OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: Pontecilla, Mariquita Hospital #: 1711217 Age/Sex: 62/F Room #: IM-Ward 424 Address: Tondo, Manila Date of Admission: July 18, 2007 Admitting Diagnosis: Anemia of Chronic Disease probably secondary to GI Malignancy PTB IV Residents-in-charge: Drs. Aguila / Receno / Dimaandal Clerks-in-charge: Ponelas/Reyes
CLINICAL ABSTRACT This is a case of a 62 year old female who came in due to generalized body weakness.and rolling of the eyeballs. History of Present Illness: 2 months PTA, patient started to experience loss of appetite. There was also weight loss and melena but no vomiting, dizziness, chest pain, and difficulty of breathing. No consult was done and no medications were taken. 1 month PTA, the patient still had 1 episode of melena. Pallor and easy fatigability were also experienced. Still no consult was done and no medications were taken. 3 days PTA, there was loss of appetite but no difficulty of breathing, cough nor colds. Persistence of the above symptoms prompted consult at OMMC IM-ER. Past Medical History: She was diagnosed to have PTB since May 2007and currently undergoing treatment. There were no hypertension, asthma, DM, allergies to food and medications and goiter. Family History: Denies any heredofamilial diseases Past Medical History: Nonsmoker and non-alcoholic beverage drinker Review of Systems: General: (-) fever HEENT: (-) dizziness, (-) headache (-) blurring of vision Respiratory: (-) colds, (+) cough, (-) hemoptysis Cardiac: (-) PND, (-) palpitation, no orthopnea Gastrointestinal: (-) abdominal pain, (-) diarrhea Neurologic: (-) seizure, (-) loss of consciousness Urinary: No dysuria, No oliguria, no frequency Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Hematology: No easy bruisability Physical Examination: Awake in cardiorespiratory distress Vital Signs: BP= 100/60 CR= 110 RR= 20 Temp= 37.6 HEENT: Anicteric sclerae, pale palpebral conjuctiva, no tonsillopharyngeal congestion, no nasoaural discharge Chest and Lungs: Symmetric chest expansion, no retractions, (+) coarse crackles on all lung fields th Heart: Adynamic precordium, normal rate and regular rhythm, PMI at 5 ICS LMCL, no murmurs Abdomen: Flat, normoactive bowel sounds, firm, soft Extremities: Grossly normal, no cyanosis, with bipedal edema grade 1 Assessment: Anemia of Chronic Disease probably secondary to GI malignancy
Plan: For CXR PA For ABG For CPK-MB For Na, K, BUN, Crea, Blood GS CS at 2 sites For sputum GS/CS For abdominal CT scan
Course in the Wards: Patient was admitted under the service of Dr. Lucero, Aguila, Receno and Dimaandal. Consent for admission was secured. Patient was placed on regular diet except dark colored foods. IVF was PNSS 1L x 8.
Diagnostics: 12-L ECG serial, CPK-MB serial, CXR-PA, , BUN, creatinine, Ca, K, CBC with PC, urinalysis, blood typing, endoscopy, UTZ of the whole abdomen and colonoscopy . Therapeutics include: 1) INH + Rif + PZA + EMB 4 mos OD, Viatamin B complex 1 tab TID PO. To be transfused with 2 u PRBC properly typed and crossmatched. Moderate to high back rest. VS q1, refer. On the first hospital day, patient was placed on regular diet c SAP. IVF PNSS 1L x 8. FF up repeat cbc. Laboratory workups previously requested were carried out and results were followed up. Medications were continued. Vital signs were monitored every hour. Patient was placed on moderate high back rest. CBG was monitored AC/HS. Patient was hooked to O2 support via nasal cannula. Patient was transfused with PRBC. Patient was watched out for chest pain, and hypertension. On the second hospital day,patient had episodes of hypoglycemia, 40mg/dl , D50 was given. Please shift present IVF to D5LR 1Lx 8. For whole abdominal ultrasound. Patient placed on temporary NPO, IVF PNSS 1L x 8. Patient for whole abdominal CT scan , PFA, Ba enema, for possible EGD. Secure and continue meds, moderate to high back rest. VS q1, CR, RR in full minute, CBG q2, I&O monitoring.
On the 3rd hospital day , patient was placed on general liquid diet c SAP, + 3 egg whites TID, maintain IVF, for CT scan of the whole abdomen, start Amenolaban sachet 1 sachet dissolved in 1 glass of water. For BT 1 u PRBC properly typed and crossmathched. moderate to high back rest. VS q1, CR, RR in full minute, CBG q2, I&O
On the 4th HD, patient was placed on general liquid diet c SAP, + 3 egg whites TID, maintain IVF, for CT scan of the whole abdomen, continue Amenolaban sachet 1 sachet dissolved in 1 glass of water. For BT 1 u PRBC properly typed and crossmathched. moderate to high back rest. VS q1, CR, RR in full minute, CBG q2, I&O monitoring On the 5th hospital day, patient may continue general liquid diet , egg whites TID, IVF to ff PNSSx8, moderate
to high back rest. VS q1, CR, RR in full minute, CBG q2, I&O monitoring. Patient for transfusion of 2 u PRBC. th On the 6 hospital day, patient placed on NPO, IVF shifted to D10 1 L x 8, for repeat RBS , repeat CBC c pc, UA, CXR PA, strict I & O monitoring. Patient was transferred to rm 424, medicine ICU and was intubated. Patient was hooked to ambubagging at 10 ppm. IVF to ff D5W 500 cc x 6, NGT was inserted, for CXR PA, for ABG after 1 hour. Meds started: Piperacillin + Tazobactam 2-25 g TIV q8 ANST, Clarithromycin 500mg tab per NGT, Salbutamol nebule q6, VS q1, CR, RR in full minute, CBG q2, I&O monitoring. Famotidine was given 200 mg IV then q6 thereafter. th On the 7 HD, DAT, gastric lavage done q6, OF feeding was started c SAP, IVF to ff : PNSS + 40 meqs KCL x 8, labs requested CA 125. patient hooked on T piece and intermittent ambubagging was donex15 min q1. patient for repeat ABG, moderate to high back rest, VS q1, CR, RR in full minute, CBG q2, I&O monitoring. Review of meds: 1) INH + Rif + PZA + EMB 4 tab OD BB 2.) Vitamin B complex 1 tab TID PO 3.) Omeprazole 40 mg vial, 1 vial TIV OD, 4.) Salbutamol + IPratropium nebulization q4 5.) Hydrocortisone 100mg vial, 50 mg TIV q8 6.) Azithromycin 2 gm/ vial , one dose POI, 7.) Pen G 2 milliunits TIV q6, 8.) Aminoleban 1 sachet dissolved in 200ml water PO TID 9.) K citrate 1 tab TID per NGT, 10.) Vitamin K 1 amp TIV q8. patient for referral to OB: t/c myoma uteri and Surgery: t/c cholecystholithiasis, secretions were suctioned regularly, VS q1, CR, RR in full minute, CBG q2, I&O monitoring.
Summary of Laboratory Reports
Whole abdominal ultrasound result
Liver parenchymal disease, normal pancreas, gallbladder with small echogenic stacks vs bile, sludge with anterior wall polyps, renal parenchymal disease bilateral, prominent spleen. There is complex mass at the left abdominal quadrant probably adherent bowel loops. CXR PTB both lungs, atheromatous aorta, pleural effusion and or thickening R PFA Splenomegaly
ABG pH pCO2 pO2 HCO3 TCO2 BEb O2st
July 25, 2007 7.385 30.30 128.00 18.30 19.20 -4.9 98.90
CBC with PC WBC RBC HGB HCT MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils July 25, 2007 11.2 3.5 9.5 29.8 85.2 27.1 32 224 82.8 9.4 6.5 1.2 0.01
CK MB BUN Craetinine Sodium Potasssium Albumin Julyy 25, 2007 1 24 .3 140 2.7 16
Peripheral blood smear Anisocytosis, poikilocytosis-slight, hypochromia-slight, platelet- adequate Prothrombin Time 15.6 sec