Presentation on theme: "小港內科 Case presentation 98/05/05 Presented by Intern : 吳勝騰."— Presentation transcript:
小港內科 Case presentation 98/05/05 Presented 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 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(-) 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(+)
小港內科 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. laboratory data laboratory data Under the impression of obstructive jaundice, she received ERBD insertion on 4/9 for symptom relief.
小港內科 Clinical course Jaundice. Decreased appetite. Loss of body weight. ERBD was inserted 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 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) =7.50/4.01 ALP = 1463 r-GT = 1504 WBC= 5290 WBC= 5290CA199=180.65 4/16 Discharged form our ward.
小港內科 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(-)
小港內科 Clinical course Under the impression of recurrent biliary tract infective episode, he was admitted again, and received antibiotic therapy. antibiotic therapyantibiotic therapy
小港內科 Past history Diabetic mellitus Diabetic mellitus: diagnosed 5 years ago, under oral anti-diabetic medication control (Diamicron 1# bid AC). Hypertension Hypertension with medication control since 民國 94 年 Olmetec 0.5# OM, Capoten 1# PRN Hepatitis non B, non C Hepatitis 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 arthritis Gouty arthritis: diagnosed on 民國 88 年 Hyperlipidemia Hyperlipidemia (+) Operation history: denied Allergy history: pyrine
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: 100/55 mmHg, PR: 94 bpm, RR: 22 cpm, BT: 39.1 ℃ General Appearance ： General Appearance ： Consciousness: alert (E4V5M6) Consciousness: alert (E4V5M6) Conjunctivae: not pale ; Sclera: not icteric Conjunctivae: not pale ; Sclera: not icteric Neck ： Supple, no palpable mass Neck ： Supple, no palpable mass – no jugular vein engorgement – no goiter – No lymphadenopathy
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 tract infective episode, he was admitted again, and received antibiotic therapy. antibiotic therapyantibiotic 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.
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.