University of Puerto Rico

Medical Sciences Campus

School of Medicine
Department of Medicine

CASE PRESENTATION
Student's Name:

Raymond Rivera Vergara

Patient's Initials:

DMU

Student Number:

801-07-7280

Date of Encounter:

JAN 3, 2015

_________________________________________________________________________________
Chief Complaint:

" Me senti bien debil, con escalofrios, diarreas y vomitos y mi hijo me llevo al hospital"

History of Present Illness:

DMU is a 85 year old male patient with history of diabetes mellitus type II, chronic pancreatitis, duodenal ulcers
and hypercholesterolemia, that was in his usual state of health and full independence of daily living until the
approximately the beginning of December patient began with nausea, dry cough, watery diarrhea, chills and
change on eyes colors to yellow. Patient said that he had a thermometer and his highest temperature was
98.7F, therefore denning fever. He also denied abdominal pain. He eat a vegetarian diet, with low fat content
motivated by animal well being and personal preference respectively. He refers that during this month, he
developed 4 episodes sporadically with above symptoms and lost around 10 pounds. Patient refers that on
December 30, 2017 he felt worse than ever and his grandson decided to call the ambulance to take patient to
hospital.
He did not come to VA emergency room because ambulance was not allowed to come to VA emergency room
so he was taken to Hospital Buen Samaritano. There he was hospitalized with the diagnosis of obstructive
jaundice, suspected cholangitis, pancreatitis and bronchial pneumonia. Studies done on Buen Samaritano were
abdominal/pelvic CT and abdominal sonogram. Abdominal/pelvic CT shows cystic duct stone, biliary tract and
common bile duct multiple stones resulting in obstructive jaundice with intrahepatic biliary ductal dilatation.
Abdominal sonogram remarkable for compatible with intrahepatic and extrahepatic biliary ductal dilatation likely
from biliary tract obstruction secondary to choledocholitiasis; the common bile duct measures 13mm in diameter
and the pancreas demonstrates slight ill defined echo texture that may represent early pancreatitis. Patient
there was treated with Zosyn and Levaquin. He refers not being evaluated by GI service.
Patient transfered VA hospital for further care and for evaluation by GI service on December 30, 2017.
Magnetic Resonance Cholangiopancreatography (MRCP) done on December 31, 2016 shows extensive
choledocholithiasis and enhancement of the common bile duct walls.
Endoscopic retrograde cholangiopancreatography (ERCP), which will be done tomorrow (January 4, 2015)
Patient now refers feeling marked improvement. He is currently in liquid diet, with some flatulences discomfort.

Case Presentation - Page 2

Allergies:

Aspirin and Penicillin

Childhood illnesses:

None

Adult medical history:

Diabetes mellitus type II, chronic pancreatitis depression, duodenal ulcers, low back pain,
diabetic neuropathy, macular degeneration, lumbar radiculopathy, hypercholesterolemia,

Medications (include doses): Acetaminophen: 650mg. two 325mg tablets po q6h prn
Atorvastatin calcium : 40mg. Give half of 80mg tab po at bedtime
Buspirone hcl 5mg tab 1 tablet po am-pm
Cholecalciferol (vit d3) 1,000unit tab 2000units po daily
Clotrimazole 1% top soln a small amount top bid
Gabapentin 400mg cap 1 capsule po bid and at-bedtime
Insulin glargine,human 100 unt/ml inj 20 units sc at bedtime
Latanoprost 0.005% oph soln 1 drop ou at bedtime
Multivit/ophth areds2/lute/zeax cap/tab 1 capsule po bid
Omeprazole 20mg ec cap 1 capsule po daily
Trazodone hcl 50mg tab 1 tablet po at bedtime
Zolpidem tartrate 5mg tab 1 tablet po at bedtime

Surgical history:

Inpt Meds Only (that are not on Outpt)

March 14, 2015 phacoemulsification and intraocular right eye, September 11, July 16, May 19
and March 14, 2015: Avastin intravitreal injection in left eye.Pancreatitis Surgery(unkn + 10Yrs)

Family history:
Father: Died from a pulmonary embolism
Mother: Died from heart complication
Older Brother: Drug overdose by malpractice hospitalization.

Social history:
Alcohol: Drank for many years, quit 22 years ago, Tobacco: smoked 1ppd for 30 years, quit 18
years ago. Married: More than 40 years, work on plummer and electronics.

Review of systems:
Yes

No

SYSTEM

General:
Recent weight loss
Recent weight gain
Weakness
Fatigue
Fever
Chills

Skin:
Rashes
Lumps
Sores
Itching
Dryness

Yes

No

SYSTEM
Changes in skin color
Changes in hair
Changes in nails
Changes in size or color of moles

Head, Eyes, Ears, Nose & Throat

Headache
Dizziness
Lightheadedness
Loss of vision
Wears glasses or contact lenses
Eye pain
Redness of the eyes
Excessive tearing

Case Presentation - Page 3

Yes

No

SYSTEM

Yes

No

SYSTEM

Head, Eyes, Ears, Nose & Throat

Cardiovascular

Blurred vision

Paroxysmal nocturnal dyspnea

Double vision

Edema

Spots, flecks, flashing lights

Gastrointestinal

Loss of hearing

Trouble swallowing

Tinnitus

Heartburn

Vertigo

Loss of appetite

Earache

Nausea and/or vomiting

Ear discharge

Change in bowel habits

Frequent ear infections

Change in stool color

Frequent colds

Change in stool consistency

Nasal stuffiness

Pain with defecation

Nasal discharge

Rectal bleeding

Nosebleeds

Tarry black stools

Sinus pain

Hemorrhoids

Neck

Constipation

Swollen glands or lumps

Diarrhea

Goiter

Abdominal pain

Pain

Excessive belching

Stiffness

Excessive flatulence

Breasts

Jaundice

Lumps

Peripheral Vacular

Pain

Intermittent claudication

Discomfort

Leg cramps

Nipple discharge

Varicose veins

Respiratory

Ulcers

Cough

Past clots in veins

Sputum

Swelling of calves, legs or feet

Hemoptysis

Color change in fingertips or toes when cold

Dyspnea

Urinary

Wheezing

Increased frequency

Pleurisy

Nocturia

Cardiovascular

Urgency

History of heart murmurs

Burning or pain during urination

Chest pain or discomfort

Frequent urinary infections

Palpitations

Flank pain

Dyspnea on exertion

History of kidney stones

Orthopnea

Hematuria

Case Presentation - Page 4

Yes

No

SYSTEM

Yes

No

SYSTEM

Urinary (Male)

Neurologic

Reduced caliber or force of urinary stream

Changes in speech

Hesitancy

Changes in orientation

Dribbling

Frequent headaches

Genital (Male)

Dizziness

Hernias

Fainting or blackouts

Discharge from penis

Weakness

Sores or ulcers

Paralysis

Testicular pain

Numbness or loss of sensation

Testicular masses

Tingling sensation

Scrotal swelling

Tremors

History of sexually transmitted disease

Involuntary movements

Genital (Female)

Seizures

Irregular menses

Hematologic

Prolonged menses

History of anemia

Excessive bleeding

Easy bruising

Bleeding between periods

Excessive bleeding

Dysmenorrhea

Past transfusions

Menopause

Endocrine

Menopausal symptoms ("hot flushes")

Heat or cold intolerance

Postmenopausal bleeding

Excessive sweating

Vaginal discharge

Excessive sweat or hunger

Vaginal itching

Polyuria

Sores, ulcers or lumps

Changes in shoe or glove size

History of sexually transmitted diseases

Musculoskeletal
Muscle pain
Joint pain
Backache
Swelling of the joints
Stiffness of the joints
Muscular weakness
Limitation of motion
History of fractures or trauma

Psychiatric
Nervousness
Anxiety
Depressed mood

Health Maintenance:
Vaccinations
Hepatitis B

Last Dose
unknown

Influenza

10/14/2009

Measles-Mumps-Rubella

unknown

Pneumococcal

09/19/2003

Tetanus toxoid

07/18/2006

Varicella

not done

Case Presentation - Page 5

Health Maintenance:
Screening

Last Performed

Bone densitometry

Screening

Last Performed

Lipid profile

Not done

Colonoscopy

10-20 years ago.

Mammography

N/A

Diabetes screening

already +

Pap smear

N/A

Physical Exam:
Vital signs:

Temperature
Weight

Normal

Abnormal

98F
135.2lb

Heart rate
Height

74
5.6 ft

Respirations
BMI

SYSTEM

19

Blood pressure
Pain

Skin: Moist skin. No ulcers, rashes, or lumps. Normal hair

and nails. No jaundice.

Neck: No palpable masses or lumps. No goiter. Neck supple.

No palpable lymph nodes. No jugular venous distention. No
carotid bruits.
Thorax and Lungs: No tenderness to palpation of spinal
processes. Normal lung expansion. Normal tactile fremitus
No egophony or whispered pectoriloquy. Lungs clear to
auscultation with no ronchi, crackles or wheezing.
Breasts and Axillae: No lumps or masses. No discharge.
Heart: Non-displaced apex. Regular rhythm. Normal S1
and S2. No S3 or S4. No audible murmurs. No clicks, rubs
or other sounds.
Abdomen: Normal bowel sounds. No abdominal bruits
No tenderness to palpation. No masses. Normal liver span.
No splenomegaly. No ascites.
Extremities: No ulcers or discoloration. No edema.
Peripheral pulses +2 throughout. No deformities of the
joints. Normal range of motion. Normal muscle bulk and
tone.

ABNORMAL FINDINGS

General: Alert, awake, and oriented. Appropriate grooming

and hygiene. No acute distress.

HEENT: Normocephalic. Sclearea white. Normal visual

acuity. Pupils equally reactive to light. Normal eye fundi.
Normal ear canal. Weber midlince. Rinne AC>BC.
Normal nasal mucosa. No sinus tenderness. Moist oral
muscosa. Good dentition. No erythema or exudates.

157/76

Poor visual acuity.

Case Presentation - Page 6

Normal

Abnormal

SYSTEM

ABNORMAL FINDINGS

Neurologic:
Mental status: Alert, awake, and oriented. Appropriate
speech. Normal mentation, insight, judgement, and memory.
Cranial nerves: Normal sense of smell. Normal visual
acuity, visual fields, and ocular fundi. Normal pupillary
reaction. Normal extraocular movements. Normal corneal
reflex, facial sensation, and jaw movements. Normal facial
movements. Normal hearing. Weber midline. Rinne AC>
BC. Normal swallowing and rise of the palate. Intact gag
reflex. Normal voice and speech. Normal shoulder and
neck movements. Normal tongue symmetry and position
Motor system: Normal muscle tone and bulk. Strength 5/5 in
all muscle groups. Point-to-point movements and rapid
alternating movements intact. Normal gait.
Sensory system: Normal sensation to pain, temperature,
light touch, vibration,and point discrimination.
Reflexes: Normal biceps, triceps, brachioradialis, patellar,
and Achilles deep tendon reflexes.

Motor evaluation for lower limb was

ommitted due to chronic back pain.
Patient refuses motor system
examination.

Laboratory Findings:

12.7
10.1

139

99

14.9

254
38.6

202
4.6

27

0.9

Segmented neutrophils

62.1%

Aspartate dehydrogenase (AST)

24

Lymphocytes

21.4%

Alanine dehydrogenase (ALT)

38

Eosinophils

6.1%

Alkaline phosphatase

266

Monocytes

9.9%

Bilirubin, total

1.4

Mean corpuscular volume

86.7fL

Bilirubin, direct

0.8 (ind=0.6)

Mean corpuscular hemoglobin

32.9pg

Magnesium

1.6

Other relevant laboratories:

Imaging studies:

Amylase:.69, lipase, 33

MRCP December 31, 2015:

Extensive choledocholithiasis accounting for biliary obstruction. Enhancement of the
common bile duct walls may represent cholangitis in the proper clinical scenario.

Electrocardiogram:

- Normal Sinus Rhythm

- Vent Rate: 66bpm
-Chest
QTc: AP
423ms
portable view December 31, 2015:

Imaging Studies

MRCP December 31, 2015:

Extensive choledocholithiasis accounting for biliary obstruction. Enhancement of the
common bile duct walls may represent cholangitis in the proper clinical scenario.

Chest AP portable view December 31, 2015:

Mild hyperexpansion and increased pulmonary markings suggesting obstructive and
interstitial lung disease. Compare with prior, no significant acute radiographic changes are
noted.
Abdominal CT and sonogram on December 30, 2015
Abdominal/pelvic CT shows cystic duct stone, biliary tract and common bile duct multiple
stones resulting in obstructive jaundice with intrahepatic biliary ductal dilatation. Abdominal
sonogram remarkable for compatible with intrahepatic and extrahepatic biliary ductal
dilatation likely from biliary tract obstruction secondary to choledocholitiasis; the common
bile duct measures 13mm in diameter and the pancreas demonstrates slight ill defined
echo texture that may represent early pancreatitis.

Case Presentation - Page 7

Assessment:

DMU is a 85 year old male patient with history of diabetes mellitus type II, chronic pancreatitis, duodenal
ulcers and hypercholesterolemia, twas in his usual state of care until December, 2015 were he experience
around 4 episodes of nausea, dry cough, watery diarrhea, chills and change on eyes colors to yellow. On
December 30,2015 patient was hospitalized in Hospital Buen Samaritano for obstructive jaundice, suspected
cholangitis, pancreatitis and broncopulmonea. He was then transfered to VA for further care and for GI
evaluation. MRCP results showes extensive choledocholithiasis accounting for biliary obstruction.
Enhancement of the common bile duct walls may represent cholangitis in the proper clinical scenario.

Patient was evaluated at bedside upon arrival at IM ward. He was alert, awake, and oriented in all spheres.
Currently patient afebrile, normotensive, hemodynamically stable, with adequate vital signs. Physical exam
findings remarkable for the above mentioned findings. Lungs essentially clear. Normal heart sounds. Benign
abdominal exam. No focal neurological deficits. No jaundiced present at time of examination but there was
elevated alkaline phosphatase and Indirect bilirubin on laboratories done on January 3,2016. Normal
Amylase and lipase levels. alkaline phospatase levels in person more than 60 y/o tend to be 1 o 1.5 more
than normal values. therefore, alkaine phospatase should be tested together with GGC an 5' glucosidase.
In view of above mentioned history and physical exam findings, most likely diagnosis is choledocholelithiasis.
Patient with CT and sonogram from Buen Samaritano shows cystic duct stone, billiary and common bile duct
stone with intrahepatic ductal dilation. Another possible diagnosis would be pancreatitis. Patient had CT and
sonogram finding suggestive of pancreatitis. He also developed the following clinical symptoms consistent
with possible diagnosis: nausea, vomiting and diarrhea. Negative findings for diagnostic were abdominal pain,
and normal amylase (60U/L) and lipase (33 U/L) levels. It is important to mention that normal amylase and
lipase level are not sensitive for chronic pancreatitis. BISAP score value were 1 base on this laboratory
values: BUN: 14.9 (less than 25) (0), cognitive competent(0), did not met SIRS criteria(0), did not present with
pleural effusion (0) at time of osculation and on A/P CT scan and patient age is more than 60 y/o (85 y/o)
(1). This give a mortality probability of 0.4%. Nevertheless, patient has improved clinically and abdominal
exam is completely benign.
Patient was started on Zosyn and Levaquin to cover pneumonic process and abdomen flora, treating or
preventing possible cholangitis. Patient was transferred for GI evaluation and the will perform an ERCP
tomorrow for evaluation and removal of choledocholithiasis in case they are present and accessible to study.

Plan:

Will hydrate patient with Ringer's lactate, vitals will be measured every 8 hours, patient activity is limited to
bed rest and will follow a liquid diet. Patient will be evaluated on January 4, 2016 with ERCP for examination
and possible removal of choledolitiasis. Patient will be treated with Heparin for BVT prophylaxis.

References:

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