INTERNAL MEDICINE

CASE PRESENTATION
REGINA ANNE BASE
PDR 3

 July 13, 2016 at 4pm

Source: patient
Reliability: 90%

General Data
A.O., 35 years old, male, married,Roman
catholic, works in VECO lives in Talisay city
born on October 1980 in Talisay city admitted in
CDUH for the 1st time on July 12 ,2016.

Chief complaint
Fever

HPI
patient was apparently well until 3 day PTA and
had sudden onset of mild abdominal pain
characterized as dull, non radiating with a pain
scale of 4/10 .no medications were taken. This was
associated with low grade fever during that night
with a maximum temperature of 38C . This was
associated with chills lasted for 40 minutes patient
self medicated with paracetomol (biogesic) 500mg
with a total of 1 tablet taken on that day which
provided temporary relief.no other signs and
symptoms were noted .no vomiting ,no nausea ,no
cough, no sorethroat, no change in urination and
bowel movement.

 2 days PTA patient still had abdominal pain

and fever with same characteristics with a
maximum temperature recorded was 39C .
Patient still took paracetomol with same
dosage for every 6hrs which gave him a
temporary relief. This was now associated with
2 episodes of vomiting characterized as
projectile consisting of food particles and
water amounting cup per episode.no
medications were taken for vomiting .no sore
throat, no change in urination and bowel
movements.

 1 day PTA patient had abdominal pain ,fever with

same characteristics and took paracetomol of
same dosage but there is no relief .this was
associated generalized headache with a pain scale
of 5/10 . no medications were taken . No sore
throat , no nausea , no change in urination and
bowel movements
On the day of admission patient had 3 episodes of
non bloody diarrhea

Past History
Patient does not recall any childhood illness but
claimed that he had complete immunizations at
health centre in talisay city . He had no history
of adult , surgical illnesses, no psychiatric
disorders

Personal & Social History

Patient is college graduate ,works in VECO. His
hobbies include watching tv ,basket ball. He
lives in own house together with his wife and a
child and with good electricity and water
supply . He is occasional drinker of alcoholic
beverages and drink about 1-2 bottles . Non
smoker. He doesnt do exercise and had normal
sleeping habits and is fond of eating street food
such as tempura, barbeque etc 3-4 times a
week. Non allergic to drugs , food , environment
His spouse 34 years old works in SM healthy
Children's include a boy 7 years old healthy

Family History
Patients father is 65 years old with known
hypertension and takes unecalled medications
with good compliance
Mother is 63 years old healthy

Patient ranked 3rd among 6 siblings, all

are alive and well except for the eldest,
male, diagnosed with hypertension.
Heredofamilal diseases include
hypertension

PHYSICAL
EXAMINATION

GENERAL SURVEY
Patient is seen on the 2nd day of
admission. He is febrile, conscious, alert,
coherent, ambulatory, cooperative and
oriented to time and place. No
involuntary and signs of respiratory
distress. Physical appearance is
appropriate for age.

VITAL SIGNS
BP 110/80 mmHg, right arm
RR 17 breaths / min, regular
PR 70bpm, right radial artery
Temp 38C, left axilla
Height 51
Weight 52kg
BMI 21.7 (normal)

SKIN & NAILS

smooth, no cyanosis, no pallor, (+) jaundice, good mobility and
turgor, no lesions, more sweaty , normal capillary refill, nails are
well trimmed with no signs of clubbing

Head & Hair

Normocephalic, no deformities, no lesions, no scaling, no
tenderness, nommasses. Hair is black and evenly distributed, no
signs of hair loss.

Eyes
Near visual acuity is OD J1+ ; OS J1+
Eyebrows and eyelashes are black, no scaling,
no hair loss.
Orbital rim has no deformities, no fractures, no
tenderness upon palpation
Eyelids: full lid closure, no swelling, no
tenderness, no discoloration
Eyelashes: no hair loss, no crusting, outward
growth
Icteric Sclera and palpebral conjunctiva
Cornea: aligned at midline, smooth, moist, no
opacities
Pupils: isocoric, brisk direct and consensual

Ears
Symmetrical, no lesions, no masses, no
tenderness upon palpation, patent ear
canal, minimal cerumen, no swelling, no
discharge, intact tympanic membrane
Weber test equally lateralizes on both
ears
Rinne test AC > BC

Nose & Paranasal sinuses

Nose is symmetric, no deformities, no lesions.
Nasal septum at midline, no nasal flaring, no
tenderness on both frontal and maxillary sinuses.

Mouth & Pharynx

Lips and oral mucosa are yellowish, no ulcers, no lesions. No
swelling of the gums, no bleeding, no discoloration. No dental
caries. Tongue at midline, moves freely, no lesions and no
atrophy. Uvula at midline. Tonsils not enlarged, no exudates.

Neck & Thyroid

No scars, no lesions, trachea at midline.
Thyroid gland palpable and rises upon
swallowing.
No lymphadenopathy
Chest & Lungs
No deformities, no lesions, no intercostal
retractions, equal chest expansion, equal
tactile fremitus, resonant lung fields, vesicular
breath sounds, no rales, no wheezing.

Cardiovascular System
NECK
No jugular vein distention on both sides. JVP is 3cm from the
Sternal angle of Lewis.

EXTREMITIES
No redness, no swelling, no pain and tenderness upon palpation.

Cardiovascular System
HEART
PMI is 7cm from MSL at the 5th ICS.
Cardiac borders: LCB is 4 cm, 7cm, 9cm at the 3rd ICS, 4th ICS,
5th ICS from the MSL respectively.
Distinct S1 and S2, no murmurs

Abdomen
No scars, no striae, no dilated veins, no
lesions/rashes, asymmetry, (+)
hepatomegaly, no splenomegaly,
normoactive bowel sounds, liver span is
10cm from MSL, 14cm from MCL, (-)
splenic percussion sign, RUQ pain &
smooth tender edge upon palpation, right
and left kidney not palpable, (-) KPS
(-) Shifting dullness, (-) Rovsings, (-)
Psoas, (-) Murphys

Back and Extremities

Spine has normal curvatures, no asymmetry, no hairy
patches, upper and lower extremities have no gross
deformities
Peripheral pulses are present
All joints have full range of motion

Neurologic exam
Mental status
Patient is alert, conscious, coherent, cooperative, oriented to
time & place.

Neurologic exam
Cranial Nerves
CN I can smell coffee on both nostrils
CN II near visual acuity OD J1+ ; OS J1+
CN II, III - (+) direct and consensual pupillary light reflex
CN III, IV, VI full EOM, no nystagmus
CN V patient is able to clench teeth, (+) corneal reflex, intact
sensation to
pain and light touch
CN VII no facial asymmetry, able to smile, frown, puff out both
cheeks, close eyes tightly and open them, raise eyebrows
CN VIII can hear whispered voice at a feet distance
CN IX and X uvula and palate rises symmetrically when
patient says ah

intact gag reflex & swallows without difficulty

CN XI able to shrug shoulder against resistance

able to turn head to the other side against resistance
CN XII tongue is at midline, movable, no atrophy and
fasciculations

Neurologic exam
Motor System
Patient is able to walk across the room without
difficulty. (-) Romberg sign, (-) Pronator drift test, no
atrophy, no hypotonia, no spasticity, no involuntary
movements, 5/5 on all extremities
Coordination
(+) RAM, (+) Finger to Nose test
Sensory
Pain and light touch sensations intact, (+) Graphesthesia, (+) point
localization

Neurologic exam
Reflexes
2+
(-) Babinski response

Summary of important findings

Logical Impression
Acute Viral Hepatitis

Basis
Vomiting
Dull, non-radiating RUQ pain
Low grade fever
Headache, nausea
Easy fatigability, body malaise
Loss of appetite
Sexually active
Fond of eating street food
Jaundiced skin, icteric sclera and palpebral conjunctiva,
yellowish lips and oral mucosa
Hepatomegaly, liver span increased

DIFFERENTIAL
DIAGNOSIS
Acute cholecystitis

RULE IN

RULE OUT

Vomiting
Nausea
Low grade fever
Loss of appetite
Fond of eating fatty food

(-) Colicky, radiating pain

(-) Murphys sign
(-) Hypoactive bowel sounds

Typhoid fever

Headache
Vomiting
Nausea
Abdominal pain
Loss of appetite
Jaundice
Food purchased from street
vendors

(-)
(-)
(-)
(-)

Gastroenteritis

Nausea
Vomiting
Fever
Loss of appetite
Food purchased from street
vendors

(-) Diarrhea
(-) crampy abdominal pain

fever (38.8-40.5C)
Rash (rose spots)
Diarrhea
Chills

Diagnostics
Serologic test
ALP
PT
BUN and Creatinine
U/A
Liver test
SGOT (AST)
SGPT (ALT)

CBC
Lymphocytosis, atypical lymphocytes
Culture to rule out typhoid fever
Ultrasound check for structural abnormalities

Management
Supportive treatment
IV rehydration

Avoid eating street food

Rest and ensure good nutrition
Improve sanitation and hygiene
Avoid any vigorous activities until
symptoms improve
Protected sexual intercourse
Avoid any alcohol intake