Yesterday, we faced a challenging and perplexing case that tested the diagnostic process.
My 83-year-old grandfather was admitted to the hospital after three days of groaning, being non-verbal, and refusing to eat. He was initially taken to a district hospital, where blood tests revealed no signs of infection, and kidney and electrolyte levels were normal. Despite this, he lay with his eyes closed, groaning but not speaking, and wasn’t eating. The doctors administered morphine for pain and planned to insert a feeding tube the next day.
Concerned, my cousin in Bangkok spoke with my uncle, who was at the hospital, and requested further testing, particularly for neurological issues. They decided to transfer him to the provincial hospital for further evaluation.
Upon arrival, we gathered more details about his condition. On October 8, 2024, he woke up as usual, ate breakfast, and walked to the bathroom on his own. On October 9, 2024, he woke up, but this time, he refused to eat and complained of back pain. The following day, on October 10, 2024, around 3 PM, he complained of abdominal pain and seemed confused. He tried to go to the bathroom but ended up at the front door instead of the bathroom door. Soon after, he started lying down with his eyes closed, groaning intermittently, and squirming as if in pain. He didn’t have a fever, vomiting, or diarrhea.
After observing his symptoms at home for a while, my relatives decided to take him to the district hospital.
My grandfather’s medical history included atrial fibrillation (AF), but he wasn’t on any anticoagulants. He had previously had heart failure, pulmonary tuberculosis, and stage 2 colon cancer, which his doctor said was cured without any follow-up needed. He also had a chronic cough and occasionally required oxygen on days he felt more tired than usual.
At the provincial hospital, he was non-verbal, groaning with his eyes closed, and curled up in discomfort. The ER doctor ordered a CT scan of the brain and a chest X-ray. The CT scan was normal, and the X-ray showed a slight increase in pleural effusion. My relatives were concerned about a blood clot in the mesenteric arteries since he had stopped his blood-thinning medication while still experiencing AF. They requested a CT scan of the abdomen.
While waiting for the abdominal CT scan, his blood pressure dropped, sending him into shock. The ER team immediately administered vasopressors and IV fluids to stabilize him.
The abdominal CT revealed dilated bile ducts and gallstones. Looking at his liver function tests again, there was clear evidence of jaundice, with elevated bilirubin levels. This led the team to suspect cholangitis with septic shock. The surgeon was consulted, and given his condition and the urgency of the situation, they decided to drain the infected bile to control the infection, along with starting antibiotics.
The family also requested a central line to avoid further discomfort from multiple blood draws, in case more interventions were needed.
In the end, this case was my grandfather’s.
He is currently in the ICU. His condition is stable and improving, with vasopressors being gradually tapered off. However, his cognitive state hasn’t yet returned to what it once was, and the path ahead remains uncertain.
From this experience, I’ve learned a few valuable lessons:
- Elderly patients can develop severe infections even when blood tests do not initially show signs of infection and there is no fever present.
- Even if a patient presents with neurological symptoms, such as confusion or non-verbal behavior, the underlying cause might not be neurological. In this case, it was septic encephalopathy from an infection in the bloodstream. So, even if brain imaging doesn’t reveal anything abnormal, we must keep searching for other potential causes.
Finally, I’d like to extend my gratitude to the medical team for respecting the family’s concerns and supporting our requests every step of the way.