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malabad - DOC

VIEWS: 62 PAGES: 3

									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Malabad, Jorge Age/sex: 52/M Address: , Manila Date of Admission: July 10, 2007 Admitting Diagnosis: Leptospirosis Final Diagnosis: Weil’s Syndrome Residents-in-charge: Drs. Dalanon/Gutierrez/Gregorio Clerks-in-charge: Ocampo/ Patayan/ Roque Patient Discharge Summary This is a case of a 52 year old male due to fever.

Hospital Number: 1707756

HISTORY OF PRESENT ILLNESS: 5 days PTC – presence of undocumented, intermittent fever, temporarily relieved by intake of Paracetamol. His fever is associated with headache frontal in location. He also has myalgia. There was no cough, no colds, no abdominal pain. No consult was done. 2 days PTC – fever was still persistent. Yellowish discoloration of sclera was noted with conjunctival suffusion. Still no consult was done. 1 day PTC – he had passage of watery stools 7 times during that day. He has vomiting of ingested food. He still has myalgia with calf tenderness. Few hours PTC with the persistence of the above signs and symptoms prompted consult. PAST MEDICAL HISTORY: S/P appendectomy (1974). No other previous hospitalization. (-) HPN, (-) DM FAMILY MEDICAL HISTORY: No known heredofamilial diseases PERSONAL and SOCIAL HISTORY: Smoker – 7 pack years Occasional alcoholic beverage drinker.

REVIEW OF SYSTEMS: Constitutional: No fever, no weight loss, no chills, no loss of appetite Skin: no pallor, no rashes, with jaundice HEENT: no tinnitus, no blurring of vision, no epistaxis, no dysphagia, Cardio: no chest pain, no palpitations, no PND, no orthopnea, no easy fatigability GIT: no changes in bowel movement, no melena GUT: no dysuria, no oliguria, no hematuria, no nocturia Endo: no polyuria, polydipsia, polyphagia, Rheuma: no joint pain, no myalgia Hema: no easy bruisability Neuro: no seizures; no Loss of consciousness Musculoskeletal: no weakness, no myalgia, no athralgia PHYSICAL EXAMINATION: Conscious, coherent, in cardiorespiratory distress Vital signs: BP: 70-90/50-60mmHg RR : 24 cycles / minute HR Temp : 110 beats / minute : 37º C (axillary)

SHEENT: subconjunctival suffuration, aniccteric sclera, pinkish palpebral conjunctiva, no naso-aural discharge, no cervical lymphadenopathy, no tonsillopharyngeal congestion, no mass, no neck vein engorgement, no supraclavicular lymphadenopathy Chest: Symmetrical chest expansion, no lagging, no retractions, clear breath sounds Heart: Adynamic precordium, tachycardic, PMI at 5thICS LMCL, no murmurs Abdomen: flat, normoactive, soft, non tender, no mass Extremities: Full equal pulses, no edema, no cyanosis Neuro: Patient oriented to three spheres CN I – Intact CN II – Pupils equally reactive to light and accommodation 2-3mm CN III, IV, VI – EOM’s intact CN V – (+) corneal reflex CN VII – No facial asymmetry CN VIII – intact CN IX, X – good gag CN XI – Good shoulder shrug

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CN XII – tongue at midle

Sensory

Motor

Deep tendon reflexes

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ASSESSMENT: Weil’s disease COURSE IN THE WARDS: Upon admission, patient was hooked on PNSS on the right and the left hand to run for 6 hours. Laboratories ordered were CBC with PC, urinalysis, fecalysis, Na, K, Cl, Ca, BUN, Crea, CXR-PA, RBS, ABG’s, SGPT, SGOT, leptospiral Ag.Medications were Pen G 2 million units TIV every 6 hours and Paracetamol 500mg tab OD PO every 6 hours, Omeprazole 40mg TIV OD, He was maintained on high back rest. He has CVP line inserted on the right arm. Vital signs monitored every hour. Strict input and output monitoring every hour. On the first hospital day, he was still hooked PNSS, furosemide drip: D5W 250cc + furosemide 25 mg amp at 10 ugtts/min. Strict input and output monitoring. Vital signs and urine output monitored every hour. On the second hospital day, he was afebrile, has calf tenderness, and has no vomiting. BP was 100/80 mmHg, CR was 94 bpm, RR was 24 cpm, Temperature was 36.2. He has subconjunctival suffuration, icteric sclerae, distended neck vein, and calf tenderness. Urine output was 25cc/hr. Pen G. was continued, vital signs, neorologic vital signs, urine ouput, CVP were monitored hourly. On the third hospital day. Vital signs were BP = 110/70 mmHg, CR = 98 bpm, RR = 24 cpm. Serum K, Crea, BUN, and ABGs. UTZ of HBT and pancreas, UTZ of KUB and Prostate were requested. Pen G and Furosemide were continued, Vital signs and urine output were monitored hourly. On the fourth hospital day, Vital signs were as follows: BP = 140/90, CR = 95, RR = 25, Temp = 37 ˚C. He has distended neck vein,has clear breath sounds. The dose of Furosemide was lowered to 80 mg TIV OD. He was hooked to O2 via face mask at 10 lpm. Vital signs, urine output, CVP were monitored hourly. On the fifth hospital day, vital signs were as follows: BP = 130/80 mmHg, CR = 97cpm, RR = 26cpm, temp = 37˚C. Chest xray, whole abdominal UTZ, AST, ALT, albumin, PT, and bilirubin were requested. Vital signs, urine output, and CVP were monitored hourly. CBG were monitored ACHS. On the sixth hospital day, vital signs were as follows: BP = 130/80 mmHg, CR = 95cpm, RR = 21cpm, temp = 38˚C. CBC w/ PC, Crea, U/A, Sputum AFB were requested. Vital signs, urine output, CVP were monitored hourly. CBG were monitored ACHS. On the seventh hospital day, vital sign were as follows: BP =C 139/90, mmHg, CR = 95cpm, RR = 21cpm, temp = 37˚C. He has icteric sclerae. There was no distended neck vein, and no difficulty of breathing, Vital signs and CVP were monitored hourly. Urine output was monitored. IFC was removed. On the eighth hospital day, vital signs were as follows: BP = 140/90 mmHg, CR = 95cpm, RR = 19cpm, temp = 36.5˚C. CVP line was removed. Vital signs were monitored hourly. Urine output was monitored. On the ninth hospital day, vital signs were as follows:140/90 mmHg, CR = 96cpm, RR = 19cpm, temp = 36.5˚C. Patient was sent home.

LABORATORY RESULTS: CBC with PC 07/10/07 WBC = 7.6 x 109/L Neutrophils = 93.5 % RBC = 4.2 x 1012/L Lymphocytes = 3.1% HGB = 13.1 g/dL Monocytes = 2.3% HCT = 38.2% Eosinophils = 1.1 % MCV = 91.1 fL Basophils = 0 % MCH = 31.3 MCHC = 34.3 Platelet = 103 x 109/L 07/11/07 WBC = 12.6 x 109/L RBC = 4.0 x 1012/L HGB = 12.7 g/dL HCT = 36.2% MCV = 91.1 fL MCH = 31.9 MCHC = 35 Platelet = 162 x 109/L 07/15/07 WBC = 11.9 x 109/L RBC = 4.1x 1012/L HGB = 12.8 g/dL HCT = 38.4% MCV = 92.5 fL MCH = 30.8 MCHC = 33 Platelet = 184 x 109/L Neutrophils = 82% Lymphocytes = 18%

Neutrophils = 29.3 % Lymphocytes = 65.3% Monocytes = 3.8% Eosinophils = 1.6 % Basophils = 0 %

Urinalysis

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07/11/07 PHYSICAL Color : yellow Transparency; clear MICROSCOPIC Epith. Cell : few Mucus thread : few Amorph Urates: few PUS cell: 4-6 /hpf Erythrocytes: many/ hpf Cast: hyaline 0-1/hpf Fine granular cast: 0-1/ hpf 07/15/07 PHYSICAL Color : yellow Transparency; clear MICROSCOPIC Epith. Cell : occasional Mucus thread : occasional Amorph Urates: occasional PUS cell: 1-2/ hpf Erythrocytes: 6-8/ hpf

CHEMICAL Albumin: +1 Sugar: neg Sp. Gravity: 1.020 pH 6.0 Bacteria: few

CHEMICAL Albumin: none Sugar: none Sp. Gravity: 1.020 pH 6.0 Bacteria: moderate

07/10/07 BUN 19.68 mmol/L Creatinine 287.26 umol/L Sodium: 144.60 mmol/L Potassium 2.02 mmol/L 07/12/07 Creatinine: 768umol/L ABG 07/12/07 pH 7 .273 pCO2 20.90 mmHg pO277.00 mmHg HCO3 9.80 mmol/L TCO2 10.40 mmol/L BEb -14.2 mmol/L O2St 93.9% 07/13/07 pH 7 .385 pCO2 19.70 mmHg pO2 63.00 mmHg HCO3 11.9 mmol/L TCO2 12.5 mmol/L BEb -10 mmol/L O2St 92.10% 07/13/07 Potassium :4.1 mmol/L 07/16/07 Creatinine: 368umol/L Potassium: 3.9 mmol/L

SALIENT FEATURES This is a case of a 52/M who came in due to fever –undocumented and intermittent, of 5 days duration. Accompanying symptoms include frontal headache, myalgia, yellowish discoloration of sclera, conjunctival suffusion, passage of watery stools, vomiting, and calf tenderness.

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