Third Year cPpe MARCH 15, 2018, 20% 41 year-old male, married, Flipina tha fist time at olleeman, Catholic, presently residing in 8 tertiary government hospital, an, Leyte, admitted for History of present illness Patient was transferse ‘ansferted fom a provincial hosp 3 with the following data ‘Medical History: Unremnarkable Clinical abstract rospital in Quezon City and was. subsequently admitted, oe Physical Examination upon Admission Genera Survey: Patients conscious, incoherent, not viene to time, place and person eyahtow Comma Scale score is 12/15 with the following vital signs. 8p: 150/100 PR: 90 RR: 25, Temp: 39¢ TRENT: Patient’ head i sprmetical and normocephali No lesions and misses were noted agate era, pale conjunctiva, pupils equa reactive to lit, no erophtainere et nophthalmos. No Nid lag and ptosis, mo a he peat . NECK: Trachea midtine. Anterior and posterior cervical lymph nodes are palpable CHEST: Thorax is symmetrical, skin is yellow and with multiple petechial rashes. Upon percussion, all ung field re dull. On auscultation, decreased breath sounds. No adventitious sounds heard HEART: Dynamic precordium. Apex beat noted at the 7" ICS AL. No murrrurs.. ‘ABDOMEN: Globular in shape with multiple petechiae scattered on both flanks, Liver size is measures at 18 ‘ems, Spleen is palpable, Fluid Wave test was negative. EXTREMITIES: Petient had bilateral non-pitting edema CRANIAL NERVE EXAM: 18 N/A, HL 1V,VI~equally reactive to light; moves in the general direction of gaze Can equally feet pain and slight touch on both sides, Comeal efiex Is present. Jaw Jerk not elicited VIIL-XI= N/a Course in the Ward Upon arrival, patient was noted to be jaundiced, feverish, complains of boy malaise with GCS of 12 On the fist hospital day the patient presented with typhoid fever-like sigrs and symptoms including moderate hemoptysis. Jaundice and hepatosplenomegaly was eminent upon admission. CBC revealed pancytopenia ‘while blood chemistry tests showed elevated liver enzymes and alkaline phosphatase and the patient started with Essentlale. The impression at that time was myelosuppression seconoary to an infections cause versus drug-induced (Chloramphenicol), Antimicrobial therapy was then shifted to Meropenem. CT scan of the ‘abdomen showed acalculous cholecystitis, renal parenchymal disease, divertculosis and pleural effusion. A ‘bone marrow aspirate was done revealing a hypocellular marrow. (On the second hospital day, there was persistence of the fever and abdominal pain. Patient was transfused ‘with 3 nits of FWB due to persistent pancytopenia. Paracetamol IVwas given to limit fever. Althe rest were unremarkable. : (On the third hospital day, CBC revealed persistent pancytopenia and was transfused with aditional 3 units of FWB. All the rest were unremarkable. paOxactin was added Panel (Flow Cytometry) On the fifth hospital day, Ventilator support was gi ‘ardiorespiratory arrast. pat cecal dy the pation was transfeedto the Cu; he patent was intially managed as 2 case proe neeDbalopathy pending ests oftborstorg vee eee a potential causes. Hepatitis Saacne Owe tHE poivty Me was then releredo nf ie eee Mematoogy services: reaceroPenem antimicrobial therapy. Slood and urine culture results were negative Viral 1 atotY, EBV IgG was postive. fg, HIV and LATS wore negative with pending CM topenia. There 4 units platelet concentrate were transfused for parsistent thrombocytopent 195 Gi bleeding per endotracheal tube noted yemodialysis {he Batient developed Acute Renal Faure and underwent 2 sessions of hemodialy mechanical veuay intractable metabolic acidosis, The plant ws noted to have cfc i breathing end pectoral Wen, The patient was unresponsive. Few minutes later, the patient had. ‘No resuscitation was done, Pationt expired, ‘MoH ‘MCE ‘ROW Platelot cMev Alkaline Phosphatase Total Bilirubin Direct Bilirubin “indirect biieubin [BUN Creatinine lH [SOT/AST ‘SGPT/ALT Sodium Potassium__No growth after 48 days of incubation j (Rgrouth ater 48 days of incubation j