小港內科

Case presentationCase presentation

98/05/05Presented by Intern :吳勝騰

小港內科

Patient profile

Name: 辜 O雄 Chart number: 00555960 Age : 74-year-old Gender: male Date of admission: 98/4/23

小港內科

Chief complaint

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

小港內科

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(+)

小港內科

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.

小港內科

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.

小港內科

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(-)

小港內科

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..

小港內科

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

小港內科

Not contributory

小港內科

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.

小港內科

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

小港內科

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

小港內科

Lab data on 4/23 (ER)

小港內科

Lab data on 4/23 (ER)

小港內科

Urine routine examination

小港內科

Stool routine examination

小港內科

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

小港內科

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.

小港內科

Hyperbilirubinemia

小港內科

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.

小港內科

Bilirubin metabolism

小港內科

小港內科

小港內科

小港內科

小港內科

小港內科

Thank you very much!

小港內科

Lab data on 4/9

小港內科

Lab data on 4/9

小港內科

Blood culture on 4/12

小港內科

小港內科

小港內科

小港內科

小港內科