DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE INC.

DEPARTMENT OF PATHOLOGY
DASMARIÑAS, CAVITE
4TH CLINICO-PATHOLOGIC CONFERENCE
PRESENTING GROUP: BIG GROUP #2 (GROUP 7A-12A)
CONSULTANTS-IN-CHARGE: DR. MA. CARMEN L. CAGAMPAN/DR. NINA NATALIA BAUTISTA
RESIDENTS-IN-CHARGE: DR. JENNIFER ROSE N. DEPLATA/DR. VENDALE JON D. FIGUERRES
DATE: AUGUST 23, 2021
TIME: 10:00AM -12:00 NN

I. General Data
R. C., a 32-year-old male, Catholic, single, born in Manila and currently residing in Imus, Cavite, admitted for the first
time on April 14, 2016, at a tertiary hospital in Imus, Cavite.

II. Chief Complaint

Body Rashes

III. History of Present Illness

Patient was apparently well until three weeks prior to consult when the patient started to note on-and-off fever with a
maximum temperature of 37.9OC, temporarily relieved by Paracetamol, and associated with body malaise. Two weeks prior to
consult, patient started to experience productive cough, nasal congestion and anosmia. There was also the appearance of multiple
erythematous rashes on his back and chest area, with no tenderness and only occasional pruritus. Patient sought consult at a
primary clinic where he was prescribed with Azithromycin 500mg/tab once a day for 3 days as well as Cetirizine 5mg/tab OD,
which provided temporary relief of symptoms.
One week prior to consult, the rashes continued to persist, now with a purplish-red hue. The patient also noted new
rashes on his lower extremities. The rashes ranged in size from a 25-centavo coin to a 5-peso coin, now associated with
undocumented fever and body malaise. There is note of occasional itchiness in the areas surrounding the lesions so the patient
self-medicated with three doses of Cetirizine 5mg/tab OD and applied unrecalled anti-itch cream on the lesions and pruritic
areas. The itchiness was relieved, but the lesions remained. In addition, patient experienced recurrent cough together with
occasional dyspnea. Persistence of symptoms prompted consult and subsequent admission.

IV. Past Medical History

Patient is a known asthmatic and is compliant with his medications. He is not hypertensive or diabetic. He has allergies
to squid and shrimp but no known allergies to any medications. Patient has alleged GERD relieved by antacid and has recalled
that he had episodes of recurring watery diarrhea lasting for 3-7 days every two months for the past two years. He was
hospitalized for pneumonia one year prior to consult and for dengue fever five months prior to consult.

V. Family History
Patient’s father is a known hypertensive while his mother has a history of invasive ductal carcinoma with complete
response to chemotherapy. His mother and two sisters have controlled bronchial asthma. His younger sister was noted to have
been infected with varicella zoster one month prior. No history of pulmonary tuberculosis.

VI. Personal Social History

Patient is a college undergraduate and currently works as a part-time online English instructor. He previously worked
as a call-center agent for 5 years. He is a known smoker since he was 25 years old and smokes 15 to 20 sticks per day. He is also
a moderate drinker and consumes 3 to 4 bottles of beer every weekend or socially with his friends. He loves eating local street
foods and fatty foods. He denies use of illicit drugs. Patient lives together with his younger sister in an apartment unit near a
creek.

VII. Physical Examination

Vital Signs: BP = 110/70, HR = 88 bpm, RR = 23 cpm, Temperature = 38.5OC, O2 Sat = 95%
General Survey: Patient is awake, lethargic, coherent, ambulatory and in slight cardiorespiratory distress. Patient weighs 52 kg
and has a height of 5’6”.
SHEENT: (+) multiple round to ovoid, purplish red, papular rashes at the back over the 7th cervical and 1st thoracic vertebrae,
at the chest area 2.0 cm inferior to the nipple; anicteric sclerae; (-) lesions on the buccal mucosa; (-) cervical lymphadenopathies
Chest/Lungs: Equal chest expansion; (+) crackles on bibasal lung fields; (+) supraclavicular lymphadenopathy
Cardiovascular: Regular rate, regular rhythm; apex beat at 5th to 6th intercostal space; no murmurs; no cardiac bruits
Abdomen: Flat, soft, non-tender, 20 bowel sounds per minute; (-) CVA tenderness
Extremities: (+) multiple round to ovoid, purplish red, maculo-papular rashes on his lower extremities; full and equal pulses;
full range of motion; (-) edema
Nervous System: intact cranial nerves
VIII. Laboratory Results (Day of Admission)

Table. 1 Laboratory data.

Patient’s Result Normal Range
Hematocrit 0.38 L/L 0.40-0.50 L/L
Hemoglobin 109 g/L 130-180 g/L
WBC 4.2 x 109/L 4.0-10.0 x109/L
Differential
Count (%)
Neutrophils 68 55-65
Band forms 1 2-5
Lymphocytes 21 25-35
Monocytes 2 3-6
Eosinophils 7 2-4
Basophils 1 0-1
Platelets 166 x 109/L 150-400 x 109/L

Chemistry
Creatinine 73 umol/L 53-97 umol/L
RBS 152 mg/dL Below 200 mg/dL

AST (SGOT) 22 U/L 5-34 U/L

ALT (SGPT) 19 U/L 0-55 U/L
Sodium 177 mmol/L 136-245 mmol/L
Potassium 4.1 mmol/L 3.5-5.1 mmol/L
Magnesium 0.95 mmol/L 0.66-1.07 mmol/L

Immunology
C-reactive Protein 32.4 mg/L < 10 mg/L

Urinalysis
Color Light Yellow
Character Clear
Specific Gravity 1.010
pH 7.2
Albumin Negative
Sugar Negative
WBC 1-2/HPF
RBC 0-1/HPF

Bacteriology After 24 hrs. After 48 hrs.

Sputum Culture No growth No growth
Blood Culture No growth No growth

IX. Imaging Studies

Chest X-ray: (+) Bilateral interstitial infiltrates at the perihilar region; (+) 2.0 x 3.0 Nodule at the left supraclavicular area;
Heart is not enlarged.

X. Course in the Wards

Patient was immediately given Paracetamol 300mg IV every 6 hours for his ongoing fever. In addition, he was started
on Ceftriaxone 1g IV BID every 12 hours. Additional laboratory tests were ordered, and blood and sputum specimens were
collected for culture. On the second hospital day, patient’s condition slightly improved. No febrile episodes were noted during
the day, but the patient still has non-productive cough. Patient was advised for biopsy of his skin lesions, to which he consented.
On the third hospital day, patient underwent punch biopsy of his skin lesions. Patient began to have sore throat and was advised
to gargle with saline solution. Patient noted one febrile episode reaching 38.0OC in the evening, which was resolved by
Paracetamol. On the fourth hospital day, there was noted progression in the size of the skin lesions with associated edema in
his lower extremities. Multiple white lesions were also noted on his oral mucosa, and mucosal scrapings were taken for testing.
On fifth hospital day, patient decided to go home against medical advice due to financial constraints. Patient was thus prescribed
medications and sent home, with instructions to follow-up once his laboratory results were released.