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November 12, 2008   
Discussant: Dr. Tomas Realiza   
Radiologist: Dr. Helga Sta. Maria   
PathologistDr. Francisco Narciso  

       "This is the case of a 21 year old caucasian male, single, who was admitted in our institution because of difficulty of breathing.  

       "History of present illness started three weeks prior to admission, while in Japan, patient developed shortness of breath not associated with cough, fever, and chest pain. He sought consult and was given Levofloxacin, Teprenone, Loxoprofen Sodium, and another medication for cough and colds which offered no relief of symptoms. Patient then traveled to the Philippines and was admitted at a private tertiary-care hospital for six days. Initial impression was an acute upper respiratory tract infection. Chest radiography done revealed hazy infiltrates in the right paracardiac region probably pneumonia. He was referred to Infectious Disease service and was given a working impression of atypical pneumonia rule out pulmonary embolism. A computed tomography angiogram of the chest was done revealing patches of ground glass haziness in both lungs. Pneumonia was a primary consideration. There was no evidence of pulmonary embolism. He was then started on Moxifloxacin, Doxophylline, Erdosteine, Hydrocortisone, and Fondaparinux. Patient had resolution of the fever on his 6th hospital day and clinical improvement on the pulmonary PE however, there was no change in the chest x-ray findings. Patient was persistently tachypneic and had frequent episodes of hypoxemia despite adequate supplementation. Prior to discharge, the patient developed wheezing which was subsequently controlled by administration of steroids. The patient was then transferred to St. Luke's Medical Center.  

       "The patient is non-hypertensive, non-diabetic, non-asthmatic. Few months prior to admission , patient worked in a nursing home in Denmark and as a lifeguard in a beach. He travelled to Russia for 1 month and then flew to Japan just a few weeks prior to admission. Patient had history of multiple sexual intercourse (hetero); HIV screening was done at that time which revealed negative results.  

       "On admission, the patient was noted to be awake, alert, and ambulatory. Vital signs were stable at BP 120/80 Heart rate 70/minute, respiratory rate 21/minute temperature of 36.8ºC, weight 78kg and height of 162 cm. He had pink palperal conjunctivae and anicteric sclerae. The neck was supple with no cervical lymphadenopathies, no tonsillopharyngeal congestion or exudates noted. He has symmetrical chest expansion, no retractions, with clear lung fields, no wheezing. Precordium was adynamic with cardiac rate of 49-50/min and regular rhythm. No murmurs were appreciated. Abdomen was flat with normoactive bowel sounds, soft and non-tender. No penile discharges. His pulses were full and equal with no edema of extremities.

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September 17, 2008

Discussant: Dr. Anthony Uygongco   
Moderator: Dr. Joseph Bocobo   
Radiologist: Dr. Roy Vizcarra   
Endoscopist: Dr. Conrado de Castro   
Pathologist: Dr. Rolando Lopez

“ 44 y/o male came in due to vomiting of blood”


1 month PTA, patient experienced for on & off, non-radiating right flank pain. Consult was done and an ultrasound done revealed nephrolithiasis and left hepatic mass. Patient was given Tramadol/Paracetamol 1 tablet every 8 hrs which afforded temporary relief of pain. An abdominal CT scan was also done. Patient was lost to follow-up until
One week PTA, patient complained of moderate epigastric pain, characterized as intermittent, burning in character, relieved by food intake and associated with nausea, Patient denied dizziness, fever, dysphagia, odinophagia, heartburn, vomiting, hematemesis, melena, diarrhea, and syncope. Patient self-medicated with Tramadol/Paracetamol (Dolcet) for pain and Ranitidine 1 tab intermittently with no relief of symptoms.
One day PTA, epigastric pain became continuous, and increased in severity (8/10). This time, it was associated with hematemesis and one episode of passing out black tarry stools. Patient denied dizziness, fever, odinophagia, dysphagia, heartburn, diarrhea, and syncope. Patient was brought to a local hospital in Dasmarinas, Cavite where patient was given Tranexamic acid (Hemostan), Ranitidine and Epinephrine affording temporary control of hematemesis. No blood transfusion was contemplated at this time.
Few hrs PTA, patient continued to have severe epigastric pain and nausea but had increased frequency of hematemesis (every 2-3 hrs, around 1 cup). There was also associated generalized pallor and weakness. Patient still denied having dizziness, fever, odinophagia, dysphagia, heartburn, melena, diarrhea, and syncope. Relatives at this time opted that patient be transferred to SLMC.

Review of Systems: (+)weight loss, 30% in 2 yrs,  (-)fever, (-)night sweats, (-)anorexia,(-)headache, (-)gum bleeding, (-)cough, (-)hematuria, (+)dysuria, (+)urinary frequency

Past Medical History:  nephrolithiasis, right, Mar 2008;hepatic mass, left, Mar 2008; (-) hypertension, DM, hepatitis, peptic ulcer disease; no known allergies

Personal and Social History:  Patient worked previously as a seaman, then as a security guard. He has been smoking 1-2 sticks of cigarette per day for 20 years and has only recently stopped. He has a fear that his liver mass could be cancer and does not want to face that possibility. His relatives are having financial difficulties shouldering the cost of his work-ups.

Family History: (+) hypertension, CVA, mother

Physical Examination:concious, coherent, ambulatory, hyposthenic, in pain (8/10, epigastric), not in cardio-respiratory distress;BP= 70/30 mmHg, HR= 91/min, RR= 22/min, T=37.6 Celsius generalized pallor, no rashes; pale palpebral conjunctivae, anicteric sclerae, pupils 3mm equal, briskly reactive to light, no tonsillopharyngeal congestion; supple neck, no cervical lymphadenopathies, flat neck veins, no carotid bruit; symmetrical chest on expansion, clear breath sounds, no retractions, no adventitious sounds; adynamic precordium, apex beat at 5th ICS LMCL, normal rate, regular rhythm, distinct S1 and S2, no murmurs; flat, abdomen normoactive bowel sounds, soft, palpable, non-tender epigastric mass, 4cm in widest diameter, firm, smooth, fixed, liver edge sharp, palpable at 4 fingerbreadths below the right subcostal angle, spleen not palpable, extremities has no gross deformities, no edema, no cyanosis, no tremors, no atrophy, decreased and equal pulse;  rectal exam done with tight sphincteric tone, no palpable mass, no pararectal tenderness, no blood but black stools per examining finger

Neuro: concious, coherent, euthymic mood, intact recent, pat and remote memory, intact EOM's, (+) corneal reflex, intact V1, V2 and V3, able to wrinkle forehead, smile and frown, symmetrical, able to hear equally with both ears, intact gag reflex, able to shrug shoulders, tongue midline on protrusion, sensory is 100% on all areas of the body, 4/5 motor strength of all extremities

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August 6, 2008

Discussant: Dr Raul Gardaya   
Moderator: Dr. Hans Ludwig Damian   
Radiologist: Dr. Bernie Laya   
Pathologist: Dr. Manny Madrid  

       "41 y/o right-handed female, admitted for headache and left sided weakness of 4 days duration”


Four days PTA, patient experienced severe headache characterized as pulsating, over the right temporo-parietal area (VAS 9/10). BP taken at this time was 170/100. No consult done nor meds taken.
Three days PTA, pateint started experiencing numbness of left arm and leg (leg more numb than arm). Patient also noted weakness of the left leg. Still no consult was done nor meds taken and condition persisted until...
One day PTA when patient had recurrence of headache and persistence of left sided weakness prompting patient to seek consult and was subsequently advised admission.

Review of Systems: (-) dizziness, blurring of vision, diplopia, slurring of speech

Past Medical Hx: hypertensive for 4 years – on Aprovel 150mg once a day

Personal/Social Hx: non-smoker, non-alcoholic beverage drinker originally from Bicol, went to Compostela Valley, Davao and worked as a nurse 2006-2007. Became a nun, cooking  for the other nuns in Antipolo July 2007

Family Hx:  both parents hypertensive

Physical Examination:  Wheelchair-borne, conscious, coherent; BP=150/80; HR=74/min;  RR=16/min;  pink palpebral conjunctivae, anicteric sclerae, supple neck, (-) cervical lymphadenopathy; equal chest expansion, clear breath sounds;  adynamic precordium, regular rate and rhythm, no murmur;  no breast dimpling,nipples protruded, no palpable mass, no discharge, flabby abdomen, normoactive bowel sounds, soft, no tenderness;  no edema on both extremities, no clubbing
Neuro Exam:
MSE- oriented to time, place and person, able to calculate, no right and left disorientation, able to follow 3-step command but noticed to be slow; intact immediate and recent but impaired remote memories
Cranial Nerves: No anosmia; Pupils OD: 2-3mm BRTL  OS: 2-3mmBRTL  OU: no visual field defect; Visual acuity: OD: 20/30 OS: 20/40;Fundoscopic findings: OU - (+)ROR, clear media, 2:3 AV, well-delineated disc; Full EOMs; Motor - good masseter strength    Sensory - intact V1, V2, V3; No facial asymmetry; otoscopy: intact tympanic membrane;Weber: normal; Rinne:  AD: AC>BC   AS:  AC>BC; Schwabach:  AD: normal   AS: normal;(+) gag reflex; uvula midline; good shoulder shrug, bilateral; tongue at midline 
MOTOR: 5/5 right upper and lower extremities; 4/5 left upper and lower extremities
SENSORY: 100% all extremities
CEREBELLUM: (-) nystagmus, (-) dysmetria, (-)dysdiadochokinesia, good heel to shin; no ataxia 
MENINGES:  No nuchal rigidity; No Brudzinski; No Kernig's; No primitive reflexes (snout, root, grasp and palmomental)
DEEP TENDON REFLEXES: bilateral (++) on biceps, triceps, brachioradialis, knee, and ankle;No toe extensor toe response; No ankle clonus; Intact position vibration sense

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June 25, 2008

Discussant: Dr. Agnes Gorospe   
Moderator: Dr. Paul Estrellas   
Radiolgist: Dr. Irma Kintanar   
Pathologist: Dr. Jaime Zamuco

“ A 50y/o male admitted for failure to pass out gas for 1 week”

HPI: History started three years prior to admission when the patient developed increasing abdominal girth with unquantified weight loss but without pain nor changes in his bowel habits. Work-up done showed multiple intra-abdominal masses and patient subsequently underwent an exploratory laparotomy. Diagnosis then was a probable mucinous cystadenoma. Patient was also advised to undergo chemotherapy which he failed to comply with. 
Eight months prior to admission, patient noted progressively decreasing caliber of stools, accompanied by a decrease in appetite and unquantified weight loss. This was followed by intermittent episodes of constipation. No intervention was instituted until...
A week prior to admission when patient developed obstipation and decided to seek consultation at SLMC.

Review of Systems: Had unquantified weight loss; Denies having abdominal pain, vomiting, hematochezia, melena, diarrhea
Past Medical/Surgical History: anal fistulotomy (1997); hemorrhoidectomy (1996)
Personal and Social History: non-smoker, non-alcoholic
Family History: (+) lung cancer, father

Physical examination on admission:  The patient was asthenic, conscious, coherent, and not in cardio-pulmonary distress. Vital signs: BP 120/80 mmHg supine right arm, HR 67 bpm,regular, RR 18 cpm and temperature 37’C. 
Pink palpebral conjunctivae, anicteric sclerae, no cervical lymphadenopathies.
Symmetrical chest expansion with no retractions, equal breath sounds. Adynamic precordium, normal heart rate, regular rhythm, no murmurs. 
Distended abdomen, normoactive bowel sounds, (+) soft, non-tender, irregularly-shaped intra-abdominal mass extending from hypogastrium to pelvic area.
Extremities showed no cyanosis, no clubbing, no edema. 
Rectal exam did not reveal any palpable masses, no tenderness and no blood per examining finger.


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October 3, 2007

Discussant: Dr. Cecil Tady   
Moderator: Dr. Roberto Barzaga 
Radiolgist: Dr. Roy Vizcarra   
Pathologist: Dr. Manuelito Madrid  

“ A 66 y/o female admitted on June 2007 for difficulty of breathing”

History of present illness: 
Patient is a diagnosed case of breast Ca, left, had MRM in 2004 and lumpectomy, left, in 2006. She has undergone 6 cycles of chemotherapy with Taxol and Carboplatin. 3 months prior to admission, she experienced shortness of breath just before her 6th cycle of chemotherapy. Her treatment was cancelled. Work-up showed elevated D-Dimer (304 ng/ml) and 2-D echocardiogram was essentially normal. Medications included Isoptin, Cholestad and Blopress. Patient was discharged but still experienced on & off shortness of breath even at rest.
10 days PTA patient was admitted again for her 6th cycle of chemotherapy. After the treatment was completed, she again experienced shortness of breath. D-Dimer was again measured and noted to be on the same level. A chest pulmonary artery CT scan was requested. The results showed stationary size and number of subcentimeter multiple pulmonary nodules which were previously identified already. Duplex venous scan showed no evidence of DVT on both lower extremities, with deep venous insufficiency in several superficial veins bilaterally. Low molecular weight heparin was started but was later discontinued due to development of hematoma and thrombocytopenia. Patient was discharged on the 6th HD (4 days PTA), improved. Meds included Isoptin, Blopress, Flixotide & Singulair which did not provide relief until….

On the day of admission, patient developed again shortness of breath, accompanied by chest discomfort lasting around 5 minutes, occurring at rest, and was brought to the ER.

Past Medical History:
(+) hypertension; on Isoptin and Blopress; (+) dyslipedemia, on Cholestad

Review of Systems: Denies cough, colds, fever, weakness

Physical examination on admission showed patient to be conscious, coherent, and not in cardio-pulmonary distress. Vital signs: blood pressure 110/70 mmHg supine right arm, heart rate 120 bpm,regular, respiratory rate 24 cpm and temperature 37C. Warm moist skin, pale nail beds, pale palpebral conjunctivae, anicteric sclerae, no cervical lymphadenopathies, symmetrical chest expansion with no retractions, equal breath sounds with crackles over the left base. Adynamic precordium, normal heart rate, regular rhythm, no murmurs. Flat abdomen, normoactive bowel sounds, (-) tenderness, no palpable mass. Extremities showed no cyanosis, no clubbing, no edema, (+) hematoma, left leg.


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15 August, 2007

Discussant: Dr. Joseph Tabora   
Moderator: Dr. Jason Rosca   
Radiologist: Dr. Bernie Laya   
Pathologist: Dr. Jaime Zamuco   

“A 17 y/o male admitted for the first time on August 23, 2003 for severe epigastric pain”

History of present illness: 12 months prior to admission, the patient experienced 2 episodes of on-and-off severe pricking epigastric pain, aggravated by food intake and accompanied by non-bilous vomiting. Consult was done and the patient was admitted for 3 days in a hospital as a case of gastritis. He was treated with IV omeprazole. He was discharged with ranitidine tablets as home medication, which afforded only temporary relief of epigastric pain. 
10 months prior to admission, he again experienced on-and-off severe epigastric pain accompanied by vomiting and melena. He was confined for 3 days and was discharged without vomiting and melena. However episodes of tolerable epigastric pain persisted.
8 months prior to admission, he was admitted again because of severe epigastric pain. Upper gastrointestinal endoscopy showed polyps; no intervention was done. The patient was given ranitidine but the pain would still recur intermittently around once every 2 months unrelieved by ranitidine.
2 days prior to admission, he passed out tarry stools admixed with fresh blood. He was then admitted at SLMC for further work-up.
Review of systems: weight loss of 15% in 12 months (from the start of illness), no fever, no rashes, no anal pain or mass protruding during defecation.
Past Medical History: no bronchial asthma, no tuberculosis, diabetes mellitus, hypertension or other illness. He has no known allergies. No previous operation.
Physical examination on admission: concious, coherent, on wheelchair, in severe pain (7/10), BP 100/70 mmHg supine right arm, HR rate 90 bpm, RR 20 cpm and temperature 36.7C. Warm moist skin, pale nail beds, pale conjunctivae, anicteric sclerae, no cervical lymphadenopathy. Symmetrical chest expansion with no retractions, clear breath sounds, with no adventitious sounds appreciated. Adynamic precordium, regular rhythm, no murmurs. Abdomen was flat, normoactive bowel sounds, (+) guarding, (+) generalized tenderness, palpable vague mass at right lower quadrant area, no rebound tenderness, no hepatomegaly. Rectal exam showed no rectal skin tags, tight anal spincteric tone, full rectal vault, no pararectal tenderness, (+) tarry stools. Extremities showed no cyanosis, no clubbing and no edema.

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04 July 2007

Discussant: Dr. Helen Ocdol   
Moderator: Dr. Edgardo Bondoc 
Radiolgist: Dr. Roy Vizcarra  
Pathologist: Dr. Emmanuel Lo  
31 year old male, previously well who developed feverish condition eight days prior to admission. This was accompanied with malaise and gradually progressive jaundice. On consultation with his physician, the following blood tests were noted: alanine transaminase 1436IU/L, aminoaspartame transaminase  1299 IU/L, Hemoglobin 14.8mg/dl, white blood count 8,003/mm3, neutrophil 70%, lymphocytes 19%, monocytes 8%, basophil 1% and eosinophil 1% with adequate platelets. He was diagnosed to have hepatitis A. However, he was eventually admitted at a tertiary hospital on the 4th day of his symptoms because of progressive jaundice and weakness. In the hospital, his level of sensorium decreased and was managed as hepatic encephalopathy. Ultrasound of the liver showed diffuse fatty change. Medications given were: metronidazole, domperidone, vitamin K and lactulose. He was transferred to another tertiary hospital for further management. On the 7th day of his symptoms, he developed generalized tonic-clinic seizure and went into a witnessed cardiac arrest. He was resuscitated with returned of spontaneous circulation in less than 5 minutes.
 Patient was admitted at the intensive care unit (ICU) on mechanical ventilatory support.

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