MEDICINE DE CURIE’

C A M P O S - B A C C AY, C O N A G
PA R A L L A G , P E K A S

DR. SHERYL CELINO-BAJET

 GENERAL DATA

Name: L.P.
Age: 31 Address: Baggao, Cagayan
Sex: Male Source of Information:
Civil Status: Married Patient
Religion: Roman Catholic Reliability: 90%
Occupation: Farmer
CHIEF COMPLAINT

• Calf pain and nose bleeding

 HISTORY OF PRESENT ILLNESS

5 days prior to admission, the patient experienced

undocumented fever with chills and generalized muscle pain.
This is accompanied by pain in the nape when head is flexed. No
consultation was done. Patient started to take Bioflu 500mg q4
and Alaxan OD and was relieved.
 HISTORY OF PRESENT ILLNESS

4 days PTA, the patient still had generalized muscle pain,

with the calves as the most affected part with a pain scale of 10
out of 10 with 10 being the most painful and 1 as the least. Patient
also has difficulty in walking. The patient also experienced
painful urination and decreased urine output. He also had
frequent watery stool with small quantity
 HISTORY OF PRESENT ILLNESS

2 days PTA, the patient had frontal headache and vomited

once. His headache had a pain scale of 8 out of 10. He decided to
seek consultation at a local clinic. He was given Co- Amoxiclav
500mg BID, Multivitamins and Iron. Later that day after
consultation, he had fever with chills and took Bioflu
 HISTORY OF PRESENT ILLNESS

1 day PTA, had no fever, calf pain, headache, nausea and

vomiting and is able to return to activities of daily living. The
patient noted to have reddish eye but with no pain, tearing and
photophobia.
 HISTORY OF PRESENT ILLNESS

Few hours PTA, the patient had nose bleeding which he

estimated about 4 tbsp. He seek consultation at a local clinic and
was referred to CVMC for further evaluation and was
consequently admitted
 PAST MEDICAL HISTORY
Childhood illness: fever, cold, cough
Adult illness:
– Medical: None
– Surgical: None
– Psychiatric: None
Health maintenance:
Immunizations: BCG
 FAMILY HISTORY
(+) hypertension PATETNAL SIDE
(-) diabetes
(+) asthma MATERNAL SIDE
(-)cancer
(-) allergies to food and drugs.
 PERSONAL AND SOCIAL HISTORY
• Born and raised in Baggao Cagayan
• Married with child
• Lives in a semiconcrete house
• Water source is mineral
• Diet consist mostly of vegetables
• Non smoker
• Drinks 150 ml Gin everyday
• Patient is a farmer
 SUBJECTIVE
• Fever
• Chills
• Headache
• Nausea Vomiting
• Muscle pain (calf pain)
• Nuchal rigidity
• Decreased UO
• Painful urination
• Red eye Diarrhea Epistaxis
 REVIEW OF SYSTEMS

• Skin: no rashes, itching, lumps, 1cm wound on left

foot plantar area
 PHYSICAL EXAMINATION

• Patient is sitting on bed conscious and coherent, oriented to

time, place and person.
• Vital signs:
• BP - 120/80 on his right arm sitting
• Temperature - 36.7 (axillary);
• HR - 68bpm.
• Respiratory rate- 19 cpm
 PHYSICAL EXAMINATION
• SKIN: Normal in appearance no rashes.No clubbing and no cyanosis, (+) 1cm
wound on left foot, plantar area
• HEENT:
•Head: No lesions or masses
•Eyes: No discharge, no edema, anicteric sclera
•Ears and Nose: Regular shape and size, no tenderness on palpation, no discharges,
scars, lesions, masses or foreign bodies
•Neck: Symmetric, no masses, lesions or other abnormalities
•Throat: Trachea is in midline position with no tenderness on palpation
 PHYSICAL EXAMINATION
• CHEST: Symmetrical chest expansion. No chest retraction. Clear breath sounds.
CARDIOVASCULAR: Point of maximum impulse located at the left fifth
intercostal space on the midclavicular line. No murmur. Regular rate and rhythm.
• ABDOMEN: Soft, no tenderness and no distention
• MUSCOLOSKELETAL: No joint pain and deformities with good range of motion.
• EXTREMITIES: Warm and without edema, no rashes no erythema, no clubbing and
cyanosis.
 PHYSICAL EXAMINATION
• NEUROLOGICAL: Patient is awake, conscious and alert.
• Cranial nerves
• CN 1: able to smell coffee
• CN 2: = (+) pupillary light reflex (2-3mm dilation)
• CN 3, 4, 6: intact extraocular muscles
• CN 5: able to contract masseter and temporal muscle
• CN 7: facial symmetry
• CN 8: intact
• CN 9, 10: able to swallow
• CN 11: able to move shoulder
• CN 12: no deviation on tongue protrusion
 OBJECTIVE

• BP: 120/80
• Temperature: 36.7
• HR 68bpm
• RR: 19 cpm (+) 1cm skin lesion on left foot
 DIAGNOSTIC PROCEDURE

• Urinalysis
• CBC
• CXR
• CULTURE
• MICROSCOPIC AGGLUTINATION TEST- gold standard
• INITIAL DIAGNOSIS: LEPTOSPIROSIS
 DIFFERENTIAL DIAGNOSIS
SALIENT FEATURES:
• Intermittent fever with • Acute red eye
chills
• Epistaxis
• Headache
• Farmer
• Generalized muscle pain
• Patient not using protective
• Calf pain footwear
• Nuchal rigidity

• BACTERIAL MENINGITIS
• An acute purulent infection within the subarachnoid space. It is associated
with a CNS inflammatory reaction
RULE IN
Fever with chills
Headache
Nuchal rigidity
Nausea and vomiting
DIFFERENTIAL DIAGNOSIS
RULE OUT
(-) rash
No history of flu like symptom
(-)Confusion or difficulty concentrating
(-)Sleepiness
(-)Photosensitivity
 DIFFERENTIAL DIAGNOSIS

• TYPHOID FEVER

RULE IN RULE OUT

Epistaxis (-)Intermittent fever
Nausea and vomiting (-) abdominal pain
Generalized muscle pain (-) rose spots
Headache (-)constipation
 DIFFERENTIAL DIAGNOSIS
• INVASIVE LOBAR CARCINOMA

Rule in Rule out

 thickening and hardening  (-) breast pain
in a specific area  (-) nipple pain
 Birth control pills  Nipple discharge
 discharge
 Lump in the breast
 DIFFERENTIAL DIAGNOSIS

• DENGUE FEVER

RULE IN RULE OUT

Fever with chills (-) periorbital pain
Epistaxis (-) rash
Nausea and vomiting (-) joint pain
Generalized muscle pain
Headache
 TREATMENT
• Prompt initiation of antimicrobial probably shortens the
course of severe leptospirosis and prevents the progression of
mild disease. Mild leptospirosis often is not specifically
identified and typically resolves without antibiotic treatment.
If clinical suspicion is high or the diagnosis is suggested or
confirmed by laboratory findings in an appropriate context
mild disease should be treated with oral antibiotics—in
particular, doxycycline
• Antimicrobial drugs (typically penicillin, ceftriaxone, or
cefotaxime) should be used to treat severe later-stage
leptospirosis