Case conference

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Case conference

• PGY 1 R1???

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• Name ?00?
• Age 66y/o
• Sex female
• Chart no 13023469
• Admission date961114
• Discharge date 961201

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Chief complain

• Fever and chillness since this afternoon
• ( ER 37.9 c )

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Present illness

• She felt fever and chills since this afternoon
• Respiratory tract cough(), sputum(-),
  wheezing(-), hemoptysis(-), accessory muscle
  use(-), nasal flaring(-), tachypnea (-)
• GI tract
• diarrhea ( soft no watery) for 5-6 times
• nausea(-), vomiting(-), hematemesis(-),
  melena(-), tarry stool(-), abdominal pain(-),
  postprandial pain(-), cramping(-),
  constipation(-), bowel habit change(-)
• Urinary tract
• Right flank knocking pain()
• Dysuria (-) frequency(-) urgency(-) burning
  sensation (-)

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• She was sent to LMD for management, but not
  improved after medication.
• Thus, she was brought to our ER for management.

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Past history

• Systemic disease
• DM(-) HTN(-) CVA(-)
• Organ disease
• CAD(-)
• Hepatobiliary system
• liver abscess history 820707 both lobe
• Hepatitis B (-)
• Hepatitis C (-)
• GI tract
• 940614 GU, clot()

• Habit
• Smoking (-)
• Betel nuts (-)
• Alcohol (-)

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Physical examination

• Vital signs 37.9c PR111/min RR20/min
  BP138/80mmHg
• General appearance acute ill
• HEENT
• LAP (-) neck supple
• Chest
• HS regular heart beat, no murmur
• BS bilateral breathing sound clear
• Abdomen
• Soft , no tenderness, no RUL knocking pain
• No palpable liver or spleen
• Extrimities
• No pitting edema
• Skin
• No skin rash, no yellowish skin

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Lab exam

• At ER, the serum lab. data showed
• WBC 8000 Seg 95.7 Lym 4.1 CRP 30.6
• Hb13.2 MCV 87.4 PLT 159000
• BUN 13 Cr0.9 Glucose 161
• GOT 31 GPT 21
• Na 136.1 K3.75 .

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• R't flank knocking was found.
• Urine analysis showed bacilli (-),WBC0-2/HPF,
  RBC3-5/
• She was admitted to general ward for further
  management.

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• Chest PA view showed
• Fullness of right hilum.
• Old fracture of left 5th rib.
• Normal heart size.
• Increased infiltration at bilateral lower lung
  fields is noted. Recommend follow up.
• Tortuous aortic arch with intimal calcification.

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• KUB
• The bowel gas pattern appears unremarkable.
• Degenerative change of L-spine with spurs
  formation.
• There is no abnormal abdominal or pelvic
  calcification.

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Impression

• Fever of unknown origin, cause
• Suspected pneumonia
• Suspected recurrent liver abscess
• Suspected UTI

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Plan

• Treatment
• Antibiotic treatment
• Symptomatic treatment

• Exam
• Abdominal echo
• Abdominal CT
• Stool routine

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160gmQD
RUQ mild tenderness
S/R
Abdomen echo
Abdomen CT
Chest lat
Consult chestman
Consult chestman
PFT
K.P
GNB
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lab
lab
sputum
sputum
Liver biopsy
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harmatoma
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Summary

• Infection focus ?
• Liver ? Lung ?
• CT or echo
• Multiple Liver cyst?
• Multiple Liver abscess?
• Liver tumor?
• Metastasis tumor ?
• Harmatoma?
• Harmatoma
• Prognosis ?
• Liver function?
• Liver failure ?
• Recurrent abscess ?

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• Chest lateral
• Mild prominent pulmonary hilar shadow noted.
• Minimal increased lung markings noted in lower
  lung fields.

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• CT of the abdomen(2nd Abdominal CT2007-Nov-17)
  without and with contrast
• medium is performed.
• Findings
• Multiple cysts are noted in both lobe of the
  liver. Some of these cystic lesions
• show indistinct margin and hypodense areas, R/O
  liver abscess or tumor growth.
• No definite focal lesion in the spleen, pancreas,
  GB, adrenal
• glands, kidneys, and UB.
• No evident retroperitoneal lymphadenopathy or
  bony destruction is noted.
• The gastrointestinal tract and the mesentery
  appear unremarkable. No free
• intraperitoneal gas or fluid is found.
• Imp Multiple hepatic cysts in both lobe. R/O
  multiple liver abscess or tumor
• growth in both lobe. Suggest clinical correlation
  and F/U.

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• Abdominal sonography shows
• Presence of ascites.
• Coarse echotexture of the liver with irregular
  surface suggesting liver
• cirrhosis.
• heterogenoeus appearance of the liver and
  multiple timy hypoechoic lesions are
• seen diffusely throughout the liver may due to
  infiltrative hepatoma or liver
• cysts.
• There is no biliary tree dilation seen.
• Normal gall bladder volume with normal wall
  thickness and no stones.
• The spleen and pancreas are unremarkable.
• Both kidneys are normal in size and echopattern,
  neither stone nor hydronephrosis
• are seen.
• Imp Liver cirrhosis.
• Infiltration hepatoma or liver cysts.
• Ascites.

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• Introduction Biliary hamartomata are benign
  hepatic lesions that can mimic metastases on
  imaging studies and during intraoperative
  exploration. As a result, these obscure lesions
  may cause diagnostic confusion and subsequent
  alterations in planned management, particularly
  with regard to synchronous metastatic liver
  disease.

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• Results and discussion The authors report four
  cases of biliary hamartomata, highlighting their
  experience with these lesions, and describe the
  spectrum of findings that may be encountered in
  patients with this condition.

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• Conclusion Although uncertainty may remain,
  biliary hamartomata that have been identified as
  clinically or histologically suspicious or
  indeterminate should be treated as malignant
  neoplasms, whereas asymptomatic biliary
  hamartomata can be observed

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