Assessing Medical Oversight: A Case Study of Jaundice Diagnosis in Hepatitis B

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I would like to ask how other physicians would diagnose a patient during their first visit on October 12.
Does this constitute medical negligence? The patient, Xu Zhanwei, a 23-year-old male senior student, was confirmed to be a carrier of hepatitis B two years ago but has not experienced any severe episodes until now.
In early October of this year, due to heavy academic workload and late-night studying, he began to feel unwell on October 8, experiencing fever, loss of appetite, fatigue, and excessive sleepiness.
On October 12, the patient visited the outpatient clinic at Shin Kong Hospital, where he consulted Dr.
Lin Yumin from the Gastroenterology and Hepatology Department.
The patient specifically informed the physician that he noticed jaundice in his eyes that morning.
The physician prescribed a seven-day supply of intestinal regulators and gastrointestinal motility agents.
Blood tests and an abdominal ultrasound were scheduled for the morning of October 14, with an outpatient appointment set for October 19.

On October 14, during the ultrasound examination, Dr.
Lin was present and even remarked to the patient, "You seem to be more yellow today," implying that the jaundice had worsened.
By October 18, the patient had been in a state of deep sleep for several days, and his condition was deteriorating, necessitating immediate action.
Accompanied by family members, he returned to the outpatient clinic at Shin Kong Hospital, where the same Dr.
Lin reviewed the biochemical report from October 14, which showed liver enzyme levels exceeding 5000 and total bilirubin nearing 20.
The patient was immediately transferred to the emergency department and admitted that afternoon.
On October 24, the patient insisted on being discharged, despite total bilirubin levels remaining high at nearly 30.
We decided to seek further expertise, and the patient is currently receiving treatment at Chang Gung Memorial Hospital, with gradual improvement in his condition.
On October 12, the patient proactively informed Dr.
Lin about the jaundice observed that morning, indicating that he was not a typical chronic hepatitis patient.
I am puzzled as to why Dr.
Lin could completely overlook the jaundice symptoms and merely diagnose it as general gastrointestinal discomfort.
Two days later, when the patient returned for blood tests and an ultrasound, Dr.
Lin was aware that the jaundice symptoms had worsened but did not insist on hospitalization or expedite the blood tests for urgent review, instead asking the patient to return on October 19 to discuss the results.
This delay in care extended for nearly a week.
As a specialist in gastroenterology and hepatology, Dr.
Lin failed to make the correct judgment when the patient presented with jaundice symptoms, only confirming liver inflammation after the test results were available.
Therefore, I would like to ask other experienced medical professionals how they would diagnose the patient during the first visit on October 12.
Does Dr.
Lin's conduct constitute medical negligence? Thank you for your assistance.

popcorn, 20~29 year old female. Ask Date: 2002/11/11

Dr. Yang Peizhen reply Gastroenterology and Hepatology

Hello! First, I must clarify that I am not a member of the Medical Evaluation Committee and do not have the authority to determine whether a physician has committed medical malpractice.
Furthermore, I was not present during the consultation between the doctor and the patient, so I cannot fully understand the circumstances.
I can only provide a professional explanation based on the condition you described and general treatment principles.
Patients with chronic hepatitis B often experience episodic acute exacerbations (i.e., elevated liver enzymes and bilirubin levels).
Symptoms such as fatigue and loss of appetite may occur, but after some time, even without specific medication, liver inflammation markers may decrease on their own.
However, if there are repeated long-term exacerbations, chronic hepatitis can easily progress to cirrhosis.
Therefore, we choose to administer specific antiviral treatments (such as interferon or entecavir) at appropriate times, hoping to eliminate the hepatitis B virus.
For chronic hepatitis B patients, we recommend regular check-ups (approximately every 3 to 6 months) for blood tests and abdominal ultrasound examinations.
Mr.
Hsu began experiencing symptoms on October 8, and there could be various potential causes, including an acute exacerbation of chronic hepatitis B.
When he sought medical attention on October 12, he reported jaundice, which strongly suggested a liver or biliary system disease.
Consequently, the doctor promptly arranged for blood tests and an abdominal ultrasound to identify the cause.
Whether hospitalization was immediately necessary depended on the patient's willingness and whether it met the hospitalization criteria set by the National Health Insurance Administration.
Therefore, the physician initially prescribed some gastrointestinal medications to improve his loss of appetite while awaiting the results of the blood tests and ultrasound to determine the next treatment steps.
Ideally, blood tests would have been conducted on October 12 or 13, and the abdominal ultrasound on October 14.
If jaundice worsened during the ultrasound, the blood test results could be reviewed immediately.
If liver enzyme levels were found to be significantly elevated or if bilirubin levels were critically high, hospitalization would be required.
Dr.
Lin arranged for the abdominal ultrasound on October 14 quite promptly, as some major medical centers may require a week of waiting.
Mr.
Hsu's blood test results showed liver enzymes exceeding 5000 and bilirubin levels nearing 20, indicating a near-fatal acute hepatitis condition.
This suggests that the liver is undergoing extensive inflammation, leading to significant hepatocyte necrosis, which could severely impair liver function and potentially progress to liver failure.
Such occurrences are uncommon in chronic hepatitis B patients, but once they happen, recovery will take time, and the complications arising during this period are what we aim to prevent or manage during hospitalization.
Adequate nutritional support must also be provided, and we must patiently wait for the liver cells to regenerate to a certain extent before liver function can gradually improve and bilirubin levels can decrease.
I want to emphasize that a one-week difference in hospitalization does not impact the progression of the disease.
In other words, once an exacerbation occurs, the condition will reach a certain severity before it can improve.
Therefore, the final outcome of continuing hospitalization at Shin Kong Hospital may not differ significantly from that at Chang Gung Hospital.
The recovery from acute hepatitis primarily relies on the patient's own liver cell regeneration capacity.
Elevated liver enzymes and bilirubin levels reflect the severity of inflammation and must reach a peak before they can decline.
Medications cannot prevent their rise; the treatment provided by physicians focuses on managing complications to prevent life-threatening situations, allowing the liver sufficient time to regenerate and recover.
However, in cases of severe liver failure, the only option to save the patient's life may be a liver transplant.
From the above explanation, it is clear that hepatitis B exacerbations can range from asymptomatic to life-threatening.
Timely and effective treatment can reduce the risks and long-term complications (such as cirrhosis and liver cancer).

Best wishes for health from the Department of Gastroenterology at Taoyuan Hospital, Ministry of Health and Welfare, Dr.
Yang Pei-Chen.

Reply Date: 2002/11/11

More Info

In assessing the case of Mr. Xu Zhanwei, a 23-year-old male with a known history of hepatitis B, it is crucial to analyze the timeline of events and the actions taken by the attending physician, Dr. Lin Yumin, during the initial consultation on October 12. The patient presented with symptoms of jaundice, fever, loss of appetite, and fatigue, which are significant indicators of liver dysfunction, particularly in a patient with a history of hepatitis B.

Upon examination, the patient reported the onset of jaundice, a clinical sign that should have raised immediate concern for potential acute liver failure or exacerbation of hepatitis. The physician's initial response was to prescribe gastrointestinal medications without conducting further diagnostic tests or considering hospitalization. This decision could be viewed as a significant oversight, given the patient's symptoms and history.

A competent physician, especially one specializing in gastroenterology and hepatology, should recognize that jaundice in a patient with hepatitis B can indicate severe liver inflammation or even acute liver failure. The standard practice would involve ordering liver function tests (LFTs) and possibly imaging studies immediately to assess the liver's condition. In this case, the physician delayed further evaluation until October 14, when blood tests were finally performed, revealing alarmingly high liver enzyme levels (over 5000) and elevated total bilirubin levels (close to 20).
The delay in diagnosis and treatment poses a serious risk to the patient’s health. The fact that the physician noted the worsening jaundice during the ultrasound on October 14 yet did not take immediate action to admit the patient or expedite the lab results is concerning. In acute cases of hepatitis, especially with jaundice, timely intervention is critical to prevent progression to liver failure, which can be life-threatening.

In terms of medical oversight, the actions taken by Dr. Lin could be construed as a failure to adhere to the standard of care expected in such situations. A reasonable physician, upon noting jaundice in a patient with a known history of hepatitis B, would likely have acted more decisively, potentially admitting the patient for observation and further testing. The delay in treatment not only exacerbated the patient's condition but also led to a prolonged period of suffering and increased risk of complications.

In conclusion, if we were to evaluate this case from a medical oversight perspective, it appears that Dr. Lin's management of the patient did not align with the expected standards of care for a patient presenting with jaundice and a history of hepatitis B. The failure to act promptly upon recognizing the severity of the patient's symptoms could constitute medical negligence. It is essential for healthcare providers to remain vigilant and responsive to clinical signs, particularly in patients with pre-existing liver conditions, to ensure timely and appropriate care.
Moving forward, it is advisable for the patient to seek a second opinion and continue treatment under a specialist who can provide comprehensive care for hepatitis B and monitor liver function closely. Regular follow-ups and adherence to treatment protocols are vital in managing chronic hepatitis B and preventing complications such as liver cirrhosis or liver cancer.

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