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Case presentation. 98/05/05 Presented by Intern : 吳勝騰. Patient profile. Name: 辜 O 雄 Chart number: 00555960 Age : 74-year-old Gender: male Date of admission: 98/4/23. Chief complaint. Fever up to 39’C with chills was noted in this morning.(4/23). Present illness.
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Case presentation 98/05/05 Presented by Intern :吳勝騰
Patient profile • Name:辜O雄 • Chart number: 00555960 • Age : 74-year-old • Gender: male • Date of admission: 98/4/23
Chief complaint • Fever up to 39’C with chills was noted in this morning.(4/23)
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(+)
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.
Clinical course Jaundice. Decreased appetite. Loss of body weight. Bil (T/D) =7.50/4.01 ALP = 1463 r-GT = 1504 WBC= 5290 CA199=180.65 4/09 Arrange ERCP , ERBD was inserted Unasyn 1 vial Q6H prophylatic for ascending cholangitis Arrange abdominal echo, Lipase=1837.9 Bil (T/D) =4.85/2.47 CRP = 6.4 4/10 4/12 Fever up to 39.1, B/C x 2 , Arrange MRCP Unasyn used day 5 4/14 4/16 Discharged form our ward.
Present illness • However, after discharged from our ward, fever up to 39’C 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(-)
Clinical course • Under the impression of recurrent biliary tract infective episode, he was admitted again, and received antibiotic therapy.
Past history • Diabetic mellitus: diagnosed 5 years ago, under oral anti-diabetic medication control (Diamicron 1# bid AC). • Hypertensionwith medication control since 民國 94 年 • Olmetec 0.5# OM, Capoten 1# PRN • Hepatitis non B, non C diagnosed on 民國92年 • HBV/HCV: HBsAg(-), Anti-HCV(-) (92.09.12) • Alcohol/Smoking(+/+): now quit for 20 yrs • Duodenal ulcer history(+) • Gouty arthritis: diagnosed on 民國88年 • Hyperlipidemia (+) • Operation history: denied • Allergy history: pyrine
Family history Not contributory
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.
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 • Neck：Supple, no palpable mass • no jugular vein engorgement • no goiter • No lymphadenopathy
Physical examination (4/23) • Chest：Symmetric expansion • BS: clear, no wheezing or crackles • Heart：Regular 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
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
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.
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.
