• Lots of inconcistencies on dates. Best to
check for consistency when the whole
presentation has been compiled.
• Replies are in blue. There are 4 hospitalization days (days
in the ward) + 1 day of admission (Sept. 16) of which labs
are done and carried out until the discharge. The references
for the values are the laboratory workups and the clinical
abstract you sent.
Ward Management
(1st hospitalization day):
• Blood Chemistry*
– BUN (29.4 mg/dL) - ↑- to check for kidney failure and explain the encephalopathy (if
liver function due to leptospirosis is being considered , ammonia levels are better; kidney is not able
to excrete ammonia in the form of urea…maybe elevated in Leptospirosis)
– Creatinine (1.8 mg/dL) - ↑- more of routine for renal function and treatment management
– Hyponatremia (134 meq/L)- ↓- this could be of a non- dilutional type; maybe diet;
maybe something else… please ask pathophysio about this; try diarrheic episodes if any
– Hypokalemia (3.3 meq/L)- ↓- try diarrheic episodes too, probably diet and probably
non- dilutional; please ask pathophysio about this
– Hypocalcemia (1.06 anong units ito? pero siguradong hypo siya kahit
ano pa units) – units are in mmol/ L; check for its correlation with muscular tetany same as
with other electrolytes, which may explain any muscular pains; check for diet and refer to
pathophysio please…
– Normal nga ba ang PT at aPTT niya noong September 18, 2009?
(See tables at end of this section.) – PT is normal (11- 15 s) while aPTT is elevated
(25- 35 s but range varies)
• CXR*: subsegmental atelectasis of the left lobe.
*For all items with an asterisk: state why this test is indicated in this case. Kung routine yung test, sabihin ang
findings expected kung leptospirosis.
**For all items with two asterisks (subsequent slides), state why this treatment is indicated in this case .- di ba
dapat pathophysiology or laboratory people ang sumasagot nito?
↑↓
- what is this? I don’t recall this on my slides
Ward Management
(1st hospitalization day):
-
IV Fluids**: pNSS- routine hydrating and infusion solution for medications and electrolytes as
well as to correct any electrolyte problems
Antibiotics
- Ceftriaxone IV antibiotic, 2 g, IV OD
- (bakit ceftriaxone? ano na ba ang working diagnosis at this point?)- probably
non- viral (bacterial or parasitic) hepatitis dahil may icterisia… the drug is used for empiric gram (±)
coverage.
-
Analgesics
- Paracetamol 500 mg/tab q4h
- Tramadol HCl 37.5 mg + Paracetamol 325 mg (Dolcet) tablet TID as needed
 pwede ba to - what do you mean pwede? If the dosage… yes pwede. If the PK, a bit
questionable considering baka may kidney and hepatic problem. But pain must always be managed. It
should decrease the dosages of each substance in a fixed dose so baka okay lang naman.
-
Diet**
-
MAT  what’s this- microscopic agglutination test (sero- specific assay of leptospiral
serovars)
- Renal diet with 35 kcal/kg/day, 60% HBV  what’s this divided into 3 meals
& 2 snacks- I don’t know either but ito yung nakalagay… best to delete it but you do it… kumokopya
lang ako ng notes ng clerk dito
- Confirmed leptospirosis
- Ceftriaxone replaced with penicillin G 1.5 M u q6h
Ward Management
(1st hospitalization day):
Behavioral Changes
Uremic Encephalopathy?
Nephrology Referral:
Dialysis
TCVS Referral for
IJC insertion: 12
Lead ECG
Not suggestive
of Uremic
Encephalopathy
BUN, Creatinine, PT, aPTT
Aseptic Meningitis?
Sinus rhythm with left
axis deviation and
non-specific ST-T
wave
Changes
Neurology Referral:
Acute Confusional
State
Continue Ward Management
Ward Management
(2nd hospitalization day):
• Clinical
– No more behavioral abnormalities
– Neurologic exam unremarkable
• no meningeal or increased ICP signs
– No signs of uremia
• Laboratory
– Creatinine improving (1.6) – but still ↑
• Medications
• For laboratory abnormalities found on the 1st day of
admission
• CaCO3 500 mg tab, 1 tab between meals
• Kalium durule, 1 durule TID x 2 days
Ward Management
(4th hospitalization day):
• Clinical
– Afebrile
– No behavioral changes
• Laboratory
–
–
–
–
BUN (21.3) – normal
Creatinine improved further – but still slightly ↑ (1.3)
Normonatremia (142)
Normokalemia (4.7)
• Medications:
– Penicillin G was then shifted to Amoxicillin 500
mg/cap 1 cap QID.
CBC, Differential count and Anti HAV IgM
(9/16/09)
Hgb
118
WBC
11.40
RBC
5.63
Neutro
0.89
Bands
0.02
Seg
0.87
Hct
0.35
MCV
61.60
Lympho
0.10
MCH
20.40
Eosino
0.01
MCHC
33.40
RDW
15.20
MPV
7.0
Plt
234
CHEMILUMINESCENT 09/16
IMMUNOASSAY
Anti HAV IgM
0.254
nonreactive
Urinalysis
URINALYSIS
09/16/09
09/17/09
Contradicts with 4 d PTA Hx- see notes above
Color
Yellow
Yellow
Transparency
Slightly turbid
Slightly turbid
pH
5.0
5.0
Specific Gravity
1.010
1.015
Albumin
-
-
Sugar
-
-
RBCs
5-7/hpf
0-1/hpf
Pus cells
3-6/hpf
3-6/hpf
Squamous cells
Few
Few
Bacteria
+
+
Amorphous urate
+
+
Blood Chemistry Panel
BLOOD CHEMISTRY
09/16
09/18
09/19
09/21
1.6
21.3
1.3
Contradicts with 4
d PTA Hx- same
BUN
Creatinine
Alkaline phos
Total bilirubin
41.6
3.3
166
5.3
Direct bilirubin
Indirect bilirubin
Na
4.2
1.1
130
K
iPO4
iCa
3.7
29.4
1.8
134
142
3.3
2.8
1.06
4.7
Hematology- addendum slide
Particulars
09/18
Prothrombin time
12.7
Normal control
12.5
PT ratio
1.0
INR
1.0
aPTT
45.6
Normal control
36.3