27980272 Visualization

A 76 Age - year Age - old Age Japanese Personal_background man Sex had experienced a decreased Sign_symptom appetite Sign_symptom , nausea Sign_symptom , and abdominal Biological_structure distension Sign_symptom since Date late Date February Date 2011 Date .
The patient passed loose Lab_value , soft Lab_value stools Diagnostic_procedure that were not Lab_value watery Lab_value once Frequency daily Frequency .
The results of blood Diagnostic_procedure tests Diagnostic_procedure performed by the primary Nonbiological_location care Nonbiological_location physician Nonbiological_location ( PCP Nonbiological_location ) between Date April Date and Date June Date were all normal Lab_value , but upper Detailed_description and Detailed_description lower Detailed_description gastrointestinal Diagnostic_procedure endoscopy Diagnostic_procedure showed atrophic Detailed_description gastritis Disease_disorder .
Therefore, we assessed the patient for Helicobacter Diagnostic_procedure pylori Diagnostic_procedure antibodies Diagnostic_procedure and performed the rapid Diagnostic_procedure urease Diagnostic_procedure test Diagnostic_procedure and a histopathological Diagnostic_procedure evaluation Diagnostic_procedure , all of which were negative Lab_value .
In June Date , the patient received medication Medication from a mental Nonbiological_location health Nonbiological_location clinic Nonbiological_location , but because the symptoms Sign_symptom did not improve and his body Diagnostic_procedure weight Diagnostic_procedure further decreased Lab_value by Lab_value 23 Lab_value kg Lab_value , he stopped the medication Medication ; he was referred Clinical_event to our department Nonbiological_location in November Date .
The patient had been suffering from hypertension History since History his History 30s History .
Amlodipine Medication ( 5 Dosage mg/day Dosage ) administration was initiated in 2005 Date , and olmesartan Medication from May Date 2008 Date ; the patient is currently receiving 30 Dosage mg/day Dosage of olmesartan Coreference .
He denied the use of any other new Medication medications Medication or nonsteroidal Medication anti Medication - inflammatory Medication drugs Medication .
He had no History history History of History smoking History or History alcohol History consumption History .
Physical Diagnostic_procedure examination Diagnostic_procedure showed that the patient had a height of 165 Height cm Height , a body weight of 47 Weight kg Weight , and body Diagnostic_procedure mass Diagnostic_procedure index Diagnostic_procedure of 17 Lab_value kg/m2 Lab_value .
His body Diagnostic_procedure temperature Diagnostic_procedure was 36.3℃ Lab_value ; pulse Diagnostic_procedure rate Diagnostic_procedure , 101/min Lab_value ; blood Diagnostic_procedure pressure Diagnostic_procedure , 101/81 Lab_value mmHg Lab_value ; respiratory Diagnostic_procedure rate Diagnostic_procedure , 12 Lab_value breaths/min Lab_value ; and saturation Diagnostic_procedure from Diagnostic_procedure pulse Diagnostic_procedure oximetry Diagnostic_procedure ( SpO2 Diagnostic_procedure ) was 98% Lab_value .
The patient had no heart Sign_symptom murmur Sign_symptom , third Sign_symptom heart Sign_symptom sound Sign_symptom or jugular Biological_structure venous Biological_structure distension Sign_symptom .
The patient had bilateral Detailed_description pitting Detailed_description edema Sign_symptom on his lower Biological_structure legs Biological_structure and presented with unilateral Detailed_description gaze Detailed_description - evoked Detailed_description nystagmus Sign_symptom as well as a mildly Severity reduced Sign_symptom tactile Sign_symptom sensation Sign_symptom and thermal Detailed_description nociception Sign_symptom in the toes Biological_structure and dorsal Biological_structure regions Biological_structure of Biological_structure both Biological_structure feet Biological_structure .
Moreover, the finger Diagnostic_procedure - to Diagnostic_procedure - nose Diagnostic_procedure test Diagnostic_procedure results and tandem Diagnostic_procedure gait Diagnostic_procedure were poor Lab_value , and his patellar Biological_structure and Achilles Biological_structure tendon Biological_structure reflexes Diagnostic_procedure had disappeared Lab_value .
Confabulation Sign_symptom was observed in the patient, and the revised Hasegawa Diagnostic_procedure Dementia Diagnostic_procedure Scale Diagnostic_procedure ( HDS Diagnostic_procedure - R Diagnostic_procedure ) score was 17/30 Lab_value (cut-off point: 20).
The hematologic Diagnostic_procedure findings Diagnostic_procedure were as follows: white Diagnostic_procedure blood Diagnostic_procedure cell Diagnostic_procedure count Diagnostic_procedure , 6,200 Lab_value /μL Lab_value ; hemoglobin Diagnostic_procedure level Diagnostic_procedure , 12.5 Lab_value g/dL Lab_value ; mean Diagnostic_procedure corpuscular Diagnostic_procedure volume Diagnostic_procedure , 88.4 Lab_value ; platelet Diagnostic_procedure count Diagnostic_procedure , 230,000 Lab_value /μL Lab_value ; sodium Diagnostic_procedure level Diagnostic_procedure , 136 Lab_value mEq/L Lab_value ; potassium Diagnostic_procedure level Diagnostic_procedure , 3.8 Lab_value mEq/L Lab_value ; chlorine Diagnostic_procedure level Diagnostic_procedure , 103 Lab_value mEq/L Lab_value ; iron Diagnostic_procedure level Diagnostic_procedure , 57 Lab_value μg/dL Lab_value (reference value: 64-187 μg/dL); ferritin Diagnostic_procedure level Diagnostic_procedure , 366 Lab_value ng/mL Lab_value (reference value: 50-200 ng/mL); B Diagnostic_procedure - type Diagnostic_procedure natriuretic Diagnostic_procedure peptide Diagnostic_procedure ( BNP Diagnostic_procedure ) level, 125.3 Lab_value pg/mL Lab_value (reference value: -18.4 pg/mL); and vitamin Diagnostic_procedure B1 Diagnostic_procedure level Diagnostic_procedure , 8 Lab_value ng/mL Lab_value (reference value: 24-66 ng/mL).
An electrocardiogram Diagnostic_procedure was normal Lab_value and chest Biological_structure X Diagnostic_procedure - rays Diagnostic_procedure showed a normal Lab_value cardiothoracic Diagnostic_procedure ratio Diagnostic_procedure ( 40.8% Lab_value ) without either pulmonary Sign_symptom congestion Sign_symptom or pleural Disease_disorder effusion Disease_disorder .
Cranial Biological_structure fluid Detailed_description - attenuated Detailed_description inversion Detailed_description recovery Detailed_description - magnetic Diagnostic_procedure resonance Diagnostic_procedure imaging Diagnostic_procedure findings revealed periaqueductal Biological_structure hyperintensities Sign_symptom (Fig.1); therefore, Wernicke Disease_disorder encephalopathy Disease_disorder was diagnosed.
Moreover, as sinus Detailed_description tachycardia Sign_symptom and a tendency towards hypotension Sign_symptom were noted, no clear symptoms of heart Disease_disorder failure Disease_disorder or dehydration Sign_symptom were observed; it was thus inferred that the vitamin Disease_disorder B1 Disease_disorder deficiency Disease_disorder had likely played a role in both of the conditions.
The antihypertensive Medication agents Medication were discontinued, and 10 Date days Date after Date the intravenous Administration administration of vitamin Medication B1 Medication , the patient's loss Sign_symptom of Sign_symptom appetite Sign_symptom , nausea Sign_symptom , and gait Sign_symptom disturbance Sign_symptom disappeared, and his body Diagnostic_procedure weight Diagnostic_procedure increased Lab_value by Lab_value 3 Lab_value kg Lab_value .
Nystagmus Sign_symptom was ameliorated on physical Diagnostic_procedure examination Diagnostic_procedure , but the patient still had confabulations Sign_symptom , and the HDS Diagnostic_procedure - R Diagnostic_procedure score Diagnostic_procedure and absence Lab_value of deep Biological_structure tendon Biological_structure reflexes Diagnostic_procedure did Lab_value not Lab_value improve Lab_value .
Since the gastrointestinal Sign_symptom symptoms Sign_symptom were ameliorated and his blood Diagnostic_procedure pressure Diagnostic_procedure increased Lab_value to 160/90 Lab_value mmHg Lab_value , the PCP Nonbiological_location resumed the administration of olmesartan Medication on late Date December, Date 2011 Date .
One Date week Date later Date , the patient complained of recurrent decreased Sign_symptom appetite Sign_symptom and nausea Sign_symptom .
After experiencing diarrhea Sign_symptom ( five Lab_value bowel Lab_value movements Lab_value during Lab_value a Lab_value 2 Lab_value - day Lab_value period Lab_value ), he passed soft Lab_value stools Diagnostic_procedure once Frequency daily Frequency , and his body Diagnostic_procedure weight Diagnostic_procedure decreased Lab_value to 47 Lab_value kg Lab_value so he came Clinical_event to our hospital Nonbiological_location again 3 Date weeks Date after Date the resumption of olmesartan Medication for treatment.
His vital Diagnostic_procedure signs Diagnostic_procedure were as follows: body Diagnostic_procedure temperature Diagnostic_procedure , 35.1℃ Lab_value ; pulse Diagnostic_procedure rate Diagnostic_procedure , 93/min Lab_value ; and blood Diagnostic_procedure pressure Diagnostic_procedure , 132/75 Lab_value mmHg Lab_value .
The neurologic Diagnostic_procedure findings Diagnostic_procedure showed no Lab_value worsening Lab_value of his symptoms.
The laboratory Diagnostic_procedure findings Diagnostic_procedure were as follows: sodium Diagnostic_procedure level Diagnostic_procedure , 139 Lab_value mEq/L Lab_value ; potassium Diagnostic_procedure level Diagnostic_procedure , 2.9 Lab_value mEq/L Lab_value ; and chlorine Diagnostic_procedure level Diagnostic_procedure , 116 Lab_value mEq/L.
Hyperchloremia Sign_symptom was noted, and the serum Lab_value sodium Lab_value level Lab_value minus Lab_value chloride Lab_value level Lab_value (139 Lab_value - 116) Lab_value was Lab_value 23 Lab_value mEq/L Lab_value ; additionally, the arterial Diagnostic_procedure blood Diagnostic_procedure gas Diagnostic_procedure findings Diagnostic_procedure were as follows: pH Diagnostic_procedure , 7.25 Lab_value ; PCO2 Diagnostic_procedure , 25 Lab_value mmHg Lab_value , and HCO3 Diagnostic_procedure , 11 Lab_value mmol/L.
The urinalysis Diagnostic_procedure findings were as follows: sodium Diagnostic_procedure level Diagnostic_procedure , 15 Lab_value mEq/L Lab_value ; potassium Diagnostic_procedure level Diagnostic_procedure , 13 Lab_value mEq/L Lab_value ; chlorine Diagnostic_procedure level Diagnostic_procedure , 100 Lab_value mEq/L Lab_value ; and urine Diagnostic_procedure anion Diagnostic_procedure gap Diagnostic_procedure , -72 mEq/L Lab_value , and there was no Lab_value apparent Lab_value increase Lab_value in bowel Diagnostic_procedure movements Diagnostic_procedure ; however, this seemed to be due to the absence Sign_symptom of Sign_symptom HCO3- from the gastrointestinal Biological_structure tract Biological_structure (6).
Plain abdominal Biological_structure radiography Diagnostic_procedure and abdominal Biological_structure computed Diagnostic_procedure tomography Diagnostic_procedure findings revealed the continuous Detailed_description dilation Sign_symptom of the entire Biological_structure intestinal Biological_structure tract Biological_structure (Fig.2); therefore, the patient was diagnosed with intestinal Disease_disorder pseudo Disease_disorder - obstruction Disease_disorder .
After discontinuing olmesartan Medication , the nausea Sign_symptom and body Sign_symptom weight Sign_symptom decreases Sign_symptom were promptly ameliorated.
Duodenal Biological_structure biopsy Diagnostic_procedure findings after discontinuing olmesartan Medication showed that the inflammation Sign_symptom observed before discontinuation as well as the fold Sign_symptom structure Sign_symptom had both clearly ameliorated (Fig.3).