CONCEPT MAP

Clinical Profile
Identifying data:
Male
23 y.o
Filipino
Brgy. Pawing, Palo, Leyte
HPI:
5 days PTA:Undocumented high grade fever with chills
Myalgia
Bitemporal, frontal throbbing headache (PSC 7/10 aggravated by walking and relieved by rest)
Sharp non-radiating Epigastric pain (PSC 6/10 aggrevated by food and unrelieved by rest)
Nausea
Projectile vomiting (blood tinged vomitus of fluids and solid food)
1 day PTA:
Urine dark yellow
Oliguria (50 mL per voiding)
No cough, dizziness, no other manifestation Physical Findings
Medical History:
Mesomorph
History of dengue (age 7) – transfused with 4 U platelet concentrate (+) mumps, measles, chicken pox
In respiratory distress
Complete immunization
Febrile (38.9)
No known allergies
Hypotensive (80/60 mmHg)
2017 – UTI
No history of DM, HPN, PTB, gastrointestinal disease, asthma and kidney diseases, no history of surgery and
Tachycardic (118 bpm)
psychiatric disease. No health maintenance. Tachypneic (25 cpm)
Family history: Unremarkable Slightly icteric sclera
Psychosocial History: Conjunctival suffusion but palpebral conjuctivae is pinkish
Pedicab driver Mouth mucousal membrane is dry
House near the river with good ventilation Dry tongue
Smoker 10 pack-years Full abdomen
Occasional alcoholic drinker (2 glass of emperador light per session) Enlarged Liver (palpable 3 cm below subcostal margin; 14 cm RMCL)
No history of illicit drug use Bilateral calf muscle tenderness
No flood exposure but with rodents at home and there are stagnant waters at their neighborhood Melena upon DRE
Review of System: Neurologic Examination: Unremarkable
Negates weight loss
Fever
Body malaise since onset of illness
Anorexia since onset of illness
Melena
Usually defecates once a day to a brown colored stool, firm in consistency
Patient usually urinate 3-4 times per day approx. 200 – 300 mL
No dysuria, no urinary infrequency, no flank pain
No orthopnea, no dysphagia,
 Pivot
Fever & tea-colored urine

LEPTOSPIROSIS HEPATITIS DENGUE HEMORRHAGIC FEVER COMPLICATED WITH ACUTE CHOLECYSTITIS

Rule-in:
 Undocumented high grade fever with
chills
 Myalgia
 Bitemporal, frontal throbbing headache
(PSC 7/10 aggravated by walking and
relieved by rest)
 Sharp non-radiating Epigastric pain (PSC
6/10 aggrevated by food and unrelieved
by rest)
 Nausea
 Projectile vomiting (blood tinged vomitus
of fluids and solid food)
 Urine dark yellow or tea-colored urine
 Oliguria (50 mL per voiding)
 Anorexia since onset of illness
 Presence of rodents at home and there
are stagnant waters at their neighborhood
 In respiratory distress
 Febrile (38.9)
 Hypotensive (80/60 mmHg)
 Tachycardic (118 bpm)
 Tachypneic (25 cpm)
 Slightly icteric sclera
 Enlarged Liver (palpable 3 cm below
subcostal margin; 14 cm RMCL)
 Bilateral calf muscle tenderness
 Melena
 Conjunctival suffusion
ACUTE RENAL FAILURE SECONDARY TO CHOLELITHIASIS
Rule-in:
 Anorexia since onset of illness Rule-in: Rule-in:
 Nausea  Undocumented high-grade fever with chills  Undocumented high-grade fever
 Projectile vomiting (blood tinged vomitus  Tea-colored urine with chills
of fluids and solid food)  Oliguria  Tea-colored urine
 Myalgia  Myalgia  Oliguria
 Bitemporal, frontal throbbing headache  Bitemporal, frontal throbbing headache (PSC 7/10  Nausea
(PSC 7/10 aggravated by walking and aggravated by walking and relieved by rest)  Anorexia
relieved by rest)  Sharp non-radiating Epigastric pain (PSC 6/10  Epigastric pain (intense pain in
 Slightly icteric sclera aggravated by food and unrelieved by rest) the epigastric or mid-right of the
 Undocumented high grade fever with  Nausea upper
chills  Projectile vomiting (blood tinged vomitus of fluids  abdomen)
 Febrile (38.9) and solid food)  Slightly icteric sclera
 Urine dark yellow or tea-colored urine  History of Dengue (age 7)
Rule-out:
 Enlarged Liver (palpable 3 cm below  Stagnant water at their neighborhood
 Pain radiating to the scapular
subcostal margin; 14 cm RMCL)  Body malaise
area
 In respiratory distress
 No reported projectile vomiting
Rule-out:  Enlarged Liver (palpable 3 cm below subcostal
with blood-tinged vomitus
 No alterations in olfaction and taste margin; 14 cm RMCL)
 Persistent  Mesomorphic physique
constitutional prodromal  Slightly icteric sclera
symptoms  Female predominance
 Melena
 Negates weights loss
 Clay colored stool not melena Rule out:
 No liver tenderness
 No conjunctival suffusion
 Epigastric pain not RUQ pain
 Dengue NS1 antigen test- used during the acute
 No Oliguria
phase
 No Respiratory distress
 Dengue IgM/IgG serological test/ELISA- test of
choice after the first 5 days of illness
 Blood chemistry- elevated BUN and Creatinine
 Urinalysis- hematuria and proteinuria
 Final Diagnosis
ACUTE KIDNEY INJURY secondary to MODERATE-SEVERE LEPTOSPIROSIS
 Test Interpretation

Findings on general laboratory studies are as follows:

Complete blood cell count (CBC)
Blood urea nitrogen and serum creatinine
 In patients with mild disease, elevated erythrocyte sedimentation rates and peripheral leukocytosis (3,000-26,000 x 109/L) with a left shift are
noted
 Significant anemia due to pulmonary and gastrointestinal hemorrhage can occur
 The platelet count may be diminished as a component of disseminated intravascular coagulation (DIC)
may be profoundly elevated in the anuric or oliguric phase

Serum creatine kinase Creatine kinase levels (MM fraction) are often elevated in patients with muscular involvement.

Urinalysis Proteinuria may be present. Leukocytes, erythrocytes, hyaline casts, and granular casts may be present in the urinary sediment

(useful only in excluding other causes of bacterial meningitis) in leptospirosis, polymorphonuclear leukocytes initially predominate and are later
Analysis of the CSF replaced by monocytes. CSF protein may be normal or elevated, whereas glucose levels remain normal. CSF pressure is normal, but a lumbar
puncture can relieve the headache.

Elevation in aminotransferases, bilirubin and alkaline phosphatase, hyperbilirubinaemia is out of proportion to jaundice in cases of icteric
Liver Functions Tests
leptospirosis

Protime Coagulation times may be prolonged in patients

The most common abnormality on chest radiography is bilateral diffuse airspace disease. Chest radiography may also reveal cardiomegaly and
Chest Radiography pulmonary edema due to myocarditis. In patients with alveolar hemorrhage due to pulmonary capillaritis, the lung parenchyma may contain multiple
patchy infiltrates.

Silver staining and immunofluorescence can identify leptospires in the liver, spleen, kidney, CNS, muscles, and heart. During the acute phase of
Histologic Findings
leptospirosis, histology reveals these organisms without much inflammatory infiltrate.

immunoglobulin M (IgM) enzyme-linked

It detects IgM, it may be useful for diagnosis of new infections within 3-5 days. Positive results should be referred for confirmatory testing
immunoabsorbent assay (ELISA)

Nucleic acid amplification (polymerase chain

Can confirm the diagnosis rapidly during the early phase of the disease, when leptospires may be present and before antibody titers are detectable
reaction [PCR]

Isolating the organism by culture allows definitive diagnosis. Blood cultures may be negative if drawn too early or too late. Leptospires may not be
detected in the blood until 4 days after the onset of symptoms (7-14 d after exposure). Once the immune system is activated, blood cultures may
Culture again become negative. Leptospires may be isolated from the cerebrospinal fluid (CSF) within the first 10 days.Leptospires may be isolated from the
urine for several weeks after the initial infection. In some patients, urine cultures may remain positive for months or years after the onset of illness.
Positive urine cultures may take as long as 8 weeks to grow.

In a patient with clinical findings consistent with the disease, a single titer exceeding 1:200 or serial titers exceeding 1:100 suggest leptospirosis;
Microscopic Agglutination Testing
however, neither is diagnostic. A 4-fold rise in titer between acute and convalescent specimens is considered a positive result.