TONDO MEDICAL CENTER

Department of Internal Medicine

Case Management
August 1, 2014



GENERAL DATA:
AB, 61y/o, male, Filipino, married, Roman Catholic, born on October 2, 1952, currently
residing at Paranaque, was admitted for the first time at our institution on May 17, 2014 at
2:30AM.

CHIEF COMPLAINT:
Rashes on all extremities

HISTORY OF PRESENT ILLNESS:
2 months prior to admission, patient started to experience on and off flank pain with
associated passage of blood and stone in his urine were. The pain was described as stabbing in
character, 6/10, not associated by food intake or movement. Consult done with a private
physician wherein he was prescribed with sambong tablet to be taken 3x a day. Patient also self
medicated with home made soursop juice 1-2L per day.
3 weeks prior to admission, patient started to experience non-productive cough, not
associated with fever. Consult with a private physician wherein patient was prescribed with
unrecalled medications which relieved the cough.
1 day prior to admission, patient noted red, flat, non-pruritic rashes on his lower
extremities. No fever or bleeding noted. No consult done or medications taken.
Few hours PTA, the rashes progressed to his upper extremities and trunk. Patient also
noted gum bleeding. Patient sought consult with a private physician and was advised transfer to
our institution hence this admission.

PAST MEDICAL HISTORY:
(-)Hypertensive
(-) DN
(-) Previous history of hospitalizations, no previous surgeries
(-) Allergy to food and drugs

FAMILY MEDICAL HISTORY:
(+) HPN sibling
(+) CAD father

PERSONAL AND SOCIAL HISTORY
Unemployed (previous ofw)
Non smoker
Non alcoholic beverage drinker
Denies intake of illicit drugs



REVIEW OF SYSTEM
General : (-) fever
Head : (-) Headache (-) nape pain
SKIN: (-) pallor
RESP: (-) DOB, (-)cough, (-) hemoptysis
CVS: (-) chest pain, (-) orthopnea, (-) palpitation
GIT: (-) melena, (-) hematochezia, (-) diarrhea, (-) vomiting
GUT: (+) flank pain (-) hematuria (-) discharge
HEMA: (+) spontaneous gum bleeding

PHYSICAL EXAMINATION:
GENERAL SURVEY: conscious, coherent, ambulatory, fairly kempt
BP: 110/70 mmHg HR: 87/ bpm RR: 21/cpm T: 36.9
SKIN: (+) petechial rash both upper and lower extremities and trunk, fair in complexion,
warm to touch
HEENT: Anicteric sclerae, pink palpebral conjunctivae, (+) spontaneous gum bleeding, no
tonsillo-pharyngeal congestion
Neck: No neck vein engorgement; no cervical lymphadenopathies, no carotid bruit
CHEST AND LUNGS: Symmetrical chest expansion, no retractions, (-) crackles, (-) wheezes
HEART: Adynamic precordium, normal rate, regular rhythm, apex beat at 5
th
LICS MCL, no
murmurs appreciated
ABDOMEN: Flat, soft, non-tender, normoactive bowel sounds
EXTREMITIES: Grossly normal, (-) edema, (-) cyanosis, full and equal pulse

Neuro examination
Unremarkable

Course in the wards:
Upon admission patient was venoclyzed with PNSS 1L to run for 8 hours. Diagnostics such
as CBC with PC, Urinalysis, BUN, CREA, Na, K, were ordered. Patient was started on prednisone
20mg/tab 1 tablet 3x a day. Transfusion of type specific platelet concentrate were ordered.
On patients 2
nd
3
rd
hospital stay, patient still with spontaneous gum bleeding, 2 units of
platelet concentrate were given. Ice chips were advised for the gum bleeding. Prednisone
20mg/tab were continued.
On patients 4
th
hospital stay, no gum bleeding were noted. Patients rashes were slowly
noticed to have subsided. Repeat of the CBC were done which revealed an increase of the
platelet count.
Patient was discharged on the 5
th
hospital stay.
Final Diagnosis: Immune Thrombocytopenia

LABORATORIES:



BUN 6.0 2.5 6.4 mmol/L
Creatinine 113.6 79.5 132.6 mmol/L
Na 145 134 145mmol/L
K 3.93 3.5 4.5 mmol/L

Urinalysis

Color
yellow
Character
Hazy
sp gr
1.030
Rxn
6.0
Alb
-
Sugar
-
PMN
1-2
RBC
0-2
Squamous cells
Few
Bacteria
-
Uric acid crystals

Amorphous
urates


CBC 5/17 5/21 Normal Values
Hgb 132 127 110-150 g/L
Hct 0.40 0.41 0.37-0.45
Wbc 5.9 9.1 4.6-10 10
9
/L
Segmenters 0.693 0.87 0.500-0.700
Lympho 0.172 0.07 0.200-0.400
Mono 0.124 0.05 0.000-0.070
Platelet
count
3 199 150 400 10
9
/L
RBC indices
MCV 88.8 90.8 80.9-99.9fL
MCH

28.8 27.9 27-31 pg
MCHC 30.8 32.5 33-37%