CASE 2
CHIEF COMPLAINT: "yellow skin ”
This previously healthy 45 year old overweight executive was admitted to the hospital with chest pain encountered during an exercise treadmill which was performed as part of an evaluation of atypical chest pain. He underwent emergency cardiac catherization and was taken to the operating room directly from the cath laboratory. Coronary artery bypass surgery was complicated by early intraoperative bleeding and hypotension. The patient stabilized and came off the bypass pump without difficulty. The patient was extubated without problem and vital signs and EKG were stable post-operatively.
Past medical history was unremarkable with the exception of a history of appendectomy and Gilbert's syndrome.
Two day post surgery the patient was noted to be jaundiced and a bilirubin value of 6.5 mg/dl was noted. This was assumed to be secondary to his known Gilbert's syndrome.
The patient's jaundice was noted to deepen and six days post-op the bilirubin was noted to be 18 mg/dl. The patient denied anorexia, fever, or other problems. Additional laboratory values included:
The patient did well post-discharge and returned to the care of a local physician. Four years following bypass he returned to the ER in the middle of the night for evaluation of severe epigastric pain associated with nausea and vomiting. The pain resolved shortly after presentation to the ER and physical exam was unremarkable with the exception of mild residual epigastric soreness. CBC, amylase and liver function tests were unremarkable. Noted in the ER evaluation was the fact that the patient had begun a liquid protein diet one month earlier and had lost 20 pounds. The patient was discharged in good condition.
Two months later, and twenty-five pounds lighter, the patient presents to the ER with recurrent severe epigastric pain. Vitals T-39, HR 100, BP 150/90. Abdomen-tenderness and guarding noted in the upper abdomen and bowel sounds are markedly decreased.
Lab Data: