PRIVATE & CONFIDENTIAL MEDICAL REPORT 15/07/2011
Name/ Age/Smoker
: Patrick O Stubbs/ 42/ No Ht:1.65 Wt:87 kg
Rank/ Nationality
: ABG/ American
Agent/ Vessel
: 3J Shipping/ USNS SGT Matej Kocak
Drug/Food Allergy
: Percocet (acetaminophen and oxycodone)
Past MHx/Sx
: Sarcoidosis/ Lap.Cholecytectomy
Date Of Admission13 /07/2011
SYMPTOMS AND SIGNS
Came for further management from Diego Garcia. Had excruciating chest pain 3 days ago. Was seen at the medical centre at the
base. Significant findings were tinge of jaundice, altered bowel movement, Normal ECG, Normal cardiac enzyme, elevated liver
enzymes, raised Bilirubin. Was treated symptomatically with pain relievers. Currently claims epigastric discomfort. Normal bowel
movement. Normal stool and urine. Known to have recently [6 months ago] diagnosed of Sarcoidosis. Was on 10mg
Prednisolone maintenance dose. Stopped medication 3 weeks ago [as instructed by his Doctor]. Laproscopic cholecytectomy
done 5 years. No bleeding tendencies. Clinically alert and conscious. Mild jaundice of the sclera. BP 120/70, 70/min. Abdomentender over the epigastric, no rebound, Heart-normal, Lungs-clear
INVESTIGATIONS
FBC-normal, ESR-8mm/hr, SGPT-raised, SGOT-raised, ALP-raised, Sr.Br-raised, Sr.Creatinine-normal, UFEME-normal, CXR
and AXR-unremarkable, ECG-normal, Ultrasound Abdomen
DIAGNOSIS:
JAUNDICE SECONDARY TO SARCOIDOSIS
RECOMMENDATION: For admission and further management.
DISPOSITION: UNFIT FOR DUTY
DR. RAVIN NAIR Maritime Medical Centre
He was referred to me and he was further investigated and the results are attached.
In summary: His liver although is structurally normal, there is significant increase of Liver enzymes of SGPT, SGOT,
SAP and SGGT with S Bil raised. 1.67. (Jaundice). This is a picture of hepatitis (swelling of the liver) with
hepatocellular damage in the obstructive (in the cellular level) phase. Other parameters of the liver function, e.g.
protein, albumin and globulin are all normal. In the absence of other evidence of infection, viral or bacteria, and the
full blood profile were normal (with the exception of liver function findings), his condition is likely to be due to his
underlying recent confirmed case of sarcoidosis, the treatment of steroids started by his doctor was stopped three
weeks ago by the doctor’s instruction. With the absence of other clinical signs and a normal blood count and ESR, I
have started back the steroids, Prednisolone 10 mg t.d.s. with one injection of I.M. Hydrocortisone 100 mg. This
morning I have reviewed his condition and he is feeling wonderful. In the presence of the abnormal Liver function
test, I would want to get the liver to improve further before I discharge him and I am discharging him on Sunday 17 th
July 2011 for repatriation for further treatment. We will give him all the results of the blood tests taken with the
original films of the Chest X-ray, CT scans of the Chest and the Abdomen with the reports as written by the
radiologist.
Diagnosis: Acute Hepatitis (? Secondary of sarcoidosis)
At present: 1. Serology of Hep A, B, C negative
2. CT Scan of Chest, Abdomen : Negative. Liver normal size, no lesions, no evidence of duct
obstruction and no portal hypertension. No abnormal lesions detected in the solid organs and no Lymphadenopathy
detected in the Abdomen and the Mediasternum. Spleen, adrenal glands and kidneys are normal. No stones or
calculus detected.
3. No evidence of haemolysis.
Progress: He should continue to improve with the present treatment as stated above.
15/07/2011 Today we are doing a Gastroscopy by the surgeon as he is still having heartburn.
Fit for discharge on 17th July 2011. Unfit for sea duty. If possible he should be given business class flight to provide
proper comfort for such a long flight back to U.S.A.
Ck
Dr
Lee
Chief Maritime Doctor
PRIVATE & CONFIDENTIAL
FINAL MEDICAL REPORT
Name/ Age/Smoker
: Patrick O Stubbs/ 42/ No Ht:1.65 Wt:87 kg
Rank/ Nationality
: ABG/ American
Agent/ Vessel
: 3J Shipping/ USNS SGT Matej Kocak
Drug/Food Allergy
: Percocet (acetaminophen and oxycodone)
Past MHx/Sx
: Sarcoidosis/ Lap.Cholecytectomy
Date Of Admission13 /07/2011
16/07/2011
CASE SUMMARY:
This case came in as a “confirmed case of Sarcoidosis" as diagnosed by his doctor in USA about 6
months ago, the biopsy was taken from the lungs. According to the patient, this was done in the Hospital
where he was treated and investigated for swelling and painful ankles. There was no chest complaints.
His could not walk at that time because of the pain of the joints of the legs and the swelling. He was
investigated and the Biopsies were taken by Bronchoscopy with three specimens. He was told that the
biopsies confirmed the diagnosis of Sarcoidosis. He was treated with steriods, Prednisolone 40mg and
than 10 mg per day was taken off about 3 weeks ago as instructed by the doctor as he was going to work
on the ship. He joined this present ship for about 2 and a half weeks.
According to patient, 5 years ago, he developed severe lethargy and passing dark colour urine and was
taken to Hospital and there he was informed that he had to removed t"he gallbladder as it would become
worse if not removed" and this was performed by Laparoscopy in the Hospital and was discharged feeling
better.
This time, on 11th July 2011, he became very sick, feeling very lethargic and passing tea colour urine and
was also having the "chest pain" and at the base clinic he was investigated for myocardial conditions and
his heart was found to be normal except that he was found to have very high liver enzymes and high
Serum Bilirubin and was clinically jaundice. He stated that he did not have any abdominal pain before,
only after the cholecystectomy and not before. He did not had any pain over the upper right abdomen or
shoulder pain at that time when he was operated for the gallbladder.
The base camp doctor contacted me about the patient’s condition and the main issue was that his liver
enzymes and S. Bilirubin was high and was going up. Because of this it was decided to sign him off the
ship for repatriation by flight back to USA. He was flown to Singapore on 13rd July 2010 and was escorted
by Dr Ravin and he was brought to Medical Centre for investigation and treatment prior to Hospitalisation
in Gleneagles Hospital. The objective was to stabilise his condition so that he could undertake the long
flight from Singapore back to USA.
The patient was brought to Gleneagles Hospital and the Dr Ravin referred him to my care.In reviewing this
patient’s condition and the further past medical history and present complaints were gathered from him
directly and the following is his declaration of the sequence of events
The progress since Admission:
The patient was better and noted that the S. Bilirubin and liver enzymes were reduced as compared to
those performed in the base clinic before transferring to us even before our treatment. The CTscans of the
Chest and Abdomen were performed. Attached are the results. Both CT Scans did not reveal any
abnormality except for the following: 1. Mild scarring of the lingular sement noted to be due to previous
infection. No pulmonary, mediastinal or hilar masses detected. The CT of abdomen did not show any focal
hepatic, splenic, pancreatic or renal masses. No fluid collection or enlarged nodes were seen. The size
and density of the liver was normal.
As he has another attack of the “lower central chest pain” last night, the pain was that of “heart burn” and
this morning he was referred to a specialist surgeon for a Gastroscopy as the nature of the pain was not
that cardiac origin and the tests so far showed no cardiac involvement. That was smoothly performed and
the result attached. The conclusion is Acute Gastritis and Duodenitis. No ulcer detected. Two Specimens
from the Gastric mucosa was taken for biopsy. Urease Test for H pylori was performed and result
pending. If it is negative, the causative agent for these inflammation may be directly related to the
chemical exposure too.
Additional blood tests were sent for analysis and the raised Alk phosphatise of 208 u/L (normal being up
to 36-120), the heat stable Alk phos being 77 u/L, being 37%, (>25%) this ALP is Hepatic in origin.
Positive ANA titre of 1:320 speckled ana pattern. Anti-ds DNA negative <25 I.U. ESR = 8mm/hr normal,
normal erythrocyte count indicated that there is no evidence of autoimmune condition e.g sarcoidosis and
the ANA result is most likely due to a chemical exposure sensitisation. (When chemicals attach themselves to
some of the body’s proteins, the immune response may become confused and become an autoimmune response. This
is frequently found after immunotoxic exposure [Bigazzi, 1997; Rich, 1996]. A positive ANA titer, positive
rheumatoid factor, and positive tissue (e.g. thyroid, myelin, smooth muscle, parietal cells, and others) antibodies are
examples of that response [Gard and Heuser, 1990; Heuser et al., 1992]. It is important to realize that autoantibodies may appear after chemical exposure but may go away once the exposure has ceased (Heuser, unpublished
data. Norma eosinophil count shows the cause of allergy is unlikely).
In the absence of any evidence of any presence hepatitis viral infection, Hep A, B, C all being negative
and absence of any focal lesions in the liver, this hepatitis is due to exposure to agents toxic to the liver.
On further review on his medical history, his exposure to paint and aerosol spray paint in an enclosed air
conditioned area was obtained. He developed this sickness after a few days of this job.
Diagnosis: Acute Chemical Hepatitis
Acute Gastritis and Duodenitis
We strongly suspect the both the conditions above to be caused by chemical exposure. We have
started on specific treatment of the above conditions. The oral Prednisolone was taken off. We will
continue to monitor his condition as to his fitness to travel on SUNDAY, 17th July 2011.
Comments:
1. If there is no other complaints within these two days, he would be certified fit for travel on business
class on 17th July 2011 with medication. Assistance would be provided on checking in and on
arrival and the air-lines staff would be informed of this requirement.
2. As there is indication that his present Acute Heptitis was due to his exposure to chemicals a spray
paint , most likely, as according to the history he declared, his condition should be reviewed by the
toxicologist specialist.
3. The “confirmed underlying condition of Sarcoidosis” should be reviewed as our investigations did
not suggest any indication of this condition. The biopsy specimens taken by bronchoscopy should
be reviewed by an independent pathologist. This diagnosis could not explain his painful and
swollen ankles on admission to the US hospital at the time. All the blood tests results, especially
the liver function tests should be obtained. This is to assess whether the liver function at that time
(6 months before were normal or not) and whether the biopsy of the specimens did show
conclusive evidence of this “Sarcoidosis” as claimed.
4. His past history of his admission 5 years ago ended with his gall bladder removed would help
ascertain whether his condition at that time was also related to this case of “chemical hepatitis”.
His history of exposure to chemicals and painting prior to his admission suggestive of a similar
cause of his complaint of “severe lethargy” with no complaints of abdominal pain. The histology of
the removed gallbladder should be similarly reviewed by
5.
6.
7.
8.
the pathologist as the history from the patient was not certain whether the gall bladder was
removed because of infection or for presence of stones. Was there evidence of “chemical
hepatitis” then?
It is important for him to have the above conditions cleared so that he could be specifically be
treated according to the definitive diagnosis. If it is due repeated exposure of the paint and
chemical related to it, he should be cautioned of it and proper protective gears to be worn when
performing such a job. It is also important to ascertain whether there was actually a case of
sarcoidosis as there is at present no evidence of it.
If this case is proven to be “Chemical Hepatitis” resulting from the exposure of the painting job, it is
of great importance that the captain of the vessel be informed so that proper precaution should be
taken for anyone else to perform the same type of job to prevent this condition to occur again.
He gives a history of allergy to Percocet (acetaminophen and oxycodone), should be assessed,
more likely he is just allergic to oxycodone only. Acetaminophen is a useful medication and if not
proven to be really allergic to him, it is to his disadvantage. This could be ascertained when he is
better.
On repatriation, his medical case should be referred to a Clinical Toxicologist to assess and to
ascertain whether his whole trail of condition as mentioned above is that of chemical exposure. He
may wish to review this histology of the gallbladder removed 5 years ago in the hospital and the
Lung biopsies which stated to have confirmed his state of “sarcoidosis” which may just be a lung
tissue reaction to the inhalation of the chemicals causing metaplasia and scar and granulomatous
tissue giving false features of “sarcoidosis”. The absence of any evidence of this condition at
present requires this uncertainty to be cleared up so that he could be freed of this label.
This morning he is better without anymore chest pain with the medications given.
He is fit for discharge on 17th July 2011 with assistance of check-in and on arrival.
Ck
Dr
Lee
Chief Maritime Doctor
16/07/2011
To: Mr Franco Leow,
Manager,
Gleneagles Hospital X-ray Dept
Singapore
Refer:
Name/ Age/Smoker
: Patrick O Stubbs/ 42/ No Ht:1.65 Wt:87 kg
Rank/ Nationality
: ABG/ American
Agent/ Vessel
: 3J Shipping/ USNS SGT Matej Kocak
X-ray Number: GHL11644374 Date done: 13 July 2011 CT Abdomen & CT Chest.
I request for a DVD copy of all the CT Scans of the Abdomen and Chest done on the patient named above. Bill the
charge into the account of CASE /MRO no. 2115063437. This Disk is to be handed to us (not to the patient as he
has the original copy and the flims already). Kindly call us to collect when ready, call Linda 62236066.
Thank you very much.
Dr Lee Choi Kheong
Principal Doctor of this case
Ck
Dr
Lee
Chief Maritime Doctor
16/07/2011
To the Air-lines Manager
To whom it may concern
Refer:
Name/ Age/Smoker
Rank/ Nationality
Agent/ Vessel
: Patrick O Stubbs/ 42/ No Ht:1.65 Wt:87 kg
: ABG/ American
: 3J Shipping/ USNS SGT Matej Kocak
This patient, under my care in Gleneagles Hospital, now being discharged for repatriation by air and he is certified fit
for air travel.
However due to his weakness, it is necessary to request from the air-lines for assistance for him at time of check-in
and to be on wheel-chair transfer to the departure hall and to board the plane safely.
He is on business class status. Should there be any transit on flight, please provide similar transfer to ensure that he
could be safely seated on the plane. On arrival, assistance should be given to him so that he be handed over to his
agent / wife to transfer back home. On flight, there is restriction on alcohol drinks and fatty food. Otherwise there is
no need for any assistance.
Dr Lee Choi Kheong
Principal Doctor of this case
Hand phone 97813360 /62236066
Ck
Dr
Lee
Chief Maritime Doctor