Fernandez_ Teresita discharge summary

Document Sample
Fernandez_ Teresita discharge summary Powered By Docstoc

Name: Fernandez, Tessie Age/Sex: 51/F Address: 397-B Hipodromo St. Sta. Manila Date of Admission: July 7, 2007, 11:00 am Admitting Diagnosis: Primary Seizure disorder Anemic probably result of pathology Final Diagnosis: Residents-in-charge: Drs. Dalanon/Gutierrez/Gregorio Clerks-in-charge: Ocampo G/ Patayan/Roque

Hospital #: 1707178 Room #: 428 Date of Discharge:

Patient Discharge Summary This is a case of a 51 year old female of Sta. Ana, Manila, who was came in due to convulsions. History of Present Illness The patient is a diagnosed case of seizure disorder maintained on Phenytoin 100mg/day but stopped fully, months ago. Her last attack was more than 1 year ago. Three days prior to admission, patient had undocumented fever which occurred on and off with accompanying difficulty of breathing. She has no abdominal pain, no change in bowel movement, no hematuria and no oliguria. She then consulted to a private clinic where she was given unrecalled antibiotics. Eight hours prior to admission, while at rest, patient had generalized stiffening accompanied by upward rolling of eyeballs and drooling of saliva which lasted for less than a minute. There was no loss of consciousness and headache. Patient was brought to UERM but was not admitted there because there were no rooms available. Thus the relatives transferred to another hospital, hence the admission. Past Medical History No HPN, no DM, no previous hospitalizations Family History Known history of hypertension and liver CA on paternal side Personal/Social History: Non-smoker Non alcoholic beverage drinker Review of Systems: General: no weight loss, no loss of appetite HEENT: no tinnitus, no blurring of vision, no dysphagia Respiratory: with occasional cough, no cold, no difficulty breathing Cardiovascular: no chest pain, no PND, no palpitations, no orthopnea, with easy fatigability Endocrine: no polyuria, no polyphagia, no polydipsia Hematologic: no easy bruisability Physical Examination: Patient is conscious, coherent, not in cardiorespiratory distress o Vital Signs BP: 130/80 HR: 80 bpm RR: 20 cpm Temp: 36 C HEENT: anicteric sclerae, pale palpebral conjuctiva, no naso-aural discharge, no palpable cervical lymph nodes, no neck mass, no tonsillopharyngeal congestion, no neck vein distention Chest and Lungs: Symmetrical chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: Flat, normoactive bowel sounds, soft, (+) direct tenderness on hypogastric area Extremities: grossly normal, no cyanosis, no edema, full equal pulses Neurologic: conscious, coherent, oriented to time, person and place. CN I – can smell CN II – intact visual fields CN III, V, VI - EOM, intact, pupils 2-3 mm CN V – with bilateral corneal reflex CN VII – no facial asymmetry

CN IX, X – good gag reflex CN XI – can shrug shoulders equally CN XII – tongue midline on protrusion



Deep tendon reflexes







++ 100% 100% 4/5 4/5


No nuchal rigidity No Babinski reflex No Kernigs sign Assessment: Plan: Primary seizure disorder

for Admission

Course in the Wards: Upon admission, the following diagnostics were requested: CBC with PC, Urine analysis, CXR-PA, 12 lead ECG, FBS, Serum Blood urea nitrogen, creatinine, sodium ans potassium, HDL, LDL, TG, and Total cholesterol. She was also scheduled for ultrasound of the whole abdomen. Cranial CT scan with contrast was also requested. The following therapeutics were ordered: Phenytoin 100mg thrice a day per orem and Diazepam 5 mg through IV as needed given during active seizure. She was put to low salt, low fat diet and positioned at moderate to high back rest with strict input and output monitoring. Vital signs were monitored every 2 hours including the neurologic vital signs. CBG was monitored also every 6 hours. Oxygen support was also given. Blood that is properly typed and crossmatched should also be transfused immediately. She was watched out for active seizure. st On the 1 hospital day, patient did not have any episodes of seizure, no headache, no vomiting, no difficulty of breathing, no chest pain, no edema, but has vough. Her BP=110/70, CR=80, RR=18. Upon PE, she had pink palpebral conjunctiva, anicteric sclera, no retractions. Abdomen is flat with normoactive bowel sounds, soft and non-tender. Present working impression is now primary seizure disorder to consider chronic kidney disease. She was still for cranial CT scan with contrast, ABG, serum Calcium, phosphate, and urinalysis. Serum Creatinine and Potassium were repeated. Medications were reviewed, drugs given were Phenytoin 125 mg/ml, 5 mL TID and Diazepam 5 mg/IU as needed foractive seizures. She was still for Blood transfusion, 2 units of packed RBC propertly typed and crossmatches. Vital signs were monitored every 2 hours, including the input and output of the patient. CBG was monitored every 6 hours. She was watc hed for active seizure, chest pain and difficulty of breathing. nd On the 2 hospital day, patient had no episodes of seizure, no headache, no vomiting, no difficulty of breathing, and no fever. Her vital signs were BP=130/70, HR of 73, RR of 20 and T=36.1. She has pink palpebral conjunctiva and anicteric sclera. Working impression was changed to primary seizure disorder, hypokalemia probably secondary to 1. RTA, t/c acute renal failure. Hence plan was to increase her potassium diet. Diagnostics ordered were ultrasound of the whole abdomen, and 24-hour urine potassium. Cranial CT scan and ABG was not done hence were ordered again. She was started on NaHCO3 tab, 1 tab three times a day and ferrous sulfate tablet, 1 tab twice a day. Her other medications were continued. She was still for Blood transfusion. Other management were continued. At 7:00 pm, patient was started on acetyl- sachet, 1 sachet to be dissoled in a glass of water to be given three timed a day. Sodium bicarbonate, 36 meq + 3 equal amounts of diluted water was also given via slow IV push after repeat ABGs. Hemodialysis was also considered. On the third hospital day, patient has been transfused with 1 unit PRBC. Initial reading of KUB ultrasound was renal parenchymal disease, bilateral, with normal urinary bladder with FC. Present management was continued except for the transfusion of another unit of PRBC which was placed on hold. th On the 4 hospital day, Patient complained of epigastric pain. Vital signs are BP=130/80, HR=64, RR=21, and T=37. physical examination revealed pink palpebral conjunctiva, anicteric sclera, SCE, no retractions, clear breath sounds, flat abdomen with normoactive bowel sounds, with direct tenderness on the right lower quadrant. She has no edema. Worki ng imoression is now CVD infarction, Right MCA; CKD probably drug induced (Phenyotoin). Phenytoin was discharged and patient was started on Calcium carbonate tablet, 1 tablet three times a day and erythropoietin 4000 units/SQ twice a week. Other medications were continued, bed sore precaution was added to present management. Later that afternoon, around 4 pm, patient was referred to the service consultant. She was seen and examined; her history and PE evaluated. Advise was to look for other possible causes of CKD, because Phenytoin unlikely caused the renal problem. Thus Phenytoin was resumed 100mg/tab, 1 tab TID and other medicationd were resumed and continued. Ancillary

procedures requested that day were CXR, CBC and repeat UA. Additional medication – Pracetamol 500mg tab, 1 tab for fever was given. th On the 5 hospital day, patient has stable vital signs and had no episodes of seizure. Previously ordered laboratory tests were followed up and present management was continued. th On the 6 hospital day, patient’s vital signs were stable. Her BP was 130/70, with HR of 78. PNSS 1L was given to be administered for 8 hours. Previously done management was continued. Laboratory test requested were repeat serum K, Creatinine, Cl, and Na. Anti HCV and HBsAG was also requested; however only Serum K, creatinine, Cl and Na was done due to lack of funds. She was also considered a candidate for possible hemodialysis. She was palced under strict input and output monitoring, vital signs to be monitored evry 1 hour (CR and RR full minute), CBG every 6 hours. She was also for referral to nephrology service consultant. Initial reading of whole abdomen ultrasound revealed normal liver, pancreas and spleen, a contracted gall bladder and bilateral renal parenchymal disease, bilateral. Urinary bladder was also found underfilled. th On the 7 hospital day, the patient’s vital signs were stable. She was conscious and cohenrent and had no difficulty breathing. There was also no abdominal pain. Patient had pink palpebral conjunctiva, anicteric sclera, has no supraclavicular retractions. Her precordium was adynamic, Abdomen was flat with normoactive bowel sounds. Examination of the extremities revealed no edema and no cyanosis. She had no episode of seizures. Previous management was continued. th On the 8 hospital day, patient’s was stable. She was conscious and coherent with BP of 120/70, HR of 72, RR of 18 and Temp=37. She has pink palpebral conjuntiva, adynamic precordiumm flat abdomen with normoactive bowel sounds. Her extremities were grossly normal with full equal pulses. She is still under low salt and low fat diet. Laboratories request ed were repeat serum creatinine and peripheral blood smear (save slides). Medications were also reviewed – (1) Phenytoin 125 mg/ml, 5mL TID PO; (2) Diazepam 5mg, ½ amp TIV as needed for active seizure; (3) NaHCO3 tab, 1 tab TID; (4) FeSO4 tab, 1 tab BID; (6) Citicholine 100g/ml, 2ml TID. Present management was continued. Laboratory Results: Radiology 1. KUB Ultrasound (July 10, 2007) – Initial reading: Renal parenchymal disease, bilateral; normal urinary bladder with folley catheter 2. Whole Abdomen (July 13, 2007) – Initial reading: Normal Liver, pancreas, spleen; contracted gallbladder; Renal parenchymal disease, bilateral; Urinary bladder was underfilled. 3. CT scan of the head (July 9, 2007) – Acute infarct, right middle cerebral artery distribution; thickened calvarium, consider hyperostosis frontalis interna, bilaterally sclerosed mastoids Blood Type – AB positive Complete Blood Count Normal Values 9 4.8-10.8 x 10 WBC /L 4.0-6.20 x RBC 12 10 /L Hgb 12-16g/dl Hct 37-47 % MCV 80-90 fL MCH 27-31 MCHC 32-36 150-400 x Platelet 10^9/L Neutrophils 55-57 Lymphocytes 20-30% Monocytes 0-7% Eosinophils 0-3% Basophils 0-1% Peripheral blood smear July 7 Hypochromia ++ Anixocytosis ++ Poikilocytosis ++ Platelet adequate – (++); Anisocytosis – (++); Poikilocytosis Urinalysis

July 7 8.7 1.9 5.3 16.2 87.0 28.3 33 297 82.5 7.8 6.1 0.8 2.8

July 8 8.5 2.7 7.9 23.2 85.4 29.2 34 222 79.9 10.1 8.6 0.8 0.6

July 12 6.7 3.19 10 27.1 84.9 32.7 38.5 155 82 11 7

Color Transparency Epithelial Cells Mucus Threads Amorphous Urates Pus Cells Erythrocytes Cast Albumin Sugar SG pH Bacteria Calcium Oxalate Yeast cells

July 7 Light yellow Slightly turbid Few Few Few 5-7 0-1 Trace Negative 1.015 6.0 Abundant

July 8 Light yellow Slightly yurbid Occasional Few Few 3-7 0-1 +1 Trace 1.010 5.0

July 12 Light yellow Slightly turbid Occasional Occassional Moderate 1 – 3 / hpf 0 – 2 / hpf +2 Trace 1.015 6.0


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 HBA1C 4.2 – 6.2 % Cholesterol 3.8 – 6.1 mmol/L Triglyceride 0.4 – 2.26 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 Protein g/L Albumin 34-48 g/dL S. Globulin 20 – 38 g/L Sodium 140-148 mmol/L Calcium 2.12 – 2.52 mmol/L Potassium 3.6 – 5.2 Chloride 100-108 mmol/L Phosphorus 0.87 –

July 7 39.36 1226

July 8 42.83 1046

July 9

July 13


5.8 3.17 1.12 0.15

2.16 6.34 0.51


131 1.78





3.5 100


1.45 mmol/L Arterial Blood Gas July 7 pH pCO2 (mmHg) pO2 (mmHg) HCO3 (mmol/L) TCO2 (mmol/L) BEb (mmol/L) O2 Sat (%) Immunopathology HBsAg Anti-HCV 7.201 18.9 150.0 7.5 8.0 -17.7 98.9 July 8 7.44 23.7 39.0 10.3 11.10 -14.4 66.3 July 9 7.294 16.0 129.0 8.2 8.7 -15 98.7

Shared By: