YONA ALAN JONES - 249

IMD 18 BATCH 5

IM CLINICS CASE 1 PART II

1. INTERPRETATION OF LABORATORY RESULTS

CBC – infection is noted because of elevated levels of wbc (neutrophils)

URINALYSIS – NORMAL

Test name result units interpretation

Hemoglobin 145 g/L normal
hematocrit 0.42 % normal
erythrocytes 4.32 10^12l normal
Leukocytes 11.3 10^9l Increased
Thrombocytes 384 10^9l normal
Neutrophils 0.81 Percentage Increased
Lymphocytes 0.41 Percentage normal
Monocytes 0.08 Percentage Normal
Eosinophils 0.01 Percentage normal
basophils 0.0 Percentage normal
MCV 85.32 fL Normal
MCH 29.5 Pg Normal
MCHC 329 g/L Normal
RDW 12.7 % Normal
MPV 8.9 fL Normal

STOOL EXAM

1. Stool is brown and watery – diarrhea

2. Entamoeba histolytica trophozoites are seen. It is indicative of acute gastroenteritis
caused by Entamoeba histolytic

2. Management

I will treat this patient as outpatient because of the reduced amount of diarrhea and he only has
moderate dehydration. He is experiencing moderate hydration which has to be addressed. Since
the trophozoites of entamoeba are seen, he should be given metronidazole 750mg po TID for 10
days.

PRESCRIPTION

PATIENT NAME – XX
AGE – 23
ADDRESS – DAVAO CITY
 Rx
1. Metronidazole 750mg #30 TAB
SIG. give 1 tablet 3x per day. After meals.

2. ORS – depending on weight (not given). Drink as much as tolerated.

Yona alan jones

Lic. N0. 1233456
PTR. No. 1234556789

Final diagnosis

Acute gastroamoebiasis

(because of trophozoites of the same protozoa seen in the stool)