OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
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
24-HOUR HISTORY 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. Input and output monitoring were also strictly monitored. He was put to moderate to high back rest. He was watched out for signs of difficulty of breathing, oliguria, and respiratory distress.