1. 小港內科 Case presentation 98/05/05 Presented by Intern : 吳勝騰

2. 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

3. 小港內科 Chief complaint  Fever up to 39’C with chills was noted in this morning.(4/23)

4. 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(+)

5. 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.

6. 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.

7. 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(-)

8. 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

9. 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

10. 小港內科 Not contributory

11. 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.

12. 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

13. 小港內科 Physical examination (4/23) Chest ： Symmetric expansion Chest ： Symmetric expansion – BS: clear, no wheezing or crackles Heart ： Regular heart beats without audible murmur Heart ： Regular heart beats without audible murmur Abdomen ： Abdomen ： Inspection : mild distended Inspection : mild distended Palpation Palpation Soft, Tender (+) RUQ, Guarding(-), Rebounding pain (+/-) Soft, Tender (+) RUQ, Guarding(-), Rebounding pain (+/-) Liver / Spleen: -/- Liver / Spleen: -/- Percussion : tympanic(-), Shifting dullness(-) Auscultation : Normoactive bowel sound Percussion : tympanic(-), Shifting dullness(-) Auscultation : Normoactive bowel sound Extremities and skin: Extremities and skin: – Pitting edema (-) – Freely movable

14. 小港內科 Lab data on 4/23 (ER)

15. 小港內科 Lab data on 4/23 (ER)

16. 小港內科 Urine routine examination

17. 小港內科 Stool routine examination

18. 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

19. 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.

20. 小港內科 Hyperbilirubinemia

21. 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.

22. 小港內科 Bilirubin metabolism

23. 小港內科

28.  Thank you very much!

29. 小港內科 Lab data on 4/9

30. 小港內科 Lab data on 4/9

31. 小港內科 Blood culture on 4/12

32. 小港內科