MEDICAL ABSTRACT

This is a the case of TP, 56 years old, male, single, Filipino, born on December 20, 1961, residing
at Ferdinand, Calanasan, Apayao admitted on September 2, 2018 due to difficulty of breathing.

Chief Complaint: Difficulty of breathing

History of Present Illness:

Two months prior to consult, the patient started complaining of body weakness, occasional
abdominal pain and abdominal distention. There were no associated fever, melena, and hematochezia.
Consult was done at Apayao where abdominal ultrasound was requested revealing “liver problem” and
“Stones”. Unrecalled medications were given which didn’t offer relief. About one month prior to
admission, patient was admitted for one week in a hospital in Apayao and was managed as a case of
“urinary tract infection”. He was discharged but still with body weakness. One week prior to admission,
he had undocumented febrile episodes associated with bilateral knee pain and generalized body
weakness and vague abdominal pain. No associated vomiting, melena, hematochezia and hematemesis
noted. Patient also noted to have yellowish discoloration of the skin and sclera. This prompted the relative
to bring the patient at Apayao District Hospital where he was advised admission however they refused
and signed a waiver. Few hours prior to admission, still with the above symptoms now associated with
difficulty of breathing, hence the admission.

Review of System

General: (-) weight loss (+) weakness/body fatigue (+) fever

Skin: (-) rashes (-) itchiness (+) color changes

HEENT: (-) headache (-) dizziness (-) lightheadedness (-) hearing loss (-) tinnitus (-) vertigo

(-) colds (-) nasal stuffiness (-) discharge (-) itching

Respiratory: (-) cough (-) hemoptysis (+) dyspnea

Cardiovascular: (-) chestpain (-) palpitation (-) orthopnea (-) PND (+) edema

Gastrointestinal: (-) heartburn ( -) dysphagia (-) nausea/vomiting (-) hemorrhoids (-)black/tarry

stools (-) constipation (-) diarrhea (+) abdominal pain

GUT: (-) Polyuria (-) frequency of urination (+) hematuria

Extremities: (-) intermittent claudication (-) leg cramps (-) varicose veins (+) joint pains (-) arthritis
Past Medical History
No history of hypertension
No history of diabetes

Family History
No family history of hypertension, diabetes, heart disease.

Personal and Social History

Patient is an alcoholic beverage drinker for 30 years.

Physical Exam
General Survey: Gasping in respiratory distress
Vital signs: BP: 90/60 CR: 102 RR: 32cpm Temperature: 36.80C
Skin: (+) yellowish discoloration
HEENT: Icteric sclera, pink palpebral conjunctiva, dry oral mucosa; no cervical lymph adenopathy; supple
neck
Chest/ Lungs: Symmetrical chest expansion, (+) crackles right lung base; No wheezes
Precordium: Adynamic; Tachycardic; No murmurs
Abdomen: Flabby, soft, non-tender
Extremities: Full equal pulses, + grade 1 bipedal edema.
GCS: E4VTM6

Course in the Ward

Patient was received in respiratory distress with blood pressure of 90/60, cardiac rate of 102 and
Respiratory rate of 32 cpm. At the emergency room, patient was intubated and hooked to bag-valve mask.
Patient was venoclysed with PNSS. Diagnostic procedure requested were the following : CBC exhibiting
anemia, leukocytosis with neutrophilic predominance and thrombocytopenia, both BUN and Creatinine
both were slightly elevated, serum Electrolytes shows hyponatremia, SGPT AND SGOT were both
elevated, Alkaline phosphatase, Total bilirubin including direct and indirect bilirubin were elevated.
Hepatitis C and hepatitis B surface Antigen screening were non-reactive.
Patient was transferred to the Intensive care unit, however, upon receiving the patient, he was in
cardiopulmonary arrest hence rescucitation was done. The patient was pronounced clinically dead after
20 minutes of cardio-pulmonary rescucitation.
Additional test were done prior to the autopsy, these includes Dengue IgG and IgM, malaria, CEA
and AFP.
 LABORATORY EXAMINATIONS
Complete Blood Count

PARAMETER NORMAL VALUES RESULT

RBC Count 4.5-5.9 x 10 12l 3.17 x 1012 /L
Hemoglobin 140-175 g/L 91 g/L
Hematocrit 0.41-0.50 0.28
MCV 80-100 fL 86.80
MCH 27-32 g/dL 28.70
RDW 12-16 17.60
WBC count 4.50-11 30.31 x 109/ L
Neutrophils 0.50-0.70 0.69
Lymphocytes 0.20-0.40 0.17
Monocytes 0.02-0.08 0.13
Eosinophils 0.01-0.04 0.01
Basophils 0.00-0.01 0.01
Platelet Count 150-450 22.00

Blood Chemistry

PARAMETER RESULT REFERENCE RANGE

Blood Urea Nitrogen 25.50 1.7-8.3 mmol/L
Creatinine 257.00 44.2-150.3 umol/L
Sodium 132.00 136-150 mmol/L
Potassium 4.61 3.4-5.3 mmol/L

Liver Function Test

PARAMETER RESULT REFERENCE RANGE

SGPT/ALT 167.02 Up to 45 U/L
SGOT/AST 136.81 Up to 35U/L

PARAMETER RESULT
Leptospira IgG NEGATIVE
Leptospira IgM NEGATIVE
 BLOOD CHEMISTRY

PARAMETER RESULT REFERENCE RANGE

Albumin 15.06 38-50 g/L
Alkaline Phosphatase 136.71 40-129
Direct Bilirubin 277.11 <5.9
Total Bilirubin 326.93 <25.7
Indirect Bilirubin 49.82 <19.8

HEPATITIS Screening

PARAMETER RESULT
Anti Hepatitis C NON-REACTIVE
HBsAg Screening NON-REACTIVE

IMMUNOLOGY

PARAMETER RESULT REFERENCE RANGE

AFP 1.07 0.00-5.80
CEA 1.81 LESS THAN 3.0

Gram stain

Specimen: Blood- Positive for gram negative bacilli