic for ascending cholangitis
Arrange abdominal echo, Lipase=1837.9
Bil (T/D) =4.85/2.47CRP = 6.4
Arrange MRCP
Unasyn used day 5
4/09
Fever up to 39.1, B/C x 2 ,4/12
4/10
4/14
Bil (T/D) =7.50/4.01Bil (T/D) =7.50/4.01 ALP = 1463ALP = 1463rr-GT = 1504-GT = 1504
WBC= 5290WBC= 5290CA199=180.65CA199=180.65
4/16 Discharged form our ward. Discharged form our ward.
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Present illness
However, after discharged from our ward, fever up However, after discharged from our ward, fever up to 39’C attacked him again with chills on 4/23, and to 39’C attacked him again with chills on 4/23, and his family brought him to our ER for help.his family brought him to our ER for help.
Associated symptoms and signs included: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(-)
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Clinical course
Under the impression of recurrent biliary Under the impression of recurrent biliary tract infective episode, he was admitted tract infective episode, he was admitted again, and received again, and received antibiotic therapy..
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Past history
• Diabetic mellitusDiabetic mellitus: diagnosed 5 years ago, under oral anti-diabetic medication control (Diamicron 1# bid AC).
• HypertensionHypertension with medication control since 民國 94 年• Olmetec 0.5# OM, Capoten 1# PRN
• Hepatitis non B, non CHepatitis non B, non C diagnosed on 民國 92 年• HBV/HCV: HBsAg(-), Anti-HCV(-) (92.09.12)
• Alcohol/Smoking(+/+):Alcohol/Smoking(+/+): now quit for 20 yrs• Duodenal ulcer history(+)Duodenal ulcer history(+) • Gouty arthritisGouty arthritis: diagnosed on 民國 88 年• HyperlipidemiaHyperlipidemia (+)• Operation history: denied• Allergy history: pyrine
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Not contributory
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Current medicine Diamicron MR(●) 1 ﹝ * BID AC * 28 D﹞ Olmetec 0.5 ﹝ * OM * 28 D﹞ Strocain( 息痛佳音錠 ) 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.
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Physical examination on ER (4/23)• Vital sign:Vital sign:
BP: BP: 100/55 mmHg,100/55 mmHg, PR: 94 bpm, RR: 22 cpm, PR: 94 bpm, RR: 22 cpm, BT: BT: 39.139.1 ℃ ℃
• General AppearanceGeneral Appearance :: Consciousness: alert (E4V5M6)Consciousness: alert (E4V5M6)• Conjunctivae: not pale ; Sclera: not Conjunctivae: not pale ; Sclera: not
ictericicteric• NeckNeck :: Supple, no palpable massSupple, no palpable mass
– no jugular vein engorgementno jugular vein engorgement– no goiterno goiter– No lymphadenopathyNo lymphadenopathy
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Physical examination (4/23)• ChestChest :: Symmetric expansionSymmetric expansion
– BS: clear, no wheezing or cracklesBS: clear, no wheezing or crackles• HeartHeart :: Regular heart beats without Regular heart beats without
audible murmuraudible murmur• AbdomenAbdomen ::
• Inspection : mild distended Inspection : mild distended • PalpationPalpation
• Soft, Soft, Tender (+) RUQTender (+) RUQ, Guarding(-), , Guarding(-), Rebounding pain (+/-) Rebounding pain (+/-)
• Liver / Spleen: -/- Liver / Spleen: -/- • Percussion : tympanic(-), Shifting dullness(-) Percussion : tympanic(-), Shifting dullness(-)
Auscultation : Normoactive bowel sound Auscultation : Normoactive bowel sound • Extremities and skin:Extremities and skin:
– Pitting edema (-)Pitting edema (-)– Freely movable Freely movable
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Lab data on 4/23 (ER)
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Lab data on 4/23 (ER)
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Urine routine examination
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Stool routine examination
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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
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Clinical course
Under the impression of recurrent biliary Under the impression of recurrent biliary tract infective episode, he was admitted tract infective episode, he was admitted again, and received again, and received antibiotic therapy..
We arranged abdominal echo on 4/25 in We arranged abdominal echo on 4/25 in comparison of prior image on 4/10comparison of prior image on 4/10.
For his condition is stable, and meet the For his condition is stable, and meet the indication of biliary surgery, he was indication of biliary surgery, he was discharged and went to KHCG for surgical discharged and went to KHCG for surgical intervention.intervention.
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Hyperbilirubinemia
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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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