CASE PRESENTATION

GROUP 5
PATRON
RAYO
REYES
SALAZAR
SANDHU
SANDOVAL
SANGALANG
SASAKI
 Identifying Data
• Patient G.C.

• 50 y/o

• female

• married

• unemployed

• Resides in Tondo, Manila

 Chief Complaint
• Generalized body weakness
History of Present Illness
• 5 months PTC:

• Gradual onset of body weakness associated with on and off

low grade afternoon fever

• Gradual weight loss

• Anorexia

• Pallor

• He went to a general practitioner and was diagnosed with

anemia. He was prescribed with ferrous sulfate tablets with
note of some improvement
• 2 month PTC:

• Palpable nodules on the right side of the neck,

axilla, inguinal area, and on the right wrist

• Slight limitation of the right wrist

• A few hours PTC:

• Increased in body weakness associated with

dizziness
 Review of Systems
• Weight loss of 50% • Vomiting
in 4 months
• Dizziness
• Fever
• Pallor
• Anorexia
• Abdominal Pain
• Dyspnea
 Past Medical History

• No previous hospitalizations and surgeries

• (-) bronchial asthma, diabetes mellitus,

hypertension, tuberculosis, goiter, allergies, cancer,
kidney disease
 Family History

• (+) Hypertension in a brother

• (+) cough and occasional fever in husband

• (-) DM, Asthma, allergies, cancer

Personal and Social History

• Patient is a housewife, married and has one child

• The husband is an itinerant laborer who is currently

unemployed

• Family rents a small room in a crowded community

• Patient denies smoking, illicit drug use and

alcoholic beverage drinking
 OB-Gyne History

• G2P2 (2002) via NSD c/o midwife in a lying in

clinic.

• Menarche at 12 y/o - 5 days per episode

consuming 2-3pads per day at regular monthly
intervals
 Initial PE at the ER
• Pale conjunctiva, anicteric sclera, (+) bilatera neck
lymphadenopathies, firm, non-tender, and slightly
moveable; dry oral mucosa

• Equal chest expansion, clear breath sounds, no subcostal

retractions, rales or wheezes

• Distinct heart sounds, normal rate, regular rhythm, no

murmurs

• Flabby tender abdomen with slight guarding, liver edge

not palpable, no masses or organomegaly

• Pale nail beds, full equal pulses, no cyanosis

 Assessment at the ER
• To consider hypovolemic shock, probable causes are:

1.Dehydration

2.Ongoing blood loss (rule out intra-abdominal bleed)

•To consider Lymphoma

•Aspiration Pneumonia

•Anemia probably secondary to:

1. Chronic disease

2. Blood loss
 Course at ER
• Conscious, coherent and ambulatory.

• Slightly irritable, in pain, pale-looking

• 5x5cm tender right submandibular mass and a

3x3c tender left submandibular mass

• Breath sounds decreased at the left lung field, no

rales/wheezes

• 2x2cm nodule on the dorm of the right wrist

• Hypotension (70/50mmHg)

• Fluid challenge and Dopamine drip was given.

• Two episodes of vomiting

• DOB with cyanosis was noted thus the patient was

intubated - food particles was noted per suction
tube.

• Blood capillary glucose - 125mg%

• Referred to General Medicine for transfer

• Upon examination by the internal medicine
resident:

• Conscious, coheren, intubated, not in distress

• VS: BP (80-120/50-60) HR (120) RR (18)

• Flat abdomen but slightly rigid with tenderness at

the left lower quadrant, no abdominal masses; liver
edge was not palpable. Traube’s space was intact.

• Ciprofloxacin 200mg IV od and Famotidine 20 mg

IV every 12hrs.

• Four units of packed RBC transfusion.

 IM Ward:
• Pale conjunctiva, anicteric sclera, (+) cervical lymphadenopathies,
firm, non-tender, and slightly moveable; dry oral mucosa

• (+) rhonchi both lung fields, decreased breath sounds in right lung

• Distinct heart sounds, normal rate, regular rhythm, no murmurs

• Flabby tender abdomen with slight guarding, liver edge not

palpable, no masses or organomegaly

• Pale nail beds, full equal pulses, no cyanosis

• Palpable lymph nodes at inguinal and axillary areas

• 1st HD: One unit of packed RBC transfused and
Laboratories were requested.

• 2nd HD: Dopamine drip titrated down. One unit

packed RBC transfused. More laboratory tests
were requested. Pt. transferred to ICU.
 At the ICU:

• 3 units of packed RBC was transfused.

• Penicillin, Ciprofloxacin, Oral KCl and sucralfate

started.

• Blood CS and ET tube aspirate GS/CS were

ordered but were not done.
• 3rd HD: patient weaned off from mech. vent. and
subsequently extubated. Vital signs were stable.

• 4th HD: Patient was transferred out of ICU and

back to the wards.

• 4am, patient was referred for cyanosis, intubation

attempted when the patient went into a systole on
the cardiac monitor. Code was called and she was
eventually intubated.

• After 3 minutes ventricular tachycardia was noted

and cardioversion was done.

• Three more episodes of cardiac arrest ensued and

the patient subsequently expired
Differential Diagnosis
non-hodgkin chronic myelogenous
sarcoidosis TB
lymphoma leukemia

generalized body
/ / / /
weakness

x (There is complain of
on and off low grade
/ fever but not specific / /
afternoon fever
in the afternoon)

gradual onset of
/ / / /
weight loss

pallor / / / /

lymphadenopathy / / / /

anorexia / / x /

dyspnea x / x /

abdominal pain x x x x
 Final Diagnosis
• Miliary Tuberculosis
 URINALYSIS 1st HD Normal Values
CBC 1ST HD 2ND HD NORMAL VALUES Appearance Yellow, Hazy

Specific Gravity 1.015 After 12 hrs of fluid

WBC 4.3 (slightly low) 4.4 - 11 X 10^3/L restriction >1.025
After 12hr
Hgb 48 (low) 93 (low) 123 - 153g/L deliberate fluid
intake </= 1.003

Hct 0.145 (low) 0.163 (low) 0.359 - 0.446 pH 6 5-9

Glucose negative
Plt 307 150-450
Albumin (+1)

Seg 0.84 (high) 0.56 RBC 0-2 0-2

WBC 8-15 (high)

Ly 0.09 (low) 0.34
Casts/Crystals (-)
Stabs 0.7 Mucous Threads (-)

Epithelial cells Few

Retics 0.012 0.005 - 0.015

ABG 1st HD Normal Values

Blood chemistry 1st HD 2nd HD Normal Values pH 7.271 7.35-7.45
glucose 4.97 pCO2 44.4 32-45mmHg
creatinine 91 27-53 umol/L pO2 22 (low) 72-104mmHg
Na 127 (low) 133 136-142mmol/L HCO3 20.7 (low) 22-30mEq/L
K 2.8 (low) 3.6 (low) 3.8 - 5 mmol/L TCO2 22
Fl 97 95-103 mmol/L BE -5.6
Uric acid 0.18 0.16 - 0.43 mmol/L O2Sat 30.5 (low) 95-100%
LDH 326

PT 1st HD Normal Values

Control 12.7 11-14 secs

Patient 12.3

Act 0.78

INR 1.22 0.8 - 1.2

PTT

Control 44.8

Patient 45.8
 Treatment
• Initial Phase (2 months)

HRZE given daily

• Continuation Phase (4 months)

HR given daily or thrice week

 Epidemiology
• 2007: 9.27 million incident cases of TB worldwide;
55% in SEA

• Philippines achieved 70% case detection for

positive TB cases, and 89% successfully treated

• Emerging concerns need to be addressed

• coverage should be broadened

• 2009: National Center for Disease Prevention and
Control of the DOH led to formulating the Philippine
Plan of Action to Control TB
• 8 strategies tube implemented (under PhilPACT):

• Localize implementation of TB control

• monitor health system performance

• engage all health care providers

• promote and strengthen positive behavior of communities

• address MDR-TB,TB-HIV and needs of vulnerable populations

• regulate and make quality TB diagnostic test and drugs

• certify and accredit TB care providers

• Secure adequate funding and improve allocation and efficiency of fund

utilization