Case discussion

Patient profile
----
HN:17582275
54 YOF
Admission date: 2017/03/09
Information source: Patient and relatives
Occupation: House wife
Chief Complaint

Tea-colored urine for 3

weeks
Present illness (2017/03/09)
Before ER
Onset
Characteristic: intermittent or progressive JD
Stool
Urine
Pruritus
Ass Pre Hep post
Constitutional symptom

Conjugated hyperbilirubinemia
Trasferred to our ER and waited for admission to our ward.
At ER, her initial vital sign was stable (TPR:35.2 , 90/min, 18/min, BP:122/79 mmHg)
- PE : showed obvious icteric sclera
mild right upper abdominal tenderness, muscle guarding or peritoneal sign.

- Laboratory data: Plain film KUB: no abnormal finding

CXR: No infiltration
EKG: normal sinus rhythm
Abdominal sonography: dilated CBD and mild dilated bilateral IHD
Under the impression of conjugated hyperbilirubinemia, she is admitted to our ward for further survey and treatmen
t.
Past history
1.Acute cholangitis
s/p endoscopic retrograde biliary drainage insertion on 2016/5/12
s/p endoscopic papillotomy with sludge retrieval on 2016/05/18
2.Gall bladder stones s/p laparoscopic cholecystectomy on 2016/06/07

TOCC:
Travel history(-),Occupation(-),Contact history(-),Cluster(-)
(2017/03/09)
Personal history
- U/D: Advanced liver fibrosis Metavir F4
- No history of cancer
- No history of hematologic disease
- No history of thyroid disease
- Sexual activity: multiple partner?
- Reject FDA
- Reject smoking
- Reject alcohol drinking
- Reject drug abuse (IVDU)
Current medications:
Family history
Cancer?
Hematologic disease? Thalassemia HbH HS
Autoimmune disease?
Viral hepatitis?
Review of systems
General : fatigue(-) , anorexia(+) , fever(+, 2 weeks ago) , chillness(-) , body
weight loss(-)
Head : headache(-)
Nose : nose discharge(-) , obstruction(-) , sinusitis(-)
Mouth : sore mouth(-) , toothache(-)
Throat : tonsilitis(-) , dysphagia(-), sore throat(-)
Neck : mass(-), neck stiffness(-) , pain(-)
Respiratory System : cough(-) , sputum(-) , hemoptysis(-) , wheezing(-) ,
dyspnea(-)
C-V System : chest tightness or pain(-) , palpitation(-) , varicose vein(-) , orthop
nea(-) , pedal edema(-) ,
G-I System : nausea(-) , vomiting(+, after meal) , belching(-) , heart burn(-) , di
arrhea(-) , constipation(-) , hemorrhoid(-) ,
G-U System : dysuria(-) , polyuria(-) , nocturia(-) , hematuria(-) , incontinence(-)
, abnormal urine color(+)
Extremities : swelling(-) , deformity(+, right third finger) , stiffness(-)
Physical examination
Vital Signs:
T: 36.5C(03/09 15:50); P: 78/min(03/09 15:50)
R: 19/min(03/09 15:50); BP: 107/75mmHg(03/09 15:50)
General appearance: good orientation, awake
HEENT: icteric sclera, not pale, parotid gland enlargement?
Neck: supple, no JVE, no LAP, no palpable thyroid mass, no palpable cervical lymph node
Chest: symmetric expansion, bilateral clear breath sounds, no adventitious sound
Heart: regular heart beat, normal S1,S2, murmur(-),S3(-),S4(-)
Abdomen: flat, no superficial vein dilatation, no caput medusae , normoactive bowel sound , soft, t
enderness (+RUQ), rebound tenderness (-), muscle guarding (-), flank pain(-), no hepatosplenomeg
aly, fluid thrill? Shifting dullness?, murphys sign(-)
Extremities: warm, pitting edema (-), terry nail, palmar erythema?
Skin: no edema, petechiae or ecchymosis, no spider nervi?

Sign of chronic liver disease and portal hypertension

Lab data:
CBC, UA
Sonography of upper abdomen shows:
Coarse echopattern of the liver parenchyma. Bilateral
hepatic cysts up to 2cm in size are noted. The gall bladde
r is absent. The IHDs and portal vein are not dilated. Both
pancreas and spleen are unremarkable. No special abnor
mality over abdominal aorta and inferior vena cava. Nor
mal size and echogenecity of bil. kidneys. Diameter of CB
D is about 1cm in width.
CXR
Problem list
Child pugh score
Differential diagnosis
Tentative diagnosis
Further lab investigation
 Problem:
Cholecholithiasis, SMOs

abdominal MRI with contrast for biliary duct evaluation

keep current empirical antibiotics with Flumarin
inform our plan