duarte_ jose by dredwardmark



Name: DUARTE, Jose Age/Sex: 35/M Address: Isla Puting Bato, Tondo, Manila Date of Admission: July 1, 2007, 2:45 am Admitting Diagnosis: Leptospirosis Residents-in-charge: Drs. Dalanon/Gutierrez/Gregorio Clerks-in-charge: Velasco/Velasco/Viar

Hospital #: 1705047 Room #: 426

Clinical Abstract This is a case of a 35 year old male who came in due to fever. History of Present Illness Seven days prior to admission, the patient noted reddening of his eyes. There was no fever noted. No medications nor consultations were done. Five days prior to admission, the patient had undocumented fever associated with headache, fronto-temporal in location and non-radiating. He also had loose, watery and soft stool happened twice. However, there was no abdominal pain, no vomiting, no dysuria, no oliguria, no hematuria noted. He self-medicated with Paracetamol, Loperamide, which offered temporary relief. Seven days prior to admission, the above symptoms persisted, this time associated with swelling of both lower extremities and calf pain. Still, no consultations were done. Few hours prior to admission, persistence of the above symptoms prompted the patient to consult and was subsequently admitted. Past Medical History The patient denies presence of HPN, DM, or BA He has allergy to pain relievers Family History Bronchial asthma on maternal side Personal/Social History Non-smoker, non alcoholic beverage drinker Works as a welder, and has a history of wading on flooded waters Review of Systems General: no weight loss, with loss of appetite HEENT: no tinnitus, no blurring of vision Respiratory: no cough, no cold, no difficulty of breathing Cardiovascular: no chest pain, no palpitaitons, no difficulty of breathing, no PND, no orthopnea GIT: no melena, no hematochezia GUT: no dysuria, no hematuria, no oliguria Endocrine: no polyuria, no polydipsia, with polyphagia Neurologic: no changes in sensorium, no loss of consciousness, no seizure

Physical Examination: Patient is conscious, coherent, not in cardiorespiratory distress o BP: 100/70 HR: 84 bpm RR: 18 cpm Temp: 37 C HEENT: anicteric sclerae, pink palpebral conjuctiva, with subconjunctival suffusion no naso-aural discharge, no cervical lymphadenopathies, no tonsillopharyngeal congestion, no neck vein distention Chest and Lungs: Symmetric chest expansion, no retractions, clear breath sounds

Heart: Adynamic precordium, PMI at 5 ICS LMCL, normal rate, regular rhythm, no murmurs Abdomen: flabby, normoactive bowel sounds, soft, no organomegaly, non tender Extremities: with multiple erythematous macules, no edema, with calf tenderness, full and equal pulses Assessment: Leptospirosis


Course in the Wards: Upon admission, consent was secured from the patient and relatives. He was immediately put to 1 liter of PNSS which run for 6 hours. The following laboratory examinations were requested: CBC with PC, UA, CXR-PA, BUN, Creatinine, Na, K, SGPT, SGOT, Albumin, TB, B1, B2, FBS, HDL, LDL, TG, TC, BUA, PT and 12 lead ECG. Intial therapeutics were given: Penicillin G 2 million Units TIV every 6 hours, Paracetamol 500mg tab every 4 hours as needed for temperature above 38.5 C. Vital signs were monitored every 2 hours. He was put to moderate to high back rest. He was watched out for signs of difficulty of breathing, oliguria, and respiratory distress. On the same day of admission, patient had fever and myalgia. He did not complain of abdominal pain. He was given Paracetamol 500mg for fever but he developed hypersensitivity reaction secondary to Paracetamol use. He developed dyspnea, wheezes, and periorbital edema. He was immediately given Hydrocortisone 50 mg IV and was advised to nebulize with Salbutamol every 8 hours. He was monitored every hour. On the 1st hospital day, vital signs were stable with good urine output.. Patient did not complain of fever, vomiting, abdominal pain and cough. There were no subconjuctival suffusion, decreased bibasal breathsounds, soft and nontender abdomen with grade 1 bipedal edema. On the 2nd and 3rd hospital day, patient’s vital signs were stable with good urine output. No fever and no difficulty of breathing. On the 4th hospital day, vital signs were stable. He had no subjective complaints. He was then advised to go home. Home Medications: 1. Penicillin V 300 mg 1 cap TID for 7 days 2. Furosemide 20 mg 1 tab BID for 3 days 3. Multivitamins tablet 1 tab OD 4. Loratidine 10mg 1 tab OD for 5 days Summary of Laboratory Results
CBC with PC WBC RBC HGB HCT MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils June 30, 2007 8.4 4.6 13.3 39.3 84.7 28.6 33.8 156 66 27.2 6 0.8 0

BLOOD CHEMISTRY July 1, 2007 Uric acid Cholesterol TG HDL LDL VLDL SGOT SGPT Albumin Total Bilirubin Direct Bilirubin Indirect Bilirubin Glucose BUN 3.55 Creatinine 92 Potassium 131 Chloride 3.3

July 2, 2007 191.76 3.62 2.57 0.73 1.71 1.18 133.4 106.23 32.81 16.66 10.16 6.5 7.2

July 4, 2007

2.87 56

Urinalysis Color Transparency Epith Cell Mucus Threads Amorph Urates Pus Cells Erythrocytes Cast Albumin Sugar Sp Gr pH June 30, 2007 Dark Yellow Slightly turbid Few Few Moderate 3-5/hpf 1-2/hpf None +1 1.015 6.0

Plan: For sputum AFB 3x For repeat SGPT, SGOT For UTZ – HBT For referral to allergologist

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