• JB

• 29/M/S
• ROMAN CATHOLIC
• FARMER
• CABASAN, BACACAY, ALBAY
• ADMITTED AT BRTTH FOR THE 1ST TIME

• INFORMANTS: PATIENT HIMSELF AND HIS MOTHER

• RELIABILITY: 90%
• FEVER FOR 4 DAYS
• 4 DAYS PTA:
• (+) FEVER – ON AND OFF, UNDOCUMENTED
• (+) HEADACHE – FRONTAL, THROBBING,
RADIATING TO TOP OF THE HEAD, GRADED 7/10

• (+) JOINT PAINS, (+) MUSCLE PAINS IN THE

CALVES RADIATING TO THE BACK
(+) NUCHAL PAIN
(+) 2X EPISODES OF VOMITING – ~½ GLASS PER
BOUT, NONPROJECTILE, NONBILIOUS

• TOOK MEDICOL (IBUPROFEN 200 MG/CAP) AND

ALAXAN (IBUPROFEN 200MG + PARACETAMOL
325 MG/TAB) WITH SLIGHT RELIEF
• NO CONSULT WAS DONE
• 3 DAYS PTA:
• THE PATIENT SOUGHT CONSULT AT CAGRARAY
DISTRICT HOSPITAL AND WAS ADMITTED FOR 2
DAYS.
• DURING HOSPITALIZATION:
• THE PATIENT WAS GIVEN PARACETAMOL 500
MG/TAB Q 4HRS, CELECOXIB 200MG/CAP OD,
OMEPRAZOLE 40MG IV OD.
• (+) ABDOMINAL PAIN RELIEVED BY DEFECATION
• (+) 5 EPISODES OF LOOSE WATERY STOOLS
• (+) YELLOWING OF EYES
• (+) TEA-COLORED URINE
• THE PATIENT OPTED FOR HAMA
• IN THE MORNING PTA:

• THE PATIENT HAD ANOTHER EPISODE OF FEVER

AND CHILLS AT HOME, PROMPTING CONSULT AT
THE SAME HOSPITAL

• STILL WITH ABOVE SIGNS AND SYMPTOMS, THE

PATIENT WAS REFERRED TO BRTTH HENCE
ADMISSION
• GENERAL: NO REPORTED WEIGHT LOSS

• HEENT: NO VISUAL DIFFICULTIES, NO HEARING

PROBLEMS, NO SORE THROAT

• RESPIRATORY: NO COUGH, NO COLDS, NO

DIFFICULTY OF BREATHING

• CARDIOVASCULAR: NO CHEST PAIN, NO

PALPITATIONS

• GENITOURINARY: (+) TEA-COLORED URINE, NO

DIFFICULTY OF URINATING, NO
DECREASED/INCREASED URINE OUTPUT

• NEUROLOGICAL: NO EPISODES OF SEIZURES OR

FAINTING, NO MOTOR AND SENSORY LOSS, NO
ALTERED SENSORIUM
• NO HISTORY OF PREVIOUS HOSPITALIZATION
• NO HISTORY OF PREVIOUS MAJOR SURGICAL
OPERATION

• (-) PTB
• (-) HPN
• (-) DM
• (-) CA
• (-) HPN
• (-) DM
• (-) CA
• (-) GOITER
• (-) HEART DISEASE
• BORN AND RAISED IN CAGRARAY ISLAND,
BACACAY, ALBAY

• NO RECENT HISTORY OF TRAVEL

• SINGLE

• WORKS AS A FARMER AND COPRA PRODUCER

• HAS FREQUENT CONTACT WITH CARABAO

• LIVES IN SEMICONCRETE HOUSE AT AN ELEVATED,
NON-FLOODPRONE AREA

• LIVES WITH PARENTS AND ONE SIBLING

• ELDEST AMONG 5 SIBLINGS
• NON-SMOKER, NON-ALCOHOLIC DRINKER

• DENIES USE OF ILLICIT DRUGS

• GENERAL: THE PATIENT IS CONSCIOUS,
COHERENT, AND NOT IN CARDIORESPIRATORY
DISTRESS
• VITAL SIGNS: 120/80, 125 BPM, 24 CPM,
37.7
• SKIN: (-) RASH, (-) PETECHIAE (-) PALLOR (-)
JAUNDICE
• HEENT: ICTERIC SCLERAE, (+) CONJUNCTIVAL
SUFFUSION, (-) ALAR FLARING
• CHEST AND LUNGS: SYMMETRIC CHEST
EXPANSION, (-) RETRACTIONS, CLEAR BREATH
SOUNDS
• CARDIOVASCULAR: ADYNAMIC PRECORDIUM,
INCREASED RATE, REGULAR RHYTHM, (-)
MURMURS
• ABDOMEN: FLAT, SOFT ABDOMEN, HYPERACTIVE
BOWEL SOUNDS, NONTENDER, (-) MASSES

• EXTREMITIES: GROSSLY NORMAL EXTREMITIES, FULL

AND EQUAL PULSES, (-) EDEMA, (-) CYANOSIS,
(+) MUSCLE TENDERNESS ON LOWER EXTREMITIES
• NEUROLOGIC: GCS 15, CRANIAL NERVES
INTACT, MOTOR RESPONSE – 5/5 ON ALL
EXTREMITIES, SENSORY RESPONSE – 100% ON
ALL EXTREMITIES, (-) MENINGEAL SIGNS
SUBJECTIVE OBJECTIVE
• 29 • MALE

• FARMER • CONJUNCTIVAL
SUFFUSION
• FEVER FOR 4 DAYS
• ICTERIC SCLERAE
• MYALGIA
• TACHYCARDIC
• HEADACHE
• (+) MUSCLE TENDERNESS
• NUCHAL PAIN

• VOMITING

• (-) DYSURIA

• (-) DOB
DIAGNOSIS RULE IN RULE OUT
LEPTOSPIROSIS FEVER, HEADACHE, CANNOT TOTALLY
MYALGIA, RULE OUT
CONJUNCTIVAL
SUFFUSION
DENGUE FEVER, HEADACHE, CONJUNCTIVAL
MYALGIA SUFFUSION
INFLUENZA FEVER, HEADACHE, CONJUNCTIVAL
MYALGIA SUFFUSION
• LEPTOSPIROSIS