Grand Case Presentation Information Name: Alindo, Alecia Bday: October 30, 1963 Address: Upper Hinaplanon, iligan

City Admission date: Jan. 31, 2014; 7:03PM Discharge Date: Feb. 9, 2014; 4:00PM Chief Complaint: Epigastric Pain Brief History: Admitted 3 nights at Dr. Uy Hosp for gallstone pain; Few hours after discharge, patient vomit mucus with epigastric pain, thus admitted to AMC-I Previous Hospitalizations: Multiple times for gallstone pain Previous Medication: Insulin for 5 years Health History: (+) Hypertension (+) DM Final Diagnoses: Gallbladder Stone with Chronic Cholecystitis Gastritis with H. Pylori infection Hypoalbuminemia Bilateral Pleural Effusion minimal with Ascites Hypokalemia DM Type II Procedure Done: Upper Gastrointestinal Endoscopy with Biopsy under IV sedation Doctors: Dr. Darlene Dela Cruz, Dr. Balacuit (Surgeon), Dr. Maramara, Dr. Benito, Dr. Macabalang (anesthesiologists), Dr. Jill Irene Z. Capistrano (Cardio) Age: 50 BirthPlace: Iligan City Status: Married

Diagnostic Tests: Dr. Uy Hospital January 28, 2014 admission CBC with platelet RBC 4-4.5 10 12/L Hematocrit 0.37-0.45 Hemoglobin 120-140 g/L WBC 5-10 10 9/L Segmenters 0.55-0.70 Lymphocytes 0.25-0.40 Monocytes 0.01-0.08 Platelet 140-440 10 9/L

3.5 0.31 104 8.9 0.66 0.29 0.05 240

HGT (60-110mg/dL): 164.0; 5PM 153.0 Creatinine (0.50-1.20mg/dL): 1.7 or 150.20 mmol/L Sodium (135-148.0 mmol/L): 143.0 Potassium (3.5-5.3 mmol/L): 2.97 Chest X-ray PA view o Minimal Cardiomegaly Whole Abdomen Ultrasound: o Minimal Hepatic Parenchymal Fatty Change o 3cm Cholelithiasis. No evidence of biliary obstruction. o Normal Sonographic Evaluation of the biliary ducts, pancreas, spleen, both kidneys, urinary bladder and uterus

January 29, 2014 HGT (60-110mg/dL): 5AM 85; 5PM 217.0 Urine Analysis: o Color: Yellow o pH: 7.0 o Specific Gravity: 1.010 o Sugar: +4 o Albumin: +3 o RBC: 7-10/HPF o Epithelial Cells: Abundant o Amorphous subs. : Few o Bacteria: Moderate January 30, 2014 HGT (60-110mg/dL): 5AM 164.0; 5PM 148.0 Albumin (38-51 g/L): 23.3 Potassium (3.5-5.3 mmol/L): 2.81 January 31, 2014 HGT (60-110mg/dL): 5AM 95

Adventist MedicalCenter -Iligan January 31, 2014 CBC with platelet RBC Hematocrit Hemoglobin WBC Segmenters Lymphocytes Stabs Monocytes Eosinophils Basophils Platelet

4-6 10 12/L 0.37-0.47 110-180 g/L 5-10 10 9/L 0.50-0.65 0.25-0.35 0.05-0.10 0.03-0.07 0.01-0.03 0.01 140-450 10 9/L

4.30 0.34 125.0 8.22 0.81 0.15 0 0.02 0.02 0 248

Creatinine (53-100 umol/L) 120.16

February 2, 2014 HBSAG (nonreactive) nonreactive Potassium (3.5-5.3 mmol/L) 2.86 February 3, 2014 Prothrombin time Patient: 12.3s Control: 13.1s Activity: 100% INR: 1.00 Bilirubin (1.7-20.5 umol/L) 7.37 B1 or indirect (1.7-17.1 umol/L) 4.92 B2 or direct (0-5.1 umol/L) 2.45 Albumin (35-54 g/L) 23.56 SGOT (8-40 Iu/L) 23.92 SGPT (5-35 u/L) 11.77 Whole Abdomen Ultrasound (Impression) o Minimal hepatic parenchymal fatty change o Cholelithiasis with chronic cholecystitis o Normal sized kidneys with minimal parenchymal changes (no urolithiasis nor signs of ureteral obstruction) o Sonologically normal biliary ducts, pancreas, spleen, urinary bladder, uterus and adnexae o Minimal bilateral pleural effusion (165cc on the right and 187cc on the left) o Minimal ascites

February 5, 2014 Creatinine (53-100 umol/L) 107.10

February 6, 2014 2D echo o Normal sized left ventricle with good wall motion and contractility, preserved overall systolic function Albumin (35-54 g/L) 28.89 (FT4) Free T4 (9-20pmol/L) 15.16 TSH (0.47-5.01 ulU/ml) 3.24

February 7, 2014 Upper Abdomen Ultrasound: o Follow-up Sonographic Evaluation showed the normal sized liver with minimal fatty infiltration. o No focal parenchymal mass lesion seen. The gland outline is smooth. o The portal vein, intrahepatic and common bile duct are dilated. CBD = 4mm, normal caliber. o The gallbladder was partially contracted with minimal thickened wall. o The 3cm cholelithiasis was again noted. o The pancreas and the spleen are normal in size and configuration. o The abdominal aorta is normal in caliber with no abnormal focal dilatation. o Normal sized kidneys with minimal parenchymal changes. o Persistent minimal ascites with no significant interval change. o Persistent bilateral pleural effusion (219cc on the right and 195cc on the left). No significant interval regression. Alkaline Phosphatase (53-141 U/L) 67.91

February 8, 2014 Upper Gastrointestinal Endoscopy o Esophagus: Unremarkable o Stomach: Some amount of food debris seen. Patchy areas of hyperemia and edematous mucosa noted. No definite mass nor ulcer seen in the visualized mucosa. Biopsy taken for rapid urease test. o Duodenum: 1st and 2nd portion: Unremarkable o H.pylori: Positive

Hemoglucotest (HGT) Monitoring Date Jan 31, 2014 Feb 1, 2014 Time 11PM 5AM 11AM 5PM 11PM Feb 2, 2014 5AM 11AM 5PM 11PM Feb 3, 2014 5AM 11AM 5PM Feb 4, 2014 5AM 11AM 5PM 11PM Feb 5, 2014 5AM 11AM 65 193 113 120 82 123 64 118 169 173 71 144 162 94 79 171 D50 W Humulin 70/30 20units prebreakfast HGT Result 119 Intervention

11PM Feb 6, 2014 5AM 11AM 5PM 11PM

155 153 87 90 106

Feb 7, 2014

5AM 11AM 5PM 11PM

107

253 212 148 196 174 187 174 133

Humulin 70/30 10units pre-supper

Feb 8, 2014

5AM 11AM 8PM 11PM

Feb 9, 2014

5AM 11PM

DRUGS

Date Ordered Jan. 31, 2014

Medication Nubain 5mg IV now Nubain 5mg q8h PRN Tramadol 50mg slow IVTT now then q6h PRN for pain Plasil 1amp IVTT now Omeprazole (Omemac) 40mg IVTT now and every before breakfast Hyoscine N Butyl Bromide 1amp IVTT now Ampicillin/Sulbactam (Silgram) 1.5gm IVTT q8h ANST (neg) Clonidine (Catapres) 75mcg 1tab q8h for BP 150/90 and above Twynsta 40/5 1tab now 8 OD Mucosta 1tab TID Humulin 70/30 20units pre breakfast Humulin 70/30 10units pre-supper

Remarks

-shifted to mepraz (feb. 5, 2014)

-d/c (feb. 5, 2014)

Feb. 3, 2014

Ganaton 1tab now and TID Tramadol IV 50mg IV q8h PRN Plasil 1amp IVTT PRN for vomiting Human Albumin (Zenalb) 20%, 50ml to run for 24hrs, OD Dulcolax 2 tabs for UTZ Dulcolax 1adult sup./rectum UTZ

-D/C (feb. 9, 2014)

Feb. 4, 2014

Lasix 40mg 1tab BID Ensure 5 scoops in 200ml water q6h D50W 50ml 1vial now

-for HGT- 79

Feb. 5, 2014

Omeprazole (Mepraz) 40mg 1tab prebreakfast

Feb. 6, 2014

Dulcolax tab 2tabs PO for UTZ Motilium 1tab TID for UTZ Disflatyl tab 2tabs for UTZ

IV fluid: (Jan 31, 2014) PNSS 1L @ 30gtts (Feb 2, 2014) Plain LR 1L @ 20gtts (Feb 3, 2014) changed to D5 NR 1L Changed to PNSS 1L + 20meq KCl @ 15-20gtts until feb 8, 2014

Discharge Medications: Amoxicillin (Amoxil) 2 capsules 2times a day (8am;6pm) for 10days Clarithromycin 500mg 1 tablet 2times a day (8am;6pm) for 10days Omeprazole (Mepraz) 40mg 1tablet 2times a day (6am;5pm) for 10days Then once a day before breakfast (6am) for 3 weeks Ganaton 1tablet 3times a day, 30minutes before meals for 1 month Mucosta 1tablet 3times a day for 1 month