ENDORSEMENT FOR fascicles of spindled cells and

MANG RAUL CASE STUDY: reactive fragments of trabecular

Ministration to Mang Raul bone.
• A year before confinement back
and rib pain, stress fractures,
Demographic data of Mang Raul: recurred for the past 8 month.
• Male Multiple surgical procedures were
• 32 years old performed, including mandibular
• Single biopsies and resections and the
• Work before as an Engineer insertion of a fibular implant, as
Abroad well as dissection of a cervical
• He doesn’t like to eat vegetables lump node on the right side;
• Loves Meat product especially pathological examination of the
bacon specimens showed a spinde-cell
• Occasional Drinker lesion infiltrating bone and soft
• He smokes 2-3 sticks a day tissue.
• His mother died due to cancer • Just this JUNE 2021 MANG RAUL
(Osteosarcoma) 11 years ago returned to the Philippines to have
some rest as advised by his
• His Father is 70 years old yet still
doctors and his company also.
healthy
• His youngest brother lives with
Emergency Room:
them and currently working as a
• According to MANG RAUL while
Resident Physician in one of the
walking, bilateral hip pain when
private hospitals in Butuan.
walking, fatigue, muscle
weakness, intermittent wheezing
History of Illness:
with exercise, and mild chronic
• MANG RAUL is always been weel
diarrhea.
• But 4 years ago, in his work place
• He had no fever, sweats, weight
developed Rib Pain and a left
loss, chest or abdominal pain, new
metatarsal stress fracture
intestinal symptoms, or hematuria.
• Pathological examination of a
• Upon assessment on
bone-biopsy specimen reportedly
examination:
revealed findings that were
o Blood pressure was 150/80
consistent with severe
mm HG
osteomalacia with interventions
o Pulse 101 bpm
and care by the hospital the
o RR 22 cpm
symptoms resolved.
o Afebrile,
• 2 years ago, during a routine o O2 sat 94% in a conducive
dental evaluation, swelling was environment
noted in the area of the second o Weight is 77.1 kg
bicuspid and the first molar on the o Height 170.2 cm
bottom right pathological
• There were brown, infiltrative
examination of the specimen
lesions (5 to 10 mm in diameter)
reportedly showed an atypical
over the trunk and back.
proliferation of mixed epithelial
and mesenchymal cells, including
 • MANG RAUL claimed to have
burning sensation during voiding
this past day and he keeps on
going to the comfort room.
• He was then advised by the ROD
(resident on duty) to be admitted
to the Medical Surgical Unit Fluid
and Electrolytes Care Crisis under
the care of Dr. Moi and Co Mngt
by Dr. Mante.

Chief Complain: Bilateral Pain, Diarrhea

X 9 Days, Weakness
Admitting Impression: Possible
Recurrent Induced Osteomalacia

Endorsement:
• MANG RAUL 32 years old
• Doctors: Dr. Moi and Dr. Mante
• IVF bottle number 1 D5W 1L plus
sodium phosphate sodium
phosphate 15 mmol via soluset in
20 mmol; Regulated at 20ggts/min
• On low Salt, Low Fat Diet
• On O2 @ 2LPM via nasal prong
• V/S Monitoring
• FBC attached to UB
Laboratories: (to be referred)
• 12 leads ECG, UA, CBC, PANEL
C, HGT, SERUM CREA, S/E
done,
• KUBU done (kidney urinary
bladder)
• UTZ Whole ABD
• Volume per Volume replacement
(1 is to 1 replacement – IV and oral
intake)
• MHBR (moderate high back rest)
• Monitor the progression of lesions
• Capillary Refill Check regularly (to
determine the perfusion of the
patient)
• Skin care
• PRN TRAMAL 100 MG CAP for
pain
Initial Rounds 10:00 AM Mang Raul asked you “unsa na
T PR RR BP O2 pagkaon ako pwede kan.on ra?
37°C 98bpm 21cpm 150/95mmHg 94% T PR RR BP O2
• Mang Raul is lying on bed, conscious, 36.8°C 90bpm 23cpm 150/90mmHg 95%
coherent and oriented • He consumed half of 500mL of mineral water
• IVF level 900mL; infusing well • The level of the urine in the UB 170mL
• O2 @ 21pm • IVF level at 830mL
• Dry and reddened nares • Mang Raul also told you “Sige ko mangatol
• Lesions noted sako likod”
• FBC to UB 100mL • You assisted him in changing his clothing
• Hyperactive bowel sound noted • Performed CBB
• Pain is still manifested by patient 7/10 • According to him, he defecated once this
• The oropharynx was normal. There was 9:45 and it is still watery
enlargement of the lingual mandible • You referred the itching to Dr. Moi via TO
anteriorly and on the right and he ordered to apply 1% Hydrocortisone
• There was a surgical scarring and fibrosis cream now
over the mandible and neck on the right side
• Over the trunk and back, consistent with 11:00 AM
mastocytosis T PR RR BP O2
• He added that he has been going back to the 36.5°C 94bpm 20cpm 150/90mmHg 94%
95% in 2
comfort room twice since this morning
several
• Stool was still watery occasions

9:00AM Dr Moi made his assessment to • IVF level was 760mL

Mang Raul and Doctor’s orders • The output 250mL
Labs Results • Intake half a liter of water and Gatorade
Calcium 14.8mg/dL • Plus a cup of milk
Creatinine 1.22mg/dL • You apply the cream to the patient and then
Platelet 226 he asked you “Para sa asa diay ni siya?”
Phosphorous 1.0
WBC 10:0 12:00Noon
Oxalate 65mg per day T PR RR BP O2
Bone-specific 202 36.6°C 90bpm 21cpm 150/80mmHg 95%
Hydroxyvitamin D 9 (repeated, 2) • IVF level 650mL
• Output level 310mL (You drain the UB
You also refer the latest lab results and accordingly)
referred your assessment to Dr. Moi • Seen Mang Raul eating his lunch that was
• On full low salt; low fat diet and may give 2 served by the dietician
bananas per serving • Half of 500mL of water was also consumed
• Give Fexofenadine (Allegra 120mg HS, • Medication was given accordingly with a
Tab, PO but give SD now by 12noon) glass of water being consumed
• TS Rocaltrol (Calcitriol) 0.23MCG TID cap,
PO 1:00PM
• To infuse by 12 Sodium Phosphate Injection T PR RR BP O2
10mL vial infusion of 15gtts 36.0°C 96bpm 22cpm 150/80mmHg 95%
• TS Bismuth Subsalicylate (Pepto-Bismol • IVF level was 570mL
262mg BID tab PO) give SD at 12noon • Patient was seen taking a nap
• Increase oral intake • The output was at the level of 50mL
• To repeat U/A pls get midstream catch in the
catheter and refer once results are available 2:00PM
T PR RR BP O2
Dr. Tina Mante made her assessment and 36.7°C 95bpm 20cpm 150/90mmHg 96%
rounds • IVF level was 700mL
• TS Celecoxib (Celebrex 200mg capsule • Patient was sitting on the bed while watching
TID, PO) TV
• Increase oral intake to 1000mL • He reported intake of 80mL
• Decrease calcium in the diet please advice • The output was 130mL
• For BUN refer once result is available • He was eating a slice of apple
• Monitor for hematuria • Endorsed accordingly