Roman Remedios PDS by dredwardmark



Name: Roman, Remedios Hospital #: 1446764 Age/Sex: 46/F Room #: 427 Address: 1334 Albina St. Sta Mesa, Manila Date of Admission: June 30, 2007, 2:45 pm Date of Discharge: Admitting Diagnosis: Drug-Induced Hepatitis Acid Peptic Disease Pleural Effusion, right probably secondary to PTB Final Diagnosis: Drug-Induced Hepatitis Acid Peptic Disease Pleural Effusion, right probably secondary to 1. PTB, 2. Parapneumonic Process Cholecystolithiasis Residents-in-charge: Drs. Dalanon/Gutierrez/Gregorio Clerks-in-charge: Velasco/Velasco/Viar

Patient Discharge Summary This is a case of a 46 year old female of Sta. Mesa, Manila, who was admitted due to abdominal pain. History of Present Illness The patient is a diagnosed case of PTB 2 weeks ago, maintained on quadruple anti – PTB medications with good adherence. The patient was apparently well, until… Four days prior to admission, the patient had epigastric pain, characterized as expanding, non – radiating pain, relieved y by food intake, associated with fever. She had no changes in bowel movement, no dysuria, no hematuria, no oliguria. No medications and consultations were done. Three days prior to admission, abdominal pain persisted. Still no consultations were done. She self medicated with Aluminum hydroxide and Magnesium hydroxide, which gave only temporary relief. Few hours prior to admission, the above symptoms persisted. This prompted the patient to seek consult in this institution and was then admitted. Past Medical History No HPN, no DM, no previous hospitalizations Family History Her mother was known to be hypertensive No BA, no DM Personal/Social History: Non-smoker Non alcoholic beverage drinker Review of Systems: General: no weight loss, with decreased appetite HEENT: no tinnitus, no blurring of vision Respiratory: with occasional cough, no cold Cardiovascular: no chest pain, no PND, no orthopnea, with occasional difficulty of breathing GIT: no abdominal pain, no diarrhea, no melena, no hematochezia GUT: no hematuria Endocrine: no polyuria, polyphagia, polydipsia Hematologic: no easy bruisability Neurologic: no changes in sensorium, no loss of consciousness, no seizure Physical Examination: Patient is conscious, coherent, not in cardiorespiratory distress o Vital Signs BP: 110/80 HR: 78 bpm RR: 20 cpm Temp: 37 C HEENT: Icteric sclerae, pink palpebral conjuctiva, no naso-aural discharge, no cervical lymphadenopathies, supple neck, no tonsillopharyngeal congestion, no neck vein distention

Chest and Lungs: Symmetric chest expansion, no retractions, decreased fremitus RLF, decreased breath sounds, RLF, with crackles, no egophony Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: Flabby, normoactive bowel sounds, soft, non tender, no organomegaly Extremities: grossly normal, no cyanosis, no edema Assessment: Drug-Induced Hepatitis Acid Peptic Disease Pleural Effusion, right probably secondary to: 1. PTB, 2. Parapneumonic Process Cholecystolithiasis

Course in the Wards: Upon admission, the following diagnostics were requested: SGPT, SGOT, HBT-UTZ, BUN, Serum Creatinine, Na, K, CBC with PC, Protime, Urine analysis, CXR-PA, with right lateral decubitus, 12 lead ECG, FBS, HDL, LDL, TG, Total cholesterol, and BUA. The following therapeutics were ordered: Ethambutol 400mg/tab, INH 150mg/tab, Omeprazole 20mg/Cap OD, Vitamin B Complex Tab OD, Vitamin K 10mg/amp 1 amp TIV q 8. She was put to low salt, low fat diet. Vital signs were monitored every 2 hours. She was put to moderate to high back rest with strict input and output monitoring. She was watched out for difficulty of breathing and chest pain. st On the 1 hospital day, abdominal pain, vomiting, and fever abated. BP=100/60, CR=89, RR=20, T=37. Upon PE, she had icteric sclerae, and with no abdominal tenderness. Previous management continued. nd On the 2 hospital day, abdominal pain reappeared, epigastric in location, non-radiating. BP=110/60, CR=80, RR=21, T=36.7. Still with icteric sclera, with flat and soft non-tender abdomen. The patient was scheduled for HBT – UTZ, initial assessment revealed obscured pancreas, liver parenchymal disease, cholecystolithiasis. The patient was then referred to surgery for further evaluation of the cholecytolithiasis. Working impression was drug-induced hepatitis, pleural effusion probably secondary to PTB or parapneumonic process, cholecystolithiasis. Previously given management continued. rd On the 3 hospital day, patient’s vital signs were stable. No subjective complaints were noted. BP=110/70, CR=96, RR=24, T=38. Repeat protime was ordered and carried out. th th On the 4 to 5 hospital day, the patient’s vital signs were stable. Abdominal pain, fever, and vomiting were not present. BP=100/70, CR= 76, RR=20, T=36.5. Auscultation of the chest and lungs revealed the presence of decreased breath sounds, and fremitus in the right mid to basal lung field, with no egophony. Physical examination of the abdomen revealed flat, soft and non-tender. Repeat Protime and TB, B1 and B2 were ordered. Other ordered management continued. th On the 6 hospital day, patient’s vital signs were stable, with no subjective complaints, but still with tender epigastrium. She was seen by the surgery department, had her history reviewed, and gave an impression of Calculus of the gallbladder, to consider cholecystolithiasis, drug-induced hepatitis. The department recommended continuation of the present management until the patient fully recovered. The patient, once discharged will come back at IM-OPD for OR scheduling. Present management continued. th On the 7 hospital day, patient’s vital signs were stable. Previously ordered management continued. Laboratory Results: Radiology 1. HBT Ultrasound (July 2, 2007) – Liver Parenchymal Disease, Cholecystolithiases

Complete Blood Count Normal June 30 July 3 Values 9 WBC 4.8-10.8 x 10 7.0 5.5 /L RBC 4.0-6.20 x 5.4 3.9 12 10 /L Hgb 12-16g/dl 14.0 10.7 Hct 37-47 % 43.6 31.7 MCV 80-90 fL 81.3 81.7 MCH 27-31 25.2 27.6 MCHC 32-36 31.0 34 Platelet 150-400 x 763 304 10^9/L Neutrophils 55-57 60.4 60.8 Lymphocytes 20-30% 30.2 31.1 Monocytes 0-7% 6.6 5.3 Eosinophils 0-3% 2.3 2.8 Basophils 0-1% 0.5 0 Hypochromia: (+); Anisocytosis: (+++); Poikilocytosis (+); TG (-)

Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphous Urates Pus Cells Erythrocytes Cast Albumin Sugar SG pH Bacteria Calcium Oxalate Blood Chemistry Normal Values BUN 2.5 - 7.10 mmol/L Creatinine 53 – 115 umol/L Uric Acid 178 – 345 umol/L Glucose 3.9 – 6.4 mmol/L FBS 3.89 – 5.84 mmol/L Cholesterol 3.8 – 6.1 mmol/L Triglycerid 0.4 – 2.26 e mmol/L HDL 0.67 – 1.94 mmol/L LDL 1.32 – 2.52 mmol/L HDL Ratio 0–4 VLDL 0.21 – 0.86 mmol/L AST 10 – 31 U/L ALT 9 – 36 U/L Total 66 – 87 g/L Protein Albumin 34-48 g/dL S. Globulin 20 – 38 g/L Sodium 140-148 mmol/L Potassium 3.6 – 5.2 Chloride 100-108 mmol/L Arterial Blood Gas pH pCO2 pO2 HCO3 June 30 Orange Slightly turbid Occasional Few Few 1 -2 / hpf 2 – 5 / hpf 1.015 6.5

June 30

July 2 1.21 52.27 216.75 3.5

3.48 2.04 0.74 2.22 5.30

152.75 191.24 77.14 30.17 46.97 141.80 3.97

TCO2 BEb O2 Sat

Hematology Report Prothrombin Time Activity INR Immunopathology May 17, 2007 HBsAg 0.302 Anti-HCV 0.004 Normal Values 11.5 – 15.0 sec 70 – 120 % 0.9 – 1.15 June 30 15.7 67.6 1.27


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