SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: Dr. Gamaliel N. Garcia

SUBMITTED BY:

SIMPORIOS, Mian Antonette SINAPUELAS, Jeunesse Inna TANATE, Kent Owen T. VALDEZ, Lawrenz K.
I. REPRESENTATIVE CASE

IDENTIFYING DATA: 42 year-old, Male, Meat Factory Worker

CHIEF COMPLAINT: Fever

HISTORY OF PRESENT ILLNESS: Patient was fit and healthy until a couple of weeks ago. Patient started with what he describes as a ‘chill’ sensation,
fever and headache. He took a day off work. Patient then decided to go back to work despite not feeling completely well but felt ill again 4-5 days later.
Patient experienced fever, cough and myalgia which prompted him to consult his general practitioner, and arranged a hospital admission.

PAST MEDICAL HISTORY: Patient has no history of hemoptysis or weight loss and no regular medications taken. No other significant data was provided.

FAMILY HISTORY: There is no family history noted.

PERSONAL AND SOCIAL HISTORY: Patient is a previous smoker of 5 pack years. Patient consumes alcohol in moderation. Patient had been to Spain
with his family 6 months ago.

REVIEW OF SYSTEMS PHYSICAL EXAMINATION

General Survey: No weight change General Survey: Ambulatory, Appears weak and in distress.
HEENT: Congested eyes. No sorethroat Vital Signs: BP: 112/70 mmHg HR: 113 beats/min Weight: Not given
Blurred vision (-) Eyeglasses/contact RR: 18 breaths/min Temp: 38.5°C O2 sat: Not given
lenses (-) Earaches (-) Tinnitus (-) Nasal
discharge (-) Sore throat (-) HEENT: Congested eyes
Chest/Lungs: Symmetrical chest expansion, Crackles on (L) base of lungs
Chest and Lungs: Cough. No Abdomen: Splenomegaly, and Hepatomegaly about 2 cm upon palpation.
Hemoptysis and Wheezing
Cardiovascular: No palpitations.

Gastrointestinal: No abdominal pain.

Musculoskeletal: Myalgia
Genitourinary: No polyuria.
CNS: Headache. No fainting, no diziness

II. PRIMARY IMPRESSION

DIAGNOSIS RULE IN RULE OUT
Mild Leptospirosis ID: Meat factory worker
HPI: CANNOT BE RULED OUT
(+) Fever
(+) Headache
(+) Myalgia
(+) Chills
(+) Cough
PE:
(+) Tachycardia
(+) Conjunctival suffusion
(+) Crackles at the (L) base of the lung upon auscultation
(+) Hepatomegaly
(+) Splenomegaly
Laboratory Findings:
(+) normal CBC
(+) elevated serum creatinine (168 u mol/L)
(+) elevated serum urea (9 mmol/L)
(+) elevated serum ALT (166 U/ L)
(+) elevated serum ALP (134 U/ L)
(+) elevated serum CRP (88 mg/ L)
(+) Equivocal Leptospira serology
III. DIFFERENTIAL DIAGNOSES
DIAGNOSIS RULE IN RULE OUT
Acute Q Fever ID: Meat factory Worker Negative Chest X-ray
HPI: Negative titers for Q fever
(+) Fever
(+) Headache
(+) Myalgia
(+) Chills
(+) Cough
PE:
(+) Crackles
(+) Hepatomegaly
(+) Splenomegaly
Laboratory Findings:
(+) normal CBC
Community ID: History of smoking Normal WBC
Acquired HPI: Normal findings of Chest-Xray
Pneumonia (+) Fever Scanty sputum with no organisms
(+) Headache Normal Upper Respiratory Flora
(+) Myalgia
(+) Chills
(+) Cough
PE:
(+) Tachycardia
(+) Crackles at the left base of the lung upon auscultation
Malaria HPI: Normal CBC
(+) Fever Elevated BUN
(+) Headache Elevted Creatinine
(+) Myalgia
(+) Cough
PE:
(+) Splenomegaly
Laboratory Findings:
(+) elevated serum creatinine (168 u mol/L)
(+) elevated serum urea (9 mmol/L)
(+) decreased serum potassium (4.7 mmol/L)
Typhoid Fever HPI: (+) Fever Tachycardic
(+) Headache Normal Chest X-ray
(+) Myalgia Normal CBC
PE: Negative titers for Brucellosis
(+) Hepatosplenomegaly
IV. RATIONAL LABORATORY & DIAGNOSTIC TESTS
PATIENT NORMAL
LAB. TEST INTERPRETATION/NECESSITY AVAILABILITY COST
RESULTS VALUES
HEMATOLOGY
Complete Blood Male: SMCFI, HCH, P220
Count 4-11 x 109/L NOPH, and other
Private
ALL PARAMETERS ARE WITHIN THE
Hemoglobin 0.55-0.70 laboratories
NORMAL RANGE. Screening test for presence
Hematocrit 0.20-0.35
of infection or blood disorders. Abnormal
WBC 0.01-0.06
increases or decreases in cell counts as revealed
Neutrophils Normal 0.01-0.04
in a complete blood count may indicate that the
Lymphocytes 0-0.01
patient has an underlying medical condition that
Eosinophils 4.6-6.2 x 1012/L
calls for further evaluation.
Monocytes 0.42-0.50
Basophils 13-18 g/dL
Platelets 150-400 x 109/L
BLOOD CHEMISTRY
UREA 9 mmol/L 2.5-7.5 mmol/L ELEVATED. Indicates sudden/ acute injury to
₱ 295.00
CREATININE 168 μ mol/L 60-110 mmol/L the kidney.
ELECTROLYTES WITHIN NORMAL RANGES. Changes in
 Sodium 135 mmol/L 137-144mmol/L electrolyte concentrations indicate secondary
 Potassium 4.7 mmol/L 3.5-4.9 mmol/L changes caused by certain diseases or ₱ 580.00
conditions.
SUMC, HCH,
LIVER FUNCTION
NOPH and other
TESTS
laboratories
 Total Bilirubin 20 μ mol/L 3-22 µmol/L ELEVATED. Increased Serum ALT, Serum ALP ₱ 250.00
 ALT 166 U/L 5-35 U/L and Serum GGT suggest that a condition or
 ALP 134 U/L 45-105 U/L disease is damaging the liver.
 GGT 196 U/L <50 U/L

CRP ELEVATED. Indicates possible inflammation. ₱ 415.00

88 mg/L <10 mg/L
MICROBIOLOGY
Sputum Culture Normal Normal Upper NORMAL. No bacteria found that can cause ₱ 400.00
SUMC, HCH,
Respiratory bacterial infections.
NOPH and other
Tract Flora
laboratories
IMAGING STUDIES
NO SIGNIFICANT FINDING. This is necessary SUMC, HCH,
Chest X-ray Normal to assess lungs since patient has cough and NOPH and other P 150
crackles. laboratories
IMMUNOLOGY/SEROLOGY
ELISA
SUMC, HCH,
Leptospirosis Equivocal EQUIVOCAL FOR LEPTOSPIROSIS. This
NOPH and other ₱ 700-950
Q Fever Negative indicates presence of the Leptospira bacteria.
laboratories
Brucellosis Negative

V. FINAL DIAGNOSIS: Leptospirosis

VI. PATHOPHYSIOLOGY

LEPTOSPIROSIS

VII. CASE MANAGEMENT

THERAPEUTIC MANAGEMENT
LIST OF PROBLEMS THERAPEUTIC OBJECTIVES
1. Fever (38.5 degrees Celsius) 1. To relieve the patient’s myalgia and headache
2. Headache 2. To stabilize the patient’s vital signs, particularly temperature
3. Cough 3. To provide supportive care to relieve other symptoms
4. Myalgia
ADVICE AND INFORMATION NON-PHARMACOLOGIC MANAGEMENT
1. Educate the patient and his family about his current 1. Admit the patient to a private room or ward.
condition: the etiology, risk factors, and course of disease, 2. Start venoclysis, LR 1L @20 gtts/min. Tepid sponge bath as needed to
signs and symptoms, medical options for treatment including relieve fever.
its benefits, adverse effects, risks, and prognosis. Increasing 3. Monitor vital signs q4H.
patient’s knowledge about his current condition improves 4. Monitor I/O q4H. 5. Diet as tolerated.
medical compliance and assists in the management of
symptoms and complications.
2. Educate patient about disease transmission and prevention
techniques such as proper hand washing and maintaining
proper personal hygiene, avoidance of exposure to urine and
 tissues from infected animals through proper eyewear,
footwear, and other protective equipment.
3. Advise the patient to increase oral fluid intake.
4. Emphasize the importance of complying with his medications
as prescribed and to report any adverse reactions.
PHARMACOLOGIC MANAGEMENT
DRUG NAME EFFICACY SAFETY SUITABILITY
Doxycycline Is bacteriostatic against a broad -Tetracyclines may aggravate Tetracyclines are useful in the acute
(100mg BID PO) range of gram-positive and gram azotemia in patients with renal disease treatment and for pro- phylaxis of
negative bacteria because of their catabolic effects leptospirosis (Leptospira spp.)
-All tetracyclines can produce GI
irritation
-Cases of hepatotoxicity have been
reported rarely with doxycy- cline,
minocycline, and tigecycline
administration.

Amoxicillin Inhibits inhibits transpeptidation step
(500mg q6h/ 1g q8h PO) of peptidoglycan synthesis in bacterial
cell wall by binding 1 or more of the
pinicilli-binding proteints, thus
inhibiting cell wall synthesis causing
cell lysis
Azithromycin It inhibits RNA-dependent protein
(1g initially. Followed by synthesis by binding to the 50s
500mg OD PO for 2 ribosomal subunit, preventing the
more days) translocation of peptide chains
-Patient with history of B-lactam
allergy, renal impairment, vomiting
diarrhea, may elevate AST and ALT
Hypersensitivity to macrolide
antibiotics. History of hepatic
dysfunction.
Leptospira spp. Is highly susceptible to
broad spectrum of Antibiotics including B-
lactam Antibiotics
Leptospira spp. Is highly susceptible to
macrolide antibiotics

PRESCRIBED DRUGS
DRUG NAME DRUG DETAILS COST
Azithromycin Efficacy: It inhibits RNA-independent protein synthesis by binding to the 50s ribosomal subunit, thus 3’s P304.92/box
(1g initially. Followed by preventing the translocation of peptide
500mg OD PO form 2 Safety: hypersensitivity to macrolide antibiotics, hepatic dysfunction
more days) Suitability: Leptospira spp. Is highly susceptible to macrolide antibiotics
VIII. MONITORING AND FOLLOW-UP
1. Refer to infection specialist when the disease progresses to moderate or if there is no response to treatment
2. If patient has history of renal failure and hepatic dysfunction it is recommended to have long term follow up

KENT OWEN TANATE, MD REFERENCES:

● Braunwald et. al. (2018). Harrison’s Principles of Internal
Silliman University Medical Center Medicine. 20th ed. McGraw Hill Medical Publishing Division:
Dumaguete, Negros Oriental USA.
(035) 225 0839 ● Ferris et al. (2018) Ferri’s Clinical Advisor 2019. Elsevier
● Katzung, B. (2007). Basic and Clinical Pharmacology. 10th Ed.
Lange McGraw-Hill. USA
Patient: X,X Date: 08/30/20
● MIMS Philippines. 113th Ed. 2007
Address: - Age/Sex: 42 y/o, Male

Azithromycin 500mg tab

Instructions: 500mg/day x 3 days

Lic. No. 1234567

20-0123456