Case No 1
19-year old man admitted to hospital due to jaundice which was preceded by vomiting and diarrhea with fever
Medical History
Present Illness: Fell to flooded river when on the river bank his head spinned (was dizzy) on the river bank, he swallowed a little of river water. He vomited later in the evening at home, next day temperature rose to 39 °C, chills without shivering, vomiting and diarrhea continued. Another day fever and vomiting subsided. Diarrhea persisted, treated with Endiaron, Carbo and Santax. The stool improved. 16 days after this accident the patient felt great calf pain, after another 2 days the skin turned to yellow. He stayed afebrile, without vomiting, no diarrhea.
FHx: Parents are healthy, younger brother is healthy too
EHx: Denies the contact with infection, was not abroad
WSHx: Car mechanic
PM/SHx: Recurrent otitis media even with paracentesis, he had chickenpox, no serious illnesses, proper vaccination
Allergies: NKDA
Medications: Not using anything
Abuse: Non-smoker, social drinking of alcohol, drugs not used
Physical Examination
TT 36,5 °C, alert and oriented, cooperating, eutrophic, icterus of skin and sclera. Head: NAD, eyes, ears, nose without any discharge. Throat clear with no erythema., tongue a little drier, with whitish coating. Neck supple with no LAD or masses. Breath sounds, HR 76', heart sounds normal, pulses 2+ equal on both sides. BP 110/60. Abdomen soft, non-tender, non-distended. No masses. No rebound/guarding. Liver palpable 2 cm below costal margin, spleen not palpable. BS+ Extremities: No edema, mild tender to palpation, Homans a plantar sign negative. Meningeal signs negative.
Laboratory examination
Hematologic laboratory:
- Blood count: Leu 4,3, ery 4,03, Hb 119, Htk 0,351, tr 55
Dif.: ne 0,60, ly 0,17, mo 0,21, eo 0,02, ba 0,00 - Hemocoagulation: Quick 12,4, INR 0,91, aPTT 34,5, D-dimer 740, ATIII 132%
Biochemical laboratory:
- Urine chem. and sed.: pH 6,5, mass density 1,026, G +1, B +2, K +1, blr +4, ubg +1, sed: leu 25/µl
- Plasma or serum chemistry: G 5,2, Na 141, K 3,55, Cl 103, urea 9,02, cr 92, blr 176, blr conj. 85, AST 7,29, ALT 2,75, ALP 1,97, GMT 2,24, CHE 91, CK 70,5, CK-MB 1,9, CB 52, alb. 28, CRP 77, myoglobin 300
Microbiology laboratory examinations:
- Stool culture - rectal swab: primoculture: Staphylococcus epidermidis, pomnožení: Escherichia coli, Klebsiella sp.
- Viral hepatitis panel: HBsAg negative, anti-HAV total positive, anti-HAV IgM negative, IgM anti-HBc negative, anti-HCV negative, anti-HEV IgG negative, anti-HEV IgM negative
- Herpesviruses serology: OCH-Erikson test negative;
anti-CMV KFR pod 1:8, IgM negative, IgG neg.;
anti-EBV EA IgM negative, - EA IgG negative, anti-EBV EBNA IgG negative, - IgM positive, anti-EBV VCA IgM negative, - VCA IgG negative
Imaging and Other Examinations
Imaging studies:
- Abdomen ultrasonography: probable hepatoptosis, otherwise a finding within the norm.
Electrophysiologic examinations:
- ECG: sinus rhythm, f 84/min, PQ 0,16, QRS 0,11, IRBBB (incomplete right bundle branch block)
Diagnostic Conclusion
Make a diagnosis
Treatment
Determine for yourself
Course
19-year old male patient admitted to hospital for jaudice. At the beginning elevated liver tests were noted, higher urea, CRP, CK and myoglobin, in the BC thrombocytopenia. Due to the fall into water patient history and swallowing of water there was a suspicion for [------], that has been confirmed [------]. Therefore [------] was prescribed. During therapy subjective problems disappeared, no icterus confirmed, and better laboratory values. Before discharging from the hospital the patient was afebrile, CRP, CK, myoglobin and renal functions were normal, thrombocytes normalized, slight hyperbilirubinemia is persisting. Discharged home in good clinical health condition.
Task
- What examination do you recommend to add to give the diagnosis and propose a therapy?