D.H.

42/Male/S
Manager

DOB
 History of Present Illness

2 months PTA
(+) onset of productive cough
(+) oral ulcers
(-) consultation done or meds taken
 History of Present Illness

1 month PTA
(+) persistence of cough
(+) weight loss ≈ 50%
(+)went to a district hospital
- CXRay revealed far advanced PTB
- was started with Anti-Koch’s medications
 History of Present Illness

1 month until on the day of admission

(+) persistence of signs & symptoms
 History of Present Illness

2 hrs PTA
(+)sudden onset of difficulty of
breathing

- was then brought to this institution

 Past Medical History

(-) HPN, DM, BA, FDA

(+) taking Anti-Koch’s medications for
1 month
Family History

No heredofamilial diseases
Personal-Social History

Non smoker
Alcoholic drinker
Manages condominiums in Manila
Sexual History

Homosexual
Living-in with a male partner for 5 years
No contraceptives were used
Pertinents:
(+) DOB
(+) on Anti-Koch’s medications
(+) Cough
(+) Weight loss

(-) History of asthma

(-) Urinary/ Bowel Changes
(-) Rashes
(-) Vomiting
 Physical Examination

General Survey:
Drowsy, stretcher-borne, cachexic,
hypotensive, tachypneic and febrile, in
Cardiopulmonary distress

Vital Signs:
BP: 80/60 CR: 64 RR: 25 Temp: 38. 9°C
SKIN
(+) ashen-gray color
(-) jaundice
(+) whitish flakes face area more
prominent in the mandibular area
Warm to touch
HEENT
• Anicteric sclerae, pale conjunctivae
• No ear Discharges, pearly gray tympanic
membrane
• Dry oral mucosa, nonhyperemic
tonsillopharyngeal walls
• (+) aphtous ulcers oral region
• No neck vein engorgement
• (+) lymphadenopathies
- posterior cervical area: 2x2 cm, fixed,
nontender well-circumscribed, hard
- submandibular: 1x3 cm, movable, non
tender, well-circumscribed, soft
THORAX AND LUNGS
• Symmetrical chest expansion,
• (+) intercostal retractions
• (+) decreased breath sounds lower
lung fields more on R
• (+) rales all lung fields
HEART
Adynamic precordium,
Tachycardic with regular rhythm,
PMI at 5th ICS MCL,
no murmurs noted
ABDOMEN
• Inspection: Flat, no varicosities, no
scar, no striae
• Auscultation: Normoactive bowel
sounds, (-) bruit
• Palpation: Soft, non-tender abdomen
non-palpable liver and spleen
EXTREMITIES
• Grossly normal
•No lesions or edema noted
•CRT: 3 sec
 Neuro Examination:
GCS 14 (E3V5M6)
Motor Sensory

5/5 5/5 100% 100%

5/5 5/5 100% 100%

Intact Cranial Nerve Examination

E.R.
Patient was for ICU admission but refused
TPR Q4h
DAT aspiration precaution
O2 @ 8 lpm via face mask

Venoclysis: R arm: PNSS 1L x 60 cc/hr

L arm: D5LR 1L X 80 cc/hr
E.R.
Meds:
1. PAI with Salbutamol, 1 neb + 2cc PNSS q
5mins for 2 hours then q1hour for 2 hours then
q4hrs for 2 hours then q6hrs.
2. PAI with Budesonide, 1 nebule q12 hours
3. Rifampicin 150 mg, INH 75 mg, ethambutol
275 mg (Fixcom3) 3 tabs OD
4. Montelukast 10mg/tab OD
E.R.
Meds:
1. PAI with Salbutamol, 1 neb + 2cc PNSS q
5mins for 2 hours then q1hour for 2 hours then
q4hrs for 2 hours then q6hrs.

2. PAI with Budesonide, 1 nebule q12 hours

3. Fixcom 3 tabs OD
4. Montelukast 10mg/tab OD
E.R.
1. CBC
CBC
Laboratories that Hct
CXR-PA
Results:
Examination shows hazy
infiltrates in both lung fields,
were slighltly
requested:
RBC inferiorly.
0.37 and
more centrally

Hgb True cardiac size 122

4.47
not
2. Creatinine ascertained.
WBC 14.58
3. SGPT Other chest structures are not
lymphremarkable. 0.05
4. CXR-PA
mono 0.04
5. ECG-12 eo 0
6. ABG **Extensive Bilateral Pulmonary
baso 0
Parenchymal Infiltrates.
polysPrimary consideration
0.91 is
Crea pulmonary edema. 0.8
SGPT 49
6 hrs
BP: 90
60
CR: 102
RR: 45
Temp: 36.9
Input: 1600
Output: 500

S: (+) dyspnea
(+) drowsy but arousable

O: (+) fine crackles all lung fields

(+) decreased breath sounds lower lung fields
(+) wheezing???
(+) GCS??
 6 hrs
A: Acute Respiratory Failure???
PTB III, pulmonary edema 2

ABG:
pH: 7.42
P: RBS stat. pCO2: 22.3
RBS= 36 → D50 water, 50 cc IVTT stat
pO2: 37
ECG-12 leads stat
Trop I stat HCO3: 37
Fast drip 100 cc then increase IVF to 100 cc/hr O2 sat: 74%
Start Dopamine 400mg/250 cc to run @ 15 gtts/min
Dobutamine drip 500mcg/250 cc @ 20 gtts/min
ABG stat
Transfer to ICU
Start Ceftazidime 1gm IVTT q8h
Increase O2 @ 8lpm
Repeat RBS 1 hour after
for HIV screening
12 hrs
(+) HIV screening
PTA
(+)patient arrested.

-folks signed DNR waiver.

-patient pronounced dead.