ORAL REVALIDA 1st SEM 18-19

CLINICAL  THERAPEUTICS  3A  

AFRPh

 
SOAP NOTES CASE 1: PULMONARY TUBERCULOSIS
v Subjective, Objective, Assessment, Plan Note IN CHILDREN (Dr. Ravelo)
v An acronym representing a widely used method of documentation for Demographics   Family  History  
v
healthcare providers in a structured and organized way
An essential piece of information about the health status of the patient as
S v 3  year  old,  male,  Filipino   v Lives  in  Payatas  in  a  
Chief  Complaint   household  comprising  of  7  
well as a communication document between health professionals v Prolonged  cough  lasting  for   members  (maternal  
v The structure of documentation is a checklist that serves as a cognitive aid 10  days,  productive  in   grandparents,  parents,  2  
and a potential index to retrieve information for learning from the record. character  occurring  anytime   siblings  and  maternal  uncle)  
v A comprehensive SOAP note has to take into account all subjective and of  the  day   v Grandfather:  diagnosed  with  
objective information, and accurately assess it to create the patient-specific History  of  Present  Illness   active  pulmonary  tuberculosis  
assessment and plan. v History  of  low  grade  fever   8  months  ago  and  is  currently  
SUBJECTIVE with  temp  range  of  38-­‐38.5C   being  treated  in  their  
v Documentation under this heading comes from the “subjective” experiences, for  the  past  5  days   Barangay  DOTS  
personal views or feelings of a patient or someone close to them. v Patient  remained  active  but   v Uncle  &  Father:  suffering  
v In the inpatient setting, interim information is included here. This section with  decreased  appetite   from  on  and  off  cough  
provides context for the Assessment and Plan. v Weight  and  height  did  not   v Father  &  Grandfather:  
v It contains: increase  for  the  past  6   cigarette  smokers  
Ø Chief Complaint months   v Grandmother:  hypertensive  
§ The presenting problem that is reported by the patient. Past  Medical  History   v (-­‐)  Bronchial  Asthma,  Atopy  
§ This can be a symptom, condition, previous diagnosis or another v Pneumonia  at  age  1  y/o  and   Personal  &  Social  History  
short statement that describes why the patient is presenting was  hospitalized  for  3  days   v Patient  is  younger  of  2  
today. v At  2  y/o,  he  had  another   siblings  
Ø History of Present Illness episode  of  pneumonia  treated   v Described  as  “sakitin”  
§ An acronym often used to organize the HPI is termed as  outpatient  basis   v His  development  is  at  par  
“OLDCARTS” v He  had  monthly  episodes  of   with  age  
§ Onset, Location, Duration, Characterization, cough  and  colds  which   v His  mother  is  a  public  school  
Alleviating/Aggravating Factors, Radiation, Temporal Factor, sometimes  resolves   teacher  while  the  father  
Severity spontaneously  after  5  days   works  as  employee  in  
Ø Medical History, Surgical History, Family History, Social History v He  was  also  reported  as   Maynilad.  
Ø Review of Systems “pihikan”  &  “mahina  kumain”  
Physical  Examination  Findings   Heart  
O
§ This is a system based list of questions that help uncover
symptoms not otherwise mentioned by the patient. v Ambulatory,  not  in  any  form   v Regular  rate  and  rhythm,  no  
Ø Current Medications, Allergies distress  with  the  following   murmurs  
measurements     Abdomen  
OBJECTIVE Vital  Signs   v Slightly  globular,  soft,  non-­‐
v Wt:  12.6kg,  Ht:  76cm,  HR:88,   tender  with  no  palpable  
v This section documents the objective data from the patient encounter.
RR:20,  Temp:36.9C   organomegaly,  normoactive  
v This includes:
HEENT   bowel  sounds  
Ø Vital Signs
v Pink  turbinates  and  throat,   Skin  
Ø Physical Examination Findings
intact  tympanic  membranes   v No  active  dermatoses  
Ø Laboratory Data
Neck   PPD  
Ø Imaging Results
v (+)  1x1cm  palpable  and   v 18mm  
Ø Other Diagnostic Data
movable  masses   Chest  X-­‐Ray  
Ø Recognition and Review of the Documentation of other Clinicians
(lymphadenitis)  at  the   v Streaky  infiltrates  with  hilar  
A common mistake is distinguishing between symptoms and signs.
retrosternal  areas  about  2  in   lymphadenopathies  
o Symptoms are the patient's subjective description and should be
number  on  the  right   Complete  Blood  Count  
documented under the subjective heading, while a sign is an objective
Chest/Lung   Hgb  12.4  g/dl                            Hct  36%            
finding related to the associated symptom reported by the patient. 3 3
v Clear  breath  sounds,  (-­‐)   WBC  10x10 /mm          Neutro  60%  
o An example of this is a patient stating he has “stomach pain,” which is
crackles  or  wheezes   Lympho  28%                              Mono  8%    
a symptom, documented under the subjective heading. Versus 3 3
Plt  213x10 /mm              Eos  4%                              
“abdominal tenderness to palpation,” an objective sign documented
Diagnosis:  Primary  Tuberculosis  or  Clinically  Active  Tuberculosis  (Class  3)    
under the objective heading.
A v History  and  PE  
Ø Prolonged  productive  cough  
ASSESSMENT Ø Low  grade  fever  38-­‐38.5C  
v This section documents the synthesis of “subjective” and “objective” Ø Wt  and  ht  did  not  increase  for  the  past  6  months  
evidence to arrive at a diagnosis. Ø Exposure  to  his  grandfather  who  was  diagnosed  with  active  
pulmonary  TB  and  possibly  from  his  father  and  uncle  who  are  also  
v This is the assessment of the patient’s status through analysis of the
suspected  to  have  the  disease  
problem, possible interaction of the problems, and changes in the status of
Ø (+)  1x1cm  palpable  and  movable  masses  (lymphadenitis)  at  the  
the problems. retrosternal  areas  about  2  in  number  on  the  right  
v Elements include the following: v Tuberculin  Skin  Test  
Ø Problem Ø Patient’s  PPD=  18mm  
§ List the problem list in order of importance. A problem is often v Radiographic  Evidence  
known as a diagnosis. Ø Streaky  infiltrates  with  hilar  lymphadenopathies  
Ø Differential Diagnoses Category:  Category  I  –  New  Pulmonary  Tuberculosis  
P
v
§ This is a list of the different possible diagnosis, from most to least v Treatment:  2HRZE/4HR  
likely, and the thought process behind this list. Ø 2  Months  of  Intensive  Phase  
§ This is where the decision-making process is explained in depth. § H:  Isoniazid  50mg/tab  PO  3tabs/day  
Included should be the possibility of other diagnoses that may § R:  Rifampicin  75mg/tab  PO  3tabs/day  
harm the patient, but are less likely. § Z:  Pyrazinamide  150mg  PO  3tabs/day  
§ E:  Ethambutol  20mg/kg/day  
PLAN Ø 4  Months  of  Continuation  Phase  
v This section details the need for additional testing and consultation with § H:  Isoniazid  50mg/tab  PO  3tabs/day  
other clinicians to address the patient's illnesses. § R:  Rifampicin  75mg/tab  PO  3tabs/day  
v It also addresses any additional steps being taken to treat the patient. v Non-­‐Pharmacologic  Treatment:  
v This section helps future physicians understand what needs to be done next. Ø Support  to  the  child  by  his/her  parents  and  immediate  family    
For each problem (4D’s): Ø Carry  out  physical  activity  
Ø Diet Plan Ø Healthy  balanced  diet  (cereals,  vegetables,  fruits,  milk,  meat,  
Ø Diagnostic Tests that will be ordered eggs,  fish,  nuts  and  oil  seeds)  
Ø Drugs/Treatments that will be prescribed  
Ø Disposition (Patient Education and Follow-Up)  

“Faith would not be real faith if you only believe when things are good.” Page 1 of 4
 CASE 2: HYPERTENSION, DYSLIPIDEMIA (Dr. Alejo) vomiting,  or  diarrhea  
Past  Medical  History  
Demographics  
S
v Chronic  smoker’s  cough  (20  years)  –  smoked  2  packs  per  days  for  the  
v 47  year  old,  male,  Filipino   past  50  years  
Chief  Complaint   Physical  Examination  Findings  
v
v
High  blood  pressure  
Nape  Pain  
O v Patient  is  conscious,  disoriented,  appears  tired,  haggard  and  
underweight  
v Chest  Tightness   Vital  Signs  
History  of  Present  Illness   v Wt:  180  lbs,  Ht:  5’7”,  BMI  28.19  (overweight),  BP:  150/90,  RR:  15,  
v BP  Measurement  at  home  for  1  week:   Temp:  36.5C  
Ø Highest:  170/105mmHg   HEENT  
Ø Lowest:  140/90mmHg   v Mildly  icteric,  pupils  equally  reactive  to  light  
Ø Average:  145/90mmHg   Neck  
v He  also  complains  of  nape  pain,  especially    after  drinking  beer  with   v Supple,  no  cervical  lymphadenopathy  
chicharron  or  fatty  foods.     Lungs  
v He  had  a  bout  of  chest  tightness  hence  this  consult.   v Decreased  breath  sounds,  with  crackles  over  the  lower-­‐right  lung  
Past  Medical  History   Heart  
v Dyslipidemia  and  Depression   v Tachycardic,  no  murmurs  
Family  History   Abdomen  
v Father-­‐  MI  and  HPN   v Soft,  non-­‐tender,  normoactive  bowel  sounds,  no  palpable  mass  
v Mother  (+)  Cholecystectomy   Extremities  
Personal  &  Social  History   v weak  pulses,  no  edema  
v Call  center  agent  for  20  years   Laboratory  
He  smokes  ½  pack  of  cigarettes/day   O2  sat  85%                              Hgb  10.8                      Hct  36                          Plt  150  
Vital  Signs  
O
3
WBC  30,000/mm      Neutro  70%            Bands  15%            Lympho  15%        
v Wt:  180  lbs,  Ht:  5’7”,  BMI  28.19  (overweight),  BP:  150/90,  RR:  15,   FBS  87mg/dl                        HBA1C  5.6%          BUN  24                      Crea  2.1  
Temp:  36.5C   Bicarbonate  23                Na  141                              Cl  98                                K  4.0  
HEENT,  Chest,  Abdomen,  Extremities   Radiology  
v Unremarkable   v Focal  consolidation  in  the  lower  right  lobe  
Cholesterol  Panel   Blood  Culture  
v HDL  52  mg/dl  (1.34murol/L)   v No  growth  after  48  hours  
v TG:  180mg/dl  (2.03murol/L)   Sputum  Culture  
v TC:  250mg/dl   v No  growth  after  48  hours  
v LDL:  190mg/dl  
Pneumococcal  Urinary  Antigen  
v All  other  lab  values  are  normal  
v Positive  
Diagnosis:  Stage  2  Hypertension  and  Dyslipidemia  
A v
v
Average  Blood  Pressure:  145/90  mmHg  
(+)  nape  pain,  chest  tightness   A
Diagnosis:  Moderate-­‐Risk  Community  Acquired  Pneumonia  

Treatment:  Ampicillin-­‐Sulbactam  1.5  gm  q6h  IV  +  Azithromycin  

P
v Risk  factors:  family  history  of  hypertension  and  dyslipidemia,  smoker,  BMI:   v
overweight   500mg  OD  PO  
v Laboratories:  ↑Triglycerides,  ↑LDL,  ↑Total  Cholesterol   v Non-­‐Pharmacologic  Treatment:  
Monitor:  
P
Ø All  patient  should  receive  appropriate  oxygen  therapy  with  
v BP,  LDL,  TG,  TC,  HDL   monitoring  of  oxygen  saturations  and  inspired  oxygen  
Hypertension   concentration  with  the  aim  to  maintain  (PaO2)  >=  8kpa  and  
v Any  of  these  combination  regimens:   oxygen  saturation  (SpO2)  94  -­‐  98%.  High  concentrations  of  
Ø Captopril  25mg/day  BID  to  TID  +  Chlorthalidone  12.5  mg  OD   oxygen  can  safely  be  given  in  patients  who  are  or  at  risk  of  
w/  maintenance  dose  of  25  mg  OD   hypercapnic  respiratory  failure.  
Ø Losartan  potassium  (Cozaar)  50  mg/day  daily  to  BID  +   Ø Oxygen  therapy  in  patients  at  risk  of  hypercapnic  respiratory  
Chlorthalidone  12.5  mg  OD  w/  maintenance  dose  of  25  mg  OD   failure  complicated  by  ventilatory  failure  should  be  guided  by  
Ø Captopril  25  mg/day  BID  to  TID  +  Felodipine  with  2.5  to  10   repeated  arterial  blood  gas  measurements.  
mg/day     Ø Patient  should  be  assessed  for  volume  depletion  and  may  
Ø Amlodipine  2.5  to  10  mg/day  given  +  Valsartan  80  to  160   require  intravenous  fluid  
mg/day  daily    
Dyslipidemia  
CASE 4: DIABETES MELLITUS (Dr. Reyes)
v Moderate  to  High  intensity  Statin:  
Demographics  
S
Ø Moderate  Intensity  Statin  
§ Atorvostatin  10  mg   v 50  y/o,  female  (G3P3)  
§ Pravastatin  40  mg   Chief  Complaint  
§ Simvastatin  20-­‐40  mg   v Frequent  episodes  of  urination  usually  at  night    
Ø  High  Intensity  Statin   v Unusually  increased  appetite  in  the  past  3  months  
§ Atorvostatin  40-­‐80  mg   Past  Medical  History  
Non-­‐Pharmacologic  Treatment   v The  patient  has  a  history  of  Polycystic  Ovarian  Syndrome  diagnosed  
rd
v Diet  emphasizing  vegetables,  fruits,  and  whole  grains   during  the  3  decade  of  her  life  
v Sodium  intake  of  less  than  2.4g  per  day   v All  her  pregnancies  were  complicated  by  Gestational  DM  
v Exercise  3-­‐4  times  a  week;  40  mins  per  session  (Overweight  patients   v She  has  hypertension  for  2  years  now  
should  engage  in  low-­‐intensity  exercise  more  frequently  and  for   v She  claimed  to  have  allergy  to  Sulfonamides  
longer  durations)   Family  History  
v Smoking  cessation   v Father:  Diabetes  
v Alcohol  intake  regulation  (not  more  than  2  drinks  for  men)   v Parents:  Hypertension  
  v Grandfather  and  Brother:  DM  and  MI  
Social  History  
CASE 3: PNEUMONIA (Dr. Co) v She  is  a  non-­‐smoker  and  a  non-­‐alcoholic  beverage  drinker  
Demographics   v She  is  fond  of  eating  fatty  foods,  meat  and  sweets  
S v 70y/o,  male   v She  is  not  physically  active  as  she  prefers  watching  teleseryes  over  
exercise.  
Chief  Complaint  
v Dry  Cough   Medications  
History  of  Present  Illness   v Propranolol  10mg  once  a  day  
Physical  Examination  Findings  
O
v 5-­‐day  history  of  dry  cough,  progressing  to  rusty  colored  sputum,  
sudden  onset  of  chills  the  previous  evening,  fever,  and  malaise   v Unremarkable  
v He  thought  he  had  a  cold,  but  the  symptoms  had  worsened,  and  he   Vital  Signs  
barely  slept  last  night  with  all  this  coughing”   v Wt:  170  lbs,  Ht:  5’3”,  BP:  150/90,  HR  80,  RR:  20  
He  denied  experiencing  shortness  of  breath  but  suggested  he  may  be   Laboratory  
breathing    “a  little  faster  than  normal”     HBA1C:  8.0%   TC:  190mg/dl   FBS:  145mg/dl
v He  related  that,  on  the  way  to  the  emergency  room,  he  felt  some     LDL-­‐C:  180mg/dl   ALT:  19U/L   TG:  160mg/dl  
sharp  right-­‐sided  chest  pain  after  a  particularly  long  bout  of  coughing     Hgb:  12mg/dl   HDL-­‐C:35mg/dl   Hct:  0.37  
v He  denied  any  leg  swelling,  orthopnea,  or  left-­‐sided/substernal  chest     UA:  Trace  protein   SCr:  1mg/dl  
pain.  He  also  denied  any  gastrointestinal  symptoms  like  nausea,  

“Faith would not be real faith if you only believe when things are good.” Page 2 of 4
 Diagnosis:  Diabetes  Mellitus  Type  2   Diagnosis:  Iatrogenic  Hypothyroidism  
A v
v
Polycystic  ovarian  syndrome:  increases  the  risk  of  diabetes.  
Gestational  diabetes:  If  you  developed  gestational  diabetes  when  you  
A v In  our  case,  the  patient  has  an  iatrogenic  hypothyroidism.  Iatrogenic  
hypothyroidism  can  be  caused  by  either  surgical  or  radiation-­‐induced  
were  pregnant,  your  risk  of  developing  type  2  diabetes  increases.  If  you   ablation.  Based  on  her  history,  he  had  post  radioactive  therapy  for  Diffuse  
gave  birth  to  a  baby  weighing  more  than  9  pounds  (4  kilograms),  you're   Toxic  Goiter  for  3  years,  which  may  cause  the  transient  hypothyroidism  
also  at  risk  of  type  2  Diabetes.   due  to  reversible  radiation  damage.  
v Family  history:  The  risk  of  type  2  diabetes  increases  if  your  parent  or   Monitor:  

v
sibling  has  type  2  diabetes.  
Inactivity:  The  less  active  you  are,  the  greater  your  risk  of  type  2  Diabetes.  
P v TSH,  FT4,  LDL,  HDL,  TG,  TC  
Treatment  
Physical  activity  helps  you  control  your  weight,  uses  up  glucose  as  energy   v Levothyroxine  (LT4)  
and  makes  your  cells  more  sensitive  to  insulin.  
Ø Since  the  patient  is  hypertensive  and  has  a  family  history  of  
v Age:  The  risk  of  type  2  diabetes  increases,  as  you  get  older,  especially  after  
cardiac  disease  with  long-­‐standing  hypothyroidism,  it  is  
age  45.  That's  probably  because  people  tend  to  exercise  less,  lose  muscle  
mass  and  gain  weight  as  they  age.  But  type  2  Diabetes  is  also  increasing   recommended  to  start  with  reduced  dosages  of  levothyroxine,  
dramatically  among  children,  adolescents  and  younger  adults.   12.5-­‐25  mcg/d  for  2  weeks,  before  increasing  by  12.5  –  25  
Monitor:   mcg/d  every  2  weeks  until  euthyroidism  is  observed  
P v BP,  HbA1c,  Random  Blood  Sugar,  FBS,  LDL,  HDL,  TG   Ø Administered  on  an  empty  stomach  (60  minutes  before  meals,  4  
hours  after  meals,  or  at  bedtime)  since  interaction  with  certain  
Diabetes  Mellitus  Type  2  
v Metformin  500mg  OD  at  bedtime  or  before  a  meal   foods  and  drugs  can  impair  its  absorption  
Dyslipidemia   Dyslipidemia  
v Simvastatin  20mg  OD  at  bedtime   v Moderate  to  High  intensity  Statin:  
Hypertension   Ø Moderate  Intensity  Statin  
v Captopril  25mg  BID  before  meals   § Atorvostatin  10  mg  
Non-­‐Pharmacologic  Treatment   § Pravastatin  40  mg  
v Medical  Nutrition  Therapy   § Simvastatin  20-­‐40  mg  
Ø Weight  loss  diet  (hypocaloric  diet)   Ø  High  Intensity  Statin  
Ø Food  with  low  glycemic  index   § Atorvostatin  40-­‐80  mg  
Ø Minimal  trans-­‐fat  consumption,  Low-­‐carbohydrate  diet   Non-­‐Pharmacologic  Treatment  
Ø Non-­‐nutrient  sweeteners,  Fructose  preferred  over  starch   v Eating  a  healthy  balanced  diet  
Ø Dietary  fiber,  vegetables,  fruits,  whole  grains,  dairy  products,   Ø Eating  well  can  maintain  a  healthy  weight  
and  sodium  intake  as  advised  for  general  population   v Eliminating  as  much  emotional  stress  as  possible  through  deep  
v Monitoring   breathing  or  meditation.    
Ø Self-­‐monitoring  of  blood  glucose   v Get  enough  sleep  
Ø HbA1c  testing,  2-­‐4  times/year   Ø Establishing  a  good  sleep  helps  to  relieve  fatigability  and  
Ø Eye  examination,  annual/biannual   tiredness  
Ø Foot  examination,  1-­‐2  times/year  by  physician;  daily  by  patient   v Moderate  exercise  for  stress  control  
Ø Screening  for  diabetic  nephropathy,  annual   Ø It  can  boost  energy,  decrease  stress  and  help  maintain  healthy  
Ø Blood  pressure  measurement   weight  
Ø Lipid  profile  and  serum  creatinine,  annual    
v Physical  Activity    
Ø Advise  to  do  at  least  150  minutes  per  week  of  moderate-­‐ CASE 6: IRON DEFICIENCY ANEMIA (Dr. Duenas)
intensity  aerobic  physical  activity  
Demographics  
v Diabetes-­‐related  Depression  
Ø Assessing  patients'  psychological  and  social  situation  as  an  on-­‐ S v 34  year  old,  female  (G3P3)  
Chief  Complaint  
going  part  of  medical  management,  including  screening  for  
v Easy  Fatigability  
depression,  diabetes-­‐related  distress  and  other  psychological  
v Dyspnea  
problems  
v Light  Headedness  
  v Dizziness  
CASE 5: HYPOTHYROIDISM (Dr. Fermin) History  of  Present  Illness  
Demographics   v She  has  no  appetite,  and  has  difficulty  in  falling  asleep  
S v 45  y/o,  female,  housewife   v She  claims  to  be  experiencing  these  symptoms  for  about  four  months  
now  
Chief  Complaint  
v Easy  fatigability   v She  had  profuse  menses  accompanied  by  blood  clots  and  hypogastric  
History  of  Present  Illness   pain  
v History  started  few  months  prior  to  consult  when  patient  noticed   v Sometimes  the  patient  is  irritable  and  feels  lazy  of  going  to  her  work  
that  she  gets  easily  tired  when  doing  household  chores  as  compared   Past  Medical  History  
to  the  previous  month.     v Childhood  asthma  resolved  by  age  14  
v No  other  symptoms  noted.     v Appendectomy  at  age  20  
v She  denies  difficulty  of  breathing,  palpitations,  weight  loss,  polyuria,   Family  History  
polydipsia  or  polyphagia.   v Mother:  total  hysterectomy  at  the  age  of  44  due  to  fibroid  
Past  Medical  History   v Father  passed  away  from  a  car  accident  at  age  30  
v (+)  Hypertension  for  2  years  on  Amlodipine  5mg  OD,  UBP:  120/70     Personal  and  Social  History  
v S/P  Cholecystectomy  x10yrs   v Patient  is  a  sari-­‐sari  store  vendor  and  currently  living  with  her  
Family  History   husband  
v Parents-­‐DM,  Heart  Disease   v She  does  not  take  alcohol  and  does  not  smoke  
v Mother-­‐HTN   v Most  of  the  time  she  skips  her  breakfast  or  just  take  some  cereals  and  
Review  of  Systems   tea  
v (+)  weight  gain  (10kg  or  22lbs  in  1  year)   Medications  
v (+)  cold  intolerance   v Started  self-­‐medicating  with  Mefenamic  Acid  500mg  during  her  
v (+)  postural  dizziness   menstrual  cycle  
v She  occasionally  take  Aluminum  Magnesium  Hydroxide  for  her  Acute  
Vital  Signs  
O v Wt:  75kg(165lbs),  Ht:  5’5”(165cm),  BMI:  27.5kg/m2,  BP:  120/70,  
v
Peptic  Disease  
No  adverse  drug  events  (ADE)  were  noted  
HR:58,  RR:18,  Temp:37C  
Vital  Signs  
HEENT  
v Puffy  face,  pupils  3mm  reactive  to  light,  full  and  equal  EOMS   O v Wt:  53.4kg,  157.7cm,  BP:120/80,  RR:22,  PR:109,  T:36C  
Skin   HEENT  
v Dry  and  thick  skin   v Pale  palpebral  conjunctivae,  anicteric  sclerae  
Extremities   Chest/Lungs  
v Non-­‐pitting  edema,  lower  extremities,  deep  tendon  reflex:  delayed   v Symmetrical  on  expansion,  clear  breath  sounds,  tachycardic,  no  
Laboratory   murmur  
  TSH:  21.6  IU/L  (NV:  0.4-­‐4.6  IU/L)   Extremities  
  FT4:  8.3  IU/L  (NV10-­‐24)   v Pale  palms  and  nail  beds  
  Na  137     K  4.6     Hgb  11.3   Laboratory  
  Hct:  0.38     LDL  197     HDL  34   v CBC,  UA,  PBS  showed  microcytic  hypochromic  anemia  
Diagnosis:  Iron  Deficiency  Anemia  
A
  Cholesterol:  250mg/dl  
  Triglyceride:  205mg/dl   v Signs  and  Symptoms  
Ø Easy  fatigability,  Dyspnea,  Light  headedness,  Dizziness,  Tachycardia,  

“Faith would not be real faith if you only believe when things are good.” Page 3 of 4
 Pale  palms  and  nail  beds  (Pallor),  Poor  appetite,  Pale  conjunctiva   Treatment  
v Hypochromic,  Microcytic  RBC   v Extraintestinal  Infection  (Liver  Abscess)  
Monitor:  
P
Ø Metronidazole  750mg  TID  or  500mg  IV  q6h  for  10  days  
v VS,  CBC,  PBS   Ø Tinidazole  2g  OD  for  5  days  
Treatment   Non-­‐Pharmacologic  Treatment  
v Oral  Iron   v Surgical  management:  entails  an  individualized  approach  based  on  the  
Ø Ferrrous  sulfate  325  mg  once  daily  on  an  empty  stomach.   underlying  clinical  condition  and  the  source  of  the  abscess.    
Typically,  for  iron  replacement  therapy,  up  to  200  mg  of   v “Source  control”  is  essential  in  the  surgical  treatment  of  pyogenic  
elemental  iron  per  day  is  given,  usually  as  three  or  four  iron   liver  abscess.    
tablets  (each  containing  50–65  mg  elemental  iron)  given  over   v Laparotomy  and  surgical  drainage  is  essential  in  eliminating  the  
the  course  of  the  day.     source  of  infection  that  seeded  the  liver.  
Ø Iron  therapy  should  continue  for  3–6  months  after  restoration    
of  normal  hematologic  values  to  replenish  iron  stores.  
CASE 8: ACETAMINOPHEN POISONING (Dr. Cruz)
v Parenteral  Iron  
Demographics  
S
Ø Ferumoxytol  delivers  510  mg  of  iron  per  injection  
Ø Ferric  gluconate  125  mg  per  injection   v 45  y/o,  female,  bag  designer  
Ø Ferric  carboxymaltose  750  mg  per  injection   Chief  Complaint  
Ø Iron  sucrose  200  mg  per  injection.   v Paracetamol  Overdose  
  History  of  Present  Illness  
  v The  patient  was  brought  to  the  ER  by  a  room  service  staff  to  the  
hotel  the  patient  was  checked  into.  
CASE 7: PARASITISM (Dr. Alejo)
v The  room  service  staff  noted  that  the  patient  was  crying  inconsolably  
Demographics  
S
by  the  bed.  She  relates  that  a  major  business  deal  fell  through  and  
v 40  y/o,  male   that  she  lost  all  of  the  money  that  she  invested  in  it.  Thinking  that  
Chief  Complaint   there  was  no  other  way  to  regain  all  of  the  money  she  lost,  she  took  
v Fever   20  tablets  of  paracetamol  500mg/tablet  at  around  6AM.  
v Malaise   v After  initial  hesitation,  the  room  service  staff  eventually  convinced  
v Anorexia   the  patient  to  head  to  the  ER  of  the  nearest  hospital.  They  arrived  at  
v Right  upper  quadrant  pain  for  the  past  2  weeks   the  ER  at  8AM.  
History  of  Present  Illness   v She  insists  on  being  discharged  because  she  says  she  feels  fine  aside  
v A  40  y/o  male  came  to  the  OPD  complaining  of  fever,  malaise,   from  feeling  mildy  nauseous.  
anorexia  and  right  upper  quadrant  pain  for  the  past  2  weeks.     Past  Medical  History  
v The  pain  radiates  to  the  right  shoulder  especially  when  taking  deep   v Unremarkable  
breaths.  The  pain  became  unbearable  hence  the  consult.     Personal  and  Social  History  
v The  patient  also  said  he  has  lost  weight  and  felt  fatigue  due  to  his  on   v Alcohol  dependent  
and  off  diarrhea  which  he  treats  with  diabetes.   Ø She  is  part  of  a  support  group  but  has  admittedly  gone  back  to  
Past  Medical  History   drinking  again  since  3  months  ago  after  her  husband  asked  for  a  
v He  had  a  history  of  bloody  diarrhea  several  months  ago  after  a   legal  separation  
camping  trip  to  the  south.   v Recovering  anorexic  
Personal  and  Social  History   Ø but  has  admittedly  been  starving  herself  again  at  around  the  
v Patient  is  fond  of  outdoor  activities.  He  occasionally  drinks  alcoholic   same  time  as  well  
beverages  and  smoke  3-­‐4  sticks  of  cigarettes/week  for  the  last  20   Physical  Examination  Findings  
years.  
Physical  Examination  Findings  
O v Essentially  normal  findings  except  for  a  BMI  of  17  

O
Laboratory  
v Patient  has  fever  with  direct  and  rebound  tenderness  on  palpation  at   v All  within  normal  limits  
the  right  upper  quadrant.  Other  PE  findings  are  within  normal.   Diagnosis:  Paracetamol  Overdose/Acute  Acetaminophen  Toxicity  
Vital  Signs  
v BP:110/60,  PR  102,  Temp  40C,  Wt:  75kg,  Ht  165cm  
A v Patient  presented  self-­‐harm  through  ingestion  of  20  tablets  of  
Paracetamol  500mg/tablet  amounting  to  10g.  In  a  normal  adult,  dose  
Diagnosis:  Liver  Abscess  Secondary  to  Amoebic  Dysentery  
A
of  more  than  6  to  7  grams  is  hepatotoxic.  
Differential  Diagnosis:   v Patient  is  alcohol  dependent    or  a  chronic  alcoholic.  
v Acute  Appendicitis   v She  has  been  starving  herself  the  same  time  as  the  incident.  Has  a  
Ø RULE  IN:  Pain  in  the  Right  upper  quadrant  is  not  the  most   BMI  of  17  (underweight).  
frequent  pain  elicited  in  Appendicitis  but  is  also  possible  to  be   Request:  
elicited.  The  patient  also  experienced  fever,  anorexia,  and  
malaise  along  with  on  and  off  diarrhea,  which  are  frequently  
P v Serum  Electrolytes,  Random  Blood  Sugar,  BUN,  Crea,  ALT/AST,  
PT/PTT,  ABG,  INR  q24h  
seen  in  appendicitis.   Treatment  
Ø RULE  OUT:  Pain  does  not  radiate  to  the  back  but  radiates  to   v N-­‐acetylcysteine  is  given  orally  until  36  hours  have  passed  since  the  
the  shoulders  instead,  pain  was  also  not  felt  in  the  RLQ,  which   time  of  ingestion.  Then  if  the  serum  acetaminophen  level  is  below  the  
is  where  pain  in  appendicitis  is  usually  felt.  Patient  also  did  not   limits  of  detection  and  liver  transaminase  levels  are  normal,  NAC  can  
note  the  feeling  of  needing  or  wanting  to  pass  gas  which  is  also   be  stopped.  If  there  is  evidence  of  hepatic  toxicity,  NAC  should  be  
a  possible  symptom  seen  in  appendicitis.   continued  until  liver  function  tests  are  improving.  
v Acute  Cholecystitis   v Oral  loading  dose  is  140mg/kg  of  the  10%  of  20%  solution  diluted  to  
Ø RULE  IN:  Pain  in  the  Right  upper  quadrant  that  radiates  to  the   5%  in  juice  or  soda  to  enhance  palatability.  Maintenance  oral  dose  70  
shoulders  along  with  Fever.  Frequent,  unexplained  diarrhea  can   mg/kg  every  4  hours.  
signal  a  chronic  gallbladder  disease.  Malaise  and  fever  is  also   v If  vomiting  interferes  with  oral  acetylcysteine  administration,  give  it  
present.   by  gastric  tube  and  use  high  dose  metoclopramide  (1-­‐2  mg/kg  IV)  or  
Ø RULE  OUT:  On  and  off  diarrhea,  history  of  bloody  diarrhea   ondansetron,  or  give  the  NAC  intravenously.  
months  ago,  travel  history  (camping  trip  to  the  south),  patient   Non-­‐Pharmacologic  Treatment  
did  not  cite  discomfort  after  fatty  meals   v Activated  charcoal  is  most  effective  when  administered  within  2-­‐3  
v Ulcerative  Colitis   hours  of  ingestion  with  decreasing  effectiveness  over  time.  Reduces  
Ø RULE  IN:  fever,  diarrhea,  fatigue,  anorexia,  weight  loss,  bloody   the  amount  of  acetaminophen  absorbed  by  the  GI  tract.  
stools,  fever   v Psychiatric/psychological  evaluation  and  treatment  via  counseling  
Ø RULE  OUT:  (-­‐)  joint  pain,  (-­‐)  photophobia,  (-­‐)  canker  sores,  (-­‐)   and  /  or  medications  for  depression,  weight  control  and  addiction/  
skin  sores   alcoholism.  
v Crohn’s  Disease   v Encourage  to  get  back  to  alcohol  cessation  and  continue  attending  
Ø RULE  IN:  Abdominal  pain,  frequent  recurring  diarrhea,  fever,   support  groups    
fatigue,  and  a  history  of  bloody  diarrhea.  Patient  also  noted  a   v Supplementation  of  milk  thistle  (silymarin)  supplementation  is  proven  
loss  of  appetite  and  unexplained  weight  loss,  all  which  are  all   to  be  hepatoprotective  
possible  symptoms  of  Crohn's  disease.   v Educate  on  risk  factors  for  acetaminophen  poisoning  based  on  risk  
Ø RULE  OUT:  Patient  did  not  present  with  mouth  sores  or  pain  in   factors:  alcoholic  and  anorexic  
the  anal  area.  Abdominal  cramping  was  also  not  noted  .  Crohn's   v Educate  on  the  ubiquity  of  acetaminophen  in  medications  and  to  be  
disease  may  present  with  joint  pain  but  pain  in  the  patient  was   cautious  in  future  due  to  current  risk  factors  
abdominal  pain  that  radiates  to  the  shoulder.     v A  healthy  diet  specifically  with  the  amino  acids  l-­‐glutamic  acid,  l-­‐
Request:  
P
cysteine  and  glycine.  Refer  to  a  dietician  or  nutrition  specialist  to  
v CBC,  ALT/AST,  Fecalysis,  EIA,  Serum  Ag  Detection   address  her  BMI  of  17,  to  promote  weight  gain  and  healthy  diet.  
Imaging    
v CXR,  Ultrasound,  CT  Scan   TO  BE  CONTINUED..  

“Faith would not be real faith if you only believe when things are good.” Page 4 of 4