Download History of the patient

General Information
Date of admission: January 26, 2010
S.A., 21 y/o female, single, Roman Catholic, residing in La Loma City (what’s here
occupation?)
Source of information: patient, mother (source reliability: 80%)
CC: left flank pain
HPI
Patient was apparently well until the 1 day PTA, patient experienced intermittent
fever with a highest temperature of 39°C, accompanied by parieto-temporal headache
graded 7/10 and chills. Fever was temporarily relived by paracetamol 500 mg/tab qid.
Few hours later, patient experienced a sudden onset of crushing left flank pain, nonradiating, which she graded as 8/10; no medications were taken. (Prior to this and
prior to the onset of fever, did she have dysuria, urinary discomfort, hypogastric pain?
Or cough, chest pain? In relation to the possible urinary symptoms, when did she
have her last menstrual period?)
Few hours PTA, there is persistence of above symptoms and increase in severity of
the left flank pain, now graded 10/10 (aggravating factors like movement? Sitting up
or lying down?). Patient had 5 episodes of vomiting around ½ cup per episode. Patient
claimed that there was no dysuria or diarrhea. Due to the unbearable pain (? What do
you mean?) and persistence of symptoms patient prompted consult, hence admission.
PMH
(+) German measles, bronchopneumonia 1989
(+) PTB 2005, treated with Myrin forte, treated for 5 months, non-compliant on the 6th
month of therapy, followed-up 1 year after with chest xray and patient was advised to
continue medications for 3 months, but patient was non compliant and took only the
medicine for 1 month.
(-) CA, asthma, DM, HPN, allergies
(-) blood transfusions
Family Hx
(+) DM, myoma – maternal grandmother (still living?)
(+) colon cancer – paternal grandmother (still living?)
(+) lung disease – paternal grandfather (Still living? Did the group ask what specific
lung disease?)
(-) HPN, thyroid disease, PTB, allergies
Personal and Social history
Prefers eating meat and vegetables
Non smoker
Non alcoholic beverage drinker
No illicit drug use and abuse
Good peer and family relationship
? Daily activities?
Menstrual history
Menarche: 11 y/o
Interval: irregular (when is here LMP, and previous menstrual period)
Duration: 2-3days
Amount: 1 pad per day, moderately soaked
Symptoms: (+) occasional dysmenorrhea
Sexual History:
No history of sexual contact (Does she have a boyfriend?)
Immunization:
Complete immunization according to mother
ROS
No weight loss or gain
No pruritus, no jaundice, no pigmentation, no rashes
No dizziness, no visual difficulties, no lacrimation, no redness
No eye or ear discharge, no deafness, no tinnitus
No epistaxis, no nasal obstruction
No neck stiffness, no limitation of motion
(+) dyspnea, (+) cough, (+) colds (started when? You may need to check on this
because you have significant lung findings plus your impression includes PTB/CAP)
No hemoptysis, (+) easy fatigability
No chest pain, no palpitations
No retching, no hematemesis, no melena, no hematochezia, no dysphagia
No diarrhea, no constipation
(+) frequency (Started when? Isn’t this related to the left flank pain?), no nocturia, no
gross hematuria
No heat-cold intolerance, no polyphagia, no polyuria, no polydipsia
No cyanosis, no edema, no varicosities
NOTE: FOR THE SLIDE PRESENTATION – SAME AS THE OTHER
PRESENTATIONS, PRESENT BOTH THE PE ON ADMISSION AND YOUR PE
(2 COLUMNS) PER SLIDE. YOUR PE FINDINGS (ON SLIDES) MAY NOT BE
AS ELABORATED AS WHAT IS WRITTEN HERE – JUST WRITE DOWN THE
KEY POINTS PER ORGAN SYSTEM
PE on admission (? Were the other findings not written in the patient’s records?)
Patient was conscious, coherent and in repiratory distress.
Vital signs were BP 100/70, PR 100, RR 38, T 38.6°C.
Pertinent PE findings were: dry lips, dry buccal mucosa, (+) palpable cervical lymph
nodes (? Side? How many? Size? Character? Tenderness?), symmetrical chest
expansion, no supravlavicular, subcostal and intercostals retractions, trachea midline,
increased tactile and vocal fremiti on the R (entire right side?), dullness on percussion
on the RUL ??, (+) fine crackles, bilateral R>L. Heart findings were unremarkable.
Abdominal exam showed Flabby abdomen, NABS, no masses, no tenderness, (+)
OVA (??) tenderness. Neurologic exam findings were unremarkable
PE on January 29, 2010 (3rd HD)
(Please make sure that you can explain the difference of your pertinent findings with
those examination abnormalities on admission)
Patient is ambulatory, conscious, and coherent who responds to questions. She
appears hyposthenic and doesn’t speak in phrases ??.
The patient has a palpatory BP of 100 bpm and an auscultatory BP of 110/80 mm Hg
right arm, supine. Her pulse rate is 72 beats per minute; regular. Meanwhile, her
respiratory rate is 18 breaths per minute and her temperature is 36.5 °C.
On HEENT exam, there were pink palpebral conjunctivae, anicteric sclerae and the
pupils were equal, round, and reactive to light and accommodation; constricted from
5mm to 4mm (or equal and briskly reactive to light?). On fundoscopy, there was
positive ROR, and disc margins are sharp; no hemorrhages or exudates. On Weber
test, the sound was perceived symmetrically while on Rinne’s test, it showed AC>BC.
External ear canals were patent and the tympanic membrane with good cone of light.
Also, sinuses were nontender. The neck is supple, without thyromegaly and no
cervical adenopathy appreciated. Patient has warm moist skin with no lesions and
rash.
On cardiovascular exam, her Jugular Venous Pressure was 2.5 cm at 30° angle while
her carotid artery pulse showed rapid upstroke, gradual down stroke, with +2
amplitude, and without bruits. Her peripheral pulses have +2 amplitude, regular.
Precordium is adynamic. Apex beat is found at 5th LICS MCL, 8 cm from the
midsternum. It occupies 2 finger breaths and is felt as soft gentle tap. No RV and LV
heaves, no pulmonic and aortic lift, no thrills over the mitral valve, tricuspid valve,
pulmonic valve, and aortic valve area. On auscultation at the apex, S1 is louder than
S2 and at the base S2 is louder than S1. Also, there was no S3 gallop appreciated.
On pulmonary exam, the chest appeared symmetrical in inspiration and expiration.
There were no intercostals, subcostal, and supraclavicular retraction noted. There
were no alar flaring, circumoral cyanosis, peripheral cyanosis, clubbing and
deformities (??) noted and there was no prominence of SCM ??. AP diameter appears
normal. There was no tenderness noted at the anterior chest, the trachea is situated in
the midline and tactile fremitus was increased over the right upper lung field (T1T6) and left lower lung field (T9-T10). But, there was no lagging appreciated. Also,
dullness was appreciated on the right upper lung field (T1-T6) and the left lower
lung field while the rest of the lung field on both sides were resonant. Upon
auscultation, vocal fremitus was increased at the right upper lung field (T1-T6)
and the left lower lung field (T9-T10). In addition, egophony, bronchophony, and
whispered pectoriloquy were appreciated at right upper lung field (T1-T6).
On abdominal exam, the abdomen was rounded but symmetrical. There were no
pulsation and striae noted. Also, the umbilicus is inverted. On auscultation, there were
normoactive bowel sounds (12/min) but no bruit over the abdominal aorta, right and
left renal arteries, and right and left iliac arteries. On percussion, there is a
predominance of tympanic sound over the abdomen. On palpation, liver edge was
smooth and palpable 1 finger breadth below the RCM. Liver span was uncertain.
There was no obliteration of the Traube’s space and no CVA tenderness was noted.
There was no shifting dullness and fluid wave.
Neurologic Exam on January 29, 2010:
Conscious, Coherent and can follow simple commands
GCS 15
Cranial Nerves:
I – No anosmia
II, III – VA: 20/50 for her left eye and 20/40 for her right eye (+) confrontation
Midline gaze, (+) direct and consensual light reflex, intact pupillary light
reflex and (+) ROR
Disc Margins are sharp; Fundi without hemorrhages or exudates
III, IV, VI – EOMs full and equal
V – Intact sensory (can feel touch in forehead, cheeks, and jaw) and motor
V, VII – (+) corneal reflex
VII – Can raise eyebrows, frown, smile, and puff out both cheeks
VIII – No hearing deficit and without lateralization (Webers test)
IX, X – Uvula midline on phonation, with gag reflex
XI – Can raise shoulder against resistance, SCM intact
XII – Tongue midline on protrusion
Motor: muscles with normal bulk and tone; MMT 5/5 on the upper extremities and
3/5 on the lower extremities.
Cerebellar: Can do Finger to Nose Test, Alternating Pronation/Supination with Ease.
Sensory: Intact to Pain, Temperature, Light Touch, and Vibration
Reflexes: (-) Babinski
Assessment
Sepsis sec to 1.) Acute pyelonephritis 2.) CAP, s/p PTB treatment (6 mos regimen,
2005), r/o PTB reactivation.
Course in the Ward
Day 1 (01/26/10)
Patient was hydrated and placed under diet: 1800 kcal/day, 270g CHO, 15g CHON,
25g fats divided into 3 meals and 2 snacks.
CBC with platelet showed WBC of 35.5 predominantly neutrophils.
Urinalysis showed yellow, slightly turbid, pH 6.5 sp gr 1.005, albumin (-), sugar (-),
RBC 0-2/hpf, pus cell 8-12/hpf and bacteria +++.
Chest X-ray showed that there is confluent density over the L paracardiac area, which
in lateral view is posterior in location and may represent a pulmonary mass to rule out
a pneumonic consolidation, with ill-defined densities over the RUL with bleb
formation.
Spot sputum AFB stain showed no acid fast bacilli
Urine GS/CS and Blood C/S were also requested (because of leukocytosis of 35 –
please don’t write this on the slide – but just make sure to mention this as “part” of the
explanations why microbiologic examinations were performed and why she was
started on antibiotic; other reasons include the manifestations of the patient).
Ceftriaxone 2g/IV OD was started and Paracetamol 500mg/tab, 1 tab q4h prn for
feces >38.3 C
Day 2 (01/27/10)
Spot sputum AFB stain still showed no acid fast bacilli.
Urine culture showed no growth after 2 days incubation.
There were still episodes of fever and cough; but no dysuria ? (she never had dysuria?
What about frequency?).
Crackles were heard bilaterally on both lung fields but decreased (was this noted in
the chart?).
Ceftriaxone was continued and Erdosteine 300mg/cap, 1 cap BID was started.
Na and K were requested showing hyponatremia and hypokalemia. Kalium durule, 2
durules TID x 6 doses was given and hyrdation with PNSS was continued.
A repeat CBC showed WBC of 11.80.
FBS was also requested showing normal value.
Day 3 (01/28/10)
Spot sputum AFB stain showed no acid fast bacilli.
Patient was referred to DOTS for further evaluation and management. Patient was
afebrile, with stable vital signs, no dysuria but still has cough and (+) bilateral
crackles, decreased (was this noted in the chart?).
Ceftriazone was shifted to Cefixime 200mg/cap, 1 cap BID until Feb 1, 2010.
Final results of urine CS and blood CS?
Patient had stable vital signs. The rest of the hospital stay was unremarkable. Patient
was then discharged improved and stable.
Discharge Medications: Cefixime 200mg/cap, 1 cap BID until Feb 1, 2010-02-06 (??
Last day unclear?)
Special Instructions: refer back to DOTS with X-ray and sputum AFB results as
outpatient, increase oral fluid intake
Follow-up or Tranfer Instructions: to come back at Med OPD on Feb 11, 2010 (Thurs,
8am) with DOTS referral
Lab findings (Another advice: just make sure you know how to interpret the abnormal
findings, explain them – and during the presentation, just state your interpretation and
not read on the results)
CBC
Date
Hgb (NV: 120-170 g/dl)
RBC (NV: 3.8-5.5x106/µL
Jan 26 2010
127
4.41
Jan 28 2010
113
3.98
Hct (NV: 0.37-0.54)
MCV (NV: 78-101 fL)
MCH (NV: 27-31 pg)
MCHC (NV: 32-36 g/dl)
RDW (NV: 11.6-14.6)
MPV (NV: 7.4-10.4 fL)
Plt (NV: 150-450x109/L
WBC (NV: 4.5-10x109/L
Neutro (NV: 0.5-0.9)
Bands (NV: 0-0.05)
Segmenters (NV: 0.5-0.7)
Lym (NV: 0.20-0.40)
Mono (NV: 0-0.07)
Eos (NV: 0-0.01)
Baso (NV: 0-0.01)
0.37
84.3
28.9
34.3
12.6
5.5
320
35.5
0.92
0.09
0.83
0.08
-
Blood chemistry
Date
Sodium (NV: 137-147 mmol/L)
Potassium (NV: 3.8-5 mmol/L)
FBS (NV: <100mg/dl)
Urinalysis
Date
Çolor
Trans
pH
sG
Alb
Sugar
Hyaline
RBC
Pus cell
Sq cell
Bacteria
0.33
83.7
28.3
33.8
12.9
5.3
298
11.8
0.63
0.63
0.34
0.02
0.01
-
Jan 27 2010
133
3.3
87
Jan 26 2010
Yellow
Turbid
6.5
1.005
Negative
Negative
02/coverslip
0-2/hpf
8-12/hpf
++
+++