CASE 1:NEONATAL PNEUMONIA

GENERAL DATA: This ia a case of C.B.B 2 days old baby boy from malinao, albay who was brought to the ER with chief complaint of Difficulty of
Breathing. The patient was admitted for the 1st time in our institution.

INFORMANT: Mother
RELIABILITY: 90%
CHIEF COMPLAINT: DOB

HISTORY OF PRESENT ILLNESS:

The patient was born to a 16 yr old G1P1 mother with 3 prenatal check up done at BHC and a private hospital during her pregnancy..
Mother had regular intake of Ferrous Sulfate and Calcium Carbonate from 5th month of pregnancy. The mother had no illnesses during
pregnancy . She received 2 doses of tetanus toxoid vaccine at her 6th and 7th month of pregnancy. She denies exposure to radiations and
teratogens. No ultrasound was taken during the course of her pregnancy. The mother claimed that she was not fond of eating during her
pregnancy
The patient was delivered term 38 wks by BS 1.8 kg SGA cephalic via NSD at Ziga hospital with an AS 8,9 with poor cry.
1 day PTA The px was noted with grunting and poor suck
Few hours PTA, the symptoms persisted now with jaundice hence transferred to our institution for further management. Hence admitted.

Birth and Maternal History

Vitamin K 0.5 mg IM was administered

Manner of delivery: NSD

Attended by: Doctor
Birth place: Ziga hospital, tabacco
Birth weight: 1.8 kg
Apgar Score: 8,9

Neonatal: Poor cry, non cyanotic , no jaundice, non pallor, no bleeding, no seizure, no fever, bowel movement / urine output occur within 24Hrs

Immunization History

No immunizations were done at referral hospital.

However upon admitting in this institution px was administered
BCG 0.05 ml ID at Left deltoid
HEPA 0.05 ml IM at Right anterolateral thigh

Family History
(-) Hypertension
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

PHYSICAL EXAMINATION

General Survey:
Patient is awake and active and in mild respiratory distress

Vital Signs:
CR: 123bpm RR: 52 cpm Temperature: 36.7 C O2 Sat: 97% (without O2 support)

Anthropometric measurements:
Wt. 1.56 kg Length: 42 cm HC: 28 cm AC: 22 cm CC: 23 cm

LUBCHENCO CHART INTERPRETATION

Weight for Gestation Age Below 10th percentile SMALLER FOR AGE

Length for Gestational Age Below 10th percentile SMALLER FOR AGE

Head circumference Below 10th percentile SMALLER FOR AGE

Skin: jaundiced. no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor
HEENT: Head and neck: Normocephalic, non bulgy anterior fontanelle, evenly distributed hair, no masses or lesions ,
no cervical lymphadenopathy.
Eyes: Symmetric, anicteric sclera, pink palpebral conjunctiva, no sunken eyes, no eye discharge,
Ears: Symmetric and equal size, no masses/lesions. no external ear discharge, no deformities,
Nose: Patent nares, septum is in midline, no deformities, no discharge, no alar flaring
Throat: Pinkish lips, moist oral mucosa, tongue is in midline, without cleft palate,
Thorax & Lungs: Symmetric chest expansion, noted subcostal retractions, , clear breath sounds, no wheezes, no
stridor, no crackles
Cardiovascular: Adynamic precordium, normal regular rate and rhythm .PMI is at the left 4th ICS MCL , no murmur,
no heaves, no thrills,
Abdomen: Abdomen is protuberant with minimal veins, no deformities, with jaundice, normoactive bowel sound with
22 clicks per minute . no organomegaly, soft and non tender, dry umbilical cord.
Extremities: Symmetric, no deformities, with jaundice, no edema, no clubbing, Capillary refill time is <2 seconds,
with full and equal peripheral pulses on all extremities
Genitals: grossly male with noted proximal penoscrotal hypospadias with bifid scrotum, descended testis and patent
anus.

Neurological Examination

Mental Status The patient is awake

CN I. : Not tested
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.(+) Glare response
CN III, IV &VI: Extraocular muscles are all intact based on observation
CN V. : (+) Rooting reflex
CN VII. : No facial asymmetry were noted, symmetric when crying
CN VIII. : disturbed to sound
CN IX & X. : The px is able to swallow
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

reflexes noted were babinski , plantar , palmar reflex and moro reflex

Motor: px can move all extremities

Sensory: respond to stimulus (100% / 100%), shows withdrawal to pain
Deep Tendon Reflexes: not tested

ADMITTING DIAGNOSIS:

Term 38 weeks by BS 1.8 kg SGA cephalic delivered via NSD Live baby boy AS 8,9 T/C Neonatal pneumonia R/O sepsis. Penoscrotal
Hypospadias with chordee

DISCUSSION:

NEONATAL PNEUMONIA

Epidemiology:

Pneumonia, defined as inflammation of the lung parenchyma, is the leading infectious cause of death globally among children younger than 5
yr, accounting for an estimated 920,000 deaths each year (Fig. 428.1 ). Pneumonia mortality is closely linked to poverty. More than 99% of
pneumonia deaths are in low- and middle-income countries, with the highest pneumonia mortality rate occurring in poorly developed countries
in Africa and South Asia

PATHOGENESIS:

Viral pneumonia usually results from spread of infection along the airways, accompanied by direct injury of the respiratory epithelium, which
results in airway obstruction from swelling, abnormal secretions, and cellular debris. The small caliber of airways in young infants makes such
patients particularly susceptible to severe infection. Atelectasis, interstitial edema, and hypoxemia from ventilation–perfusion mismatch often
accompany airway obstruction. Viral infection of the respiratory tract can also predispose to secondary bacterial infection by disturbing normal
host defense mechanisms, altering secretions, and through disruptions in the respiratory microbiota.

Bacterial pneumonia most often occurs when respiratory tract organisms colonize the trachea and subsequently gain access to the lungs, but
pneumonia may also result from direct seeding of lung tissue after bacteremia. When bacterial infection is established in the lung parenchyma,
the pathologic process varies according to the invading organism. M. pneumoniae attaches to the respiratory epithelium, inhibits ciliary action,
and leads to cellular destruction and an inflammatory response in the submucosa. As the infection progresses, sloughed cellular debris,
inflammatory cells, and mucus cause airway obstruction, with spread of infection occurring along the bronchial tree, as is seen in viral
pneumonia. S. pneumoniae produces local edema that aids in the proliferation of organisms and their spread into adjacent portions of lung,
often resulting in the characteristic focal lobar involvement. Group A streptococcus lower respiratory tract infection typically results in more
diffuse lung involvement with interstitial pneumonia. The pathology includes necrosis of tracheobronchial mucosa; formation of large amounts
of exudate, edema, and local hemorrhage, with extension into the interalveolar septa; and involvement of lymphatic vessels with frequent
pleural involvement. S. aureus pneumonia manifests as confluent bronchopneumonia, which is often unilateral and characterized by the
presence of extensive areas of hemorrhagic necrosis and irregular areas of cavitation of the lung parenchyma, resulting in pneumatoceles,
empyema, and, at times, bronchopulmonary fistulas.

Recurrent pneumonia is defined as 2 or more episodes in a single year or 3 or more episodes ever, with radiographic clearing between
occurrences. An underlying disorder should be considered if a child experiences recurrent pneumonia

TREATMENT:

Treatment of suspected bacterial pneumonia is based on the presumptive cause and the age and clinical appearance of the child. For mildly ill
children who do not require hospitalization, amoxicillin is recommended. With the emergence of penicillin-resistant pneumococci, high doses of
amoxicillin (90 mg/kg/day orally divided twice daily) should be prescribed unless local data indicate a low prevalence of resistance . Therapeutic
alternatives include cefuroxime and amoxicillin/clavulanate. For school-aged children and adolescents or when infection with M. pneumoniae
or C. pneumoniae is suspected, a macrolide antibiotic is an appropriate choice for outpatient management. Azithromycin is generally preferred,
while clarithromycin or doxycycline (for children 8 yr or older) are alternatives. For adolescents, a respiratory fluoroquinolone (levofloxacin,
moxifloxacin) may also be considered as an alternative if there are contraindications to other agents.

CASE 2: DENGUE WITH WARNING SIGNS

GENERAL DATA: This is a case of B.M.N , an 8 years old female patient from legazpi city who came in to the er with a chief complaint of
generalized body weakness. The patient was admitted for the 1st time in our institution.

INFORMANT: Mother
RELIABILITY: 90%
CHIEF COMPLAINT: Generalized body weakness

HISTORY OF PRESENT ILLNESS:

4 days PTA, mother noted patient having 3 episodes of fever, highest at 39°C. She gave 240 mkdose of Paracetamol for every episode of fever
which provided temporary relief. No other symptoms noted. No consult was done.
3 days PTA, fever persists now with poor appetite. Paracetamol still given with same dose.
Few hours PTA, symptoms persist now with body weakness and shortness of breath, hence admission.

Review of Systems
General: (-) weight loss (-) fatigability
Skin: (-) rash (-) lumps (-) sores (-) pain (-) dryness (-) itchiness
HEENT: Eyes: (-) redness (-) pain (-) discharge
Ears: (-) decreased hearing (-) pain (-) discharge
Nose: (-) nasal congestion (-) discharge / drainage (-) nosebleed (-) decreased smell Throat/mouth: (-)
bleeding gums (-) dry mouth (-) hoarse voice (-) thrush (-) dental caries (-)sores
Head & Neck : (-) neck stiffness (-) mass / lumps (-) pain
Respiratory :(-) cough (-) colds (-) frequent chest infections (-) hemoptysis
Cardiovascular : (-) palpitations (-) SOB on exertion (-) chest tightness / pain (-) edema
GIT: (-) loose watery stools (-) nausea (-) vomiting (-) bowel changes (-) abdominal Pain (-) diarrhea/constipation (-) blood in stools
(-) melena / black tarry stool (-) difficulty swallowing (-) heartburn
GUT: (-) dysuria (-) frequency (-) nocturia (-) hematuria (-) decreased
CNS: (-) loss of consciousness (-) seizure
Hematologic: (-) easy bruising (-) bleeding episodes
M/S: (-) paralysis
Psychiatric: (-) sleep difficulties

Birth and Maternal History

Patient was born to a 27-year-old G5P5 mother who had only 8 PNCU at the barangay Health Center and took ferrous sulfate during the course
of her pregnancy and denies presence of maternal illnesses and complications, smoking, alcohol consumption, use of illicit drugs, and exposure
to teratogens and radiation. Patient was delivered via NSD, full term at unrecalled weeks of gestation, attended by a midwife at home, claimed
to have a good cry and activity upon birth.

Feeding and Nutritional History

Patient was given a combination of breastmilk and formula milk of Bonna 2 tbsp/ 250mL for 6 months before complementary feeding was
done. Current diet consists of steamed rice with fish or meat. Appebon being taken 1 tbsp per day. No other supplements taken.

Immunization History
The mother claimed that the patient had complete immunization but she cannot recall the names nor the site of injection.

Growth & Development:

Development are at par with age.

Past Medical History/ Accidents

No previous hospitalizations, no known allergies, congenital diseases, previous surgeries, no current medications being taken, and wasn’t
involved in any accidents. She had a history of chickenpox when she was 2 years old.

Family History
(-) Hypertension
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Socioeconomic and Environmental History

Her father is a delivery driver and her mother a housewife. Patient takes a bath regularly. Their house is a one-storey cemented house located
at the city center, claimed to be non- congested and well-ventilated. The family drinks mineral water and uses charcoal for cooking. They have a
proper sewage disposal and disposes garbage through garbage trucks rotating twice a week in their barangay

PHYSICAL EXAMINATION

General Survey:
Patient is awake and active and not in respiratory distress

Vital Signs:
BP: 90/60 CR: 120bpm RR: 36cpm Temperature: 36.5C O2 Sat: 99%

Anthropometric measurements:
Wt: 24kg height: 133cm. BMI: 13.6

Z-SCORE INTERPRETATION

Weight for Age 0 Normal weight

Height for Age 0 Normal height

BMI for Age -1 Normal

 Skin: generalized pallor.no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor
HEENT: Head and neck: Normocephalic, evenly distributed hair, no masses or lesions , no cervical lymphadenopathy.
Eyes: Symmetric, anicteric sclera, pink palpebral conjunctiva, no sunken eyes, no eye discharge,
Ears: Symmetric and equal size, no masses/lesions. no external ear discharge, no deformities,
Nose: Patent nares, septum is in midline, no deformities, no discharge, no alar flaring
Throat: Pale lips, dry oral mucosa, tongue is in midline, without cleft palate,
Thorax & Lungs: Symmetric chest expansion, resonant upon palpation, clear breath sounds, no wheezes, no stridor,
no crackles
Cardiovascular: Adynamic precordium, normal regular rate and rhythm .PMI is at the left 5th ICS MCL , no murmur,
no heaves, no thrills,
Abdomen: Abdomen is flat and soft, no deformities, tenderness on epigastric area, normoactive bowel sound
with 22 clicks per minute . no organomegaly
Extremities: Symmetric, no deformities,, no edema, no clubbing, Capillary refill time is <2 seconds, with full and
equal peripheral pulses on all extremities

Neurological Examination

Mental Status GCS 15

CN I: (>32 wks): with intact smell

CN II: pupils are 3-4mm equally reactive to light, with intact blink
reflex
CN III, IV &VI: regards to object in all directions
CN V: patient reacts when stimulus is applied to forehead, cheeks, and mandibular area
CN VII: no facial asymmetry noted when the patient is asked to smile
CN VIII: turns to sound
CN IX & X: able to gag
CN XI: able to turn head side to side
CN XII: able to protrude tongue, no fasciculations

Motor: px can move all extremities . 5/5

Sensory: respond to stimulus (100% / 100%), shows withdrawal to pain
Deep Tendon Reflexes: Normoreflexive

ADMITTING DIAGNOSIS:
DENGUE FEVER WITH WARNING SIGNS

DISCUSSION:

DENGUE FEVER

Dengue fever is a benign syndrome caused by several arthropod-borne viruses and is characterized by biphasic fever, myalgia or arthralgia,
rash, leukopenia, and lymphadenopathy. There are at least four distinct antigenic types of dengue virus (dengue 1, 2, 3, and 4), members of the
family Flaviviridae. In addition, three other arthropodborne viruses (arboviruses) cause similar dengue fever syndromes with rash
Dengue viruses are transmitted by mosquitoes of the Stegomyia family. Aedes aegypti, a daytime biting mosquito, is the principal vector, and all
four virus types have been recovered from it. Transmission occurs from viremic humans by bite of the vector mosquito where virus multiplies
during an extrinsic incubation period and then by bite is passed on to a susceptible human in what is called the urban transmission cycle.

The incubation period is 1-7 days. The clinical manifestations are variable and are influenced by the age of the patient. In infants and young
children, the disease may be undifferentiated or characterized by fever for 1-5 days, pharyngeal inflammation, rhinitis, and mild cough. A
majority of infected older children and adults experience sudden onset of fever, with temperature rapidly increasing to 39.4-41.1°C (103-
106°F), usually accompanied by frontal or retroorbital pain, particularly when pressure is applied to the eyes. Occasionally, severe back pain
precedes the fever (back-break fever). A transient, macular, generalized rash that blanches under pressure may be seen during the first 24-48
hr of fever. The pulse rate may be slow relative to the degree of fever. Myalgia and arthralgia occur soon after the onset of fevers and increase
in severity over time. From the second to sixth day of fever, nausea and vomiting are apt to occur, and generalized lymphadenopathy,
cutaneous hyperesthesia or hyperalgesia, taste aberrations, and pronounced anorexia may develop.

Treatment of uncomplicated dengue fever is supportive. Bed rest is advised during the febrile period. Antipyretics should be used to keep the
body temperature < 40°C (104°F). Analgesics or mild sedation may be required to control pain. Aspirin is contraindicated and should not be
used because of its effects on hemostasis. Fluid and electrolyte replacement is required for deficits caused by sweating, fasting, thirsting,
vomiting, and diarrhea.
CASE 3: AMOEBIASISS

GENERAL DATA: This s a case of P.L.E an 8 months old baby girl from guinabatan, albay who was brought to the ER due to vomiting.

INFORMANT: MOTHER

RELIABILITY: 95%

CHIEF COMPLAINT: VOMITING

HISTORY OF PRESENT ILLNESS:

An 8 months old baby girl was brought to ER with a chief complaint of vomiting( white, clean and sticky amounting to 50 ml) together with
fever, cough and colds. The pt was admitted in AGH on 2nd of August 2021 for fever, vomiting, and bloody stool, and was diagnosed with
Amoebiasis and was discharged when the condition improved which was 2 days PTA. the px was given paracetamol 1.2 ml every 4 hours and
erceflora two times a day until the day of admission.
1 day PTA patient vomited 4 times and had fever with cough and cold and loose watery diarrhea.
FHPTA, frequency of the vomiting increased to 6 times hence the visit and subsequent admission.

Birth and Maternal History

Patient was born to a 3o year old G1P1 mother.

The following were administered upon birth:

Vitamin K 0.5 mg IM
Erythromycin ophthalmic ointment 0.5%
BCG 0.05 ml ID at Left deltoid
HEPA 0.05 ml IM at Right anterolateral thigh

Manner of delivery: NSD

Attended by: Doctor
Birth weight: 2.6 kg
Apgar Score: 8,9

Neonatal: goodcry, non cyanotic , no jaundice, non pallor, no bleeding, no seizure, no fever, bowel movement / urine output occur within 24Hrs

Feeding History:
Patient was given mixed feeding since birth and the formula used was S26 gold.

Growth & Development:

Development are at par with age.

Immunization History:
Fully immunized for the age.

Past Medical History:

Patient was admitted in AGH 10 days PTA for amoebiasis.

Family History
(+) Hypertension
(+) DM
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Social History:
Patient lives in a 2 story house with 5 members. Source of income is the father who is an employee. No exposure to cigerette smoke. Water
source is wilkins mineral water. They have a pet dog.
PHYSICAL EXAMINATION:

Vital Signs:
Temp: 37.5C
CR: 116bpm
RR: 41cpm
SpO2: 96%
Wt. 8.5 kgs
Lt: 57.5cm

General Appearance: awake and crying, in mild respiratory distress

Head: normocephaly, equal distribution of hair with normal texture. Closed posterior fontanel, slightly sunken anterior fontanel
Face: symmetrical; no facial deformity, no lumps and bumps
Eyes: Anicteric sclera, slightly dry conjunctiva, sunken eyes
Ears: (-) masses, no discharge noted
Nose: no deformity, no noted septal deviation or perforation
Mouth: dry buccal mucosa
Neck: No lymphadenopathy, no masses or lesions
Chest and Lungs: Tachypnea, mild crackles were heard on auscultations
Abdomen: distended abdomen, no noted tenderness, no presence of masses, lesions, rashes
Extremities: warm to touch, no presence of cyanosis or edema.

Neurological Examination

Mental Status The patient is awake

CN I. : Not tested
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.(+) Glare response
CN III, IV &VI: Extraocular muscles are all intact based on observation
CN V. : (+) Rooting reflex
CN VII. : No facial asymmetry were noted, symmetric when crying
CN VIII. : disturbed to sound
CN IX & X. : The px is able to swallow
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

reflexes noted were babinski , plantar , palmar reflex and moro reflex
Motor: px can move all extremities
Sensory: respond to stimulus (100% / 100%), shows withdrawal to pain
Deep Tendon Reflexes: not tested

ADMITTING DIAGNOSIS:
AMOEBIASIS; PNEUMONIA SEVERE

DISCUSSION:

AMEBIASIS

Entamoeba species infect or colonize up to 10% of the world's population, particularly in resource-limited settings. In most infected individuals,
Entamoeba histolytica or a related species parasitizes the lumen of the gastrointestinal tract and causes few symptoms or sequelae. Four
morphologically identical but genetically distinct species of Entamoeba are known to infect humans. Entamoeba dispar, the most prevalent
species, does not cause symptomatic disease. Entamoeba moshkovskii, previously thought to be nonpathogenic, has increasingly been shown
to cause diarrhea in infants and children, and asymptomatic infection with E. moshkovskii may be as common as E. dispar infection in some
communities. E. histolytica, the main pathogenic species, causes a spectrum of disease and can become invasive in 4–10% of infected patients.

PATHOGENESIS:
Trophozoites are responsible for tissue invasion and destruction. Hypersecretion of mucus by colonic goblet cells is induced by secreted amebic
cysteine protease 5, which eventually leads to degradation of the mucus layer, exposing colonic epithelial cells. Amebae then attach using a
galactose and N -acetyl-D galactosamine–specific lectin. This lectin also provides resistance to complement-mediated lysis, and its intermediate
subunit has been found to have hemagglutinating, hemolytic, and cytolytic activity. Once attached to the colonic mucosa, trophozoites
penetrate the epithelial layer, destroying host cells by cytolysis and induction of apoptosis. Cytolysis is mediated by trophozoite release of
amebapores (pore-forming proteins), phospholipases, and hemolysins. Trogocytosis, where amebae ingest pieces of living cells and induce
intracellular calcium elevation leading to apoptosis, was recently described as a mechanism for direct host cell killing by amebae.
Clinical presentations range from asymptomatic cyst passage to amebic colitis, amebic dysentery, ameboma, and extraintestinal disease. Up to
10% of infected persons develop invasive disease within a year, and asymptomatic carriers should be treated. Severe disease is more common
in young children, pregnant women, malnourished individuals, and persons taking corticosteroids, and invasive disease is more common in
men. Extraintestinal disease usually involves the liver, but less common extraintestinal manifestations include amebic brain abscess,
pleuropulmonary disease, ulcerative skin, and genitourinary lesions.

TREATMENT:
Invasive amebiasis is treated with a nitroimidazole such as metronidazole or tinidazole and then a luminal amebicide (Table 307.1 ). Tinidazole
has similar efficacy to metronidazole, with shorter and simpler dosing, and is better tolerated. Adverse effects include nausea, abdominal
discomfort, and a metallic taste that disappears after completion of therapy. Therapy with a nitroimidazole should be followed by treatment
with a luminal agent, such as paromomycin (which is preferred) or iodoquinol. Diloxanide furoate can also be used in children > 2 yr of age, but
it is no longer available in the United States.

CASE 4: ACUTE APPENDICITIS

GENERAL DATA: This is a case of patient N.L.K, 19 year old male from naga city, who came in to ER with a chief complaint of abdominal pain.

RELIABILITY: 95%

HISTORY OF PRESENT ILLNESS:

1 day prior to consult patient experienced vague abdominal pain with pain scale of 6\10. No consult was done and no meds taken. 6 hours
prior to consult the pain localized in the RLQ with a pain scale 8\10 now acccompanied with fever and 2 episodes of vomiting. Few hours prior
to consult, persistance of symptoms prompted consult.

Past Medical History: Unremarkable

Family History:
(+) Hypertension
(-) DM
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Personal and Social History: non smoker, non alcoholic drinker

Review of system:

General (+) loss of apetite, (-) easy fatigability, (-) weight change

Skin (-) rashes, (-) itching, (-) dryness, (-) changes in hair or nails

HEENT (-) headache, (-) dizziness, (-) lightheadedness, (-) pain, (-) redness, (-) excessive tearing, (-) minimal eye
tears, (-) blurred vision and use of glasses or contact lenses, (+) nasal discharge, (-) bleeding gums, (-) sore
tongue, (-) sore throat, (-) hoarseness

Neck (-) pain, (-) stiffness in the neck, (-) nuchal rigidity

Respiratory (-) dry cough, (-) dyspnea, (-) presence of sputum, (-) increased work of breathing

Gastrointestinal (-) vomiting, (-) change in bowel movement

Cardiovascular (-) cyanosis, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitation

Urinary (-) dysuria, (-) change in color of urine, (-) abnormal discharge, (-) burning or pain on urination.

Peripheral vascular (-) pallor, (-) ecchymosis, (-) cyanosis, (-) edema

Musculoskeletal (-) stiffness, (-) limping, (-) history of trauma

 Neurologic Can move all extremities with ease, (-) history of convulsions, (-) tremors, (-) mental deterioration

Endocrine (-) heat and cold intolerance, (-) excessive sweating, (-) changes in urine frequency and amount

PHYSICAL EXAMINATION:

BP: 120/80
HR: 95
RR: 20
TEMP: 37.9
O2: 99%

General :awake, conscious, coherent, not in distress

SKIN :no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor

HEENT :Anicteric sclerae, pink palpebral conjunctiva, no. cervical lymphadenopathy

CHEST/LUNGS :symmetric chest expansion, no retractions, clear breath sounds

CVS :adynamic precordium, normal rate regular rhythm, no murmur, PMI is at the left 5th ICS MCL

ABDOMEN :flat, soft, (+) rebound tenderness on RLQ, (+)dunphys sign,(+) obturator sign, (+) psoas sign, (-) rovsings sign

EXTREMITIES :no edema,full equal pulse, CRT <2secs

Neurological Examination

Mental Status The patient is awake, GCS 15

CN I. : No Anosmia
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.
CN III, IV &VI: Extraocular muscles are all intact
CN V. : equal facial sensation to pinprick.
CN VII. : face symmetry withnormal eye closure ans smile
CN VIII. : Intact gross hearing
CN IX & X. : (+) gag reflex
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

Motor: 5/5 in all extremities

Sensory: intact bilaterally, 100%

ALVARADO SCORE: 9\10 (high probability, surgical exploration)

ADMITTING DIAGNOSIS:
ACUTE SUPPURATIVE APPENDICITIS

DISCUSSION:

APPENDICITIS

Inflammation of the appendix caused by obstruction of the appendiceal lumen ( this produces a closed loop, resulting in necrosis and\or
perforation)
Appendicitis is one of the most common surgical emergencies in contemporary medicine, with a yearly incidence rate of about 100 per 100,000
inhabitants. Lifetime risk for appendicitis is 8.6% for males and 6.7% for females, with the highest incidence in the second decade of life.

Right lower quadrant pain, gastrointestinal symptoms starting after the onset of pain, and a systemic inflammatory response with leukocytosis
and neutrophilia, increased C-reactive protein concentration, and fever are considered diagnostic of appendicitis. The Appendicitis
Inflammatory Response Score or Alvarado score can help improve diagnostic accuracy.
Computed tomography scan has improved diagnostic accuracy in individual studies. However, in population-wide studies, the rate of
misdiagnosis of appendicitis remains constant. Rates of misdiagnosis are highest in female patients of child-bearing age and patients on the
extremes of age (i.e., very young and very old).
The role of nonoperative treatment for uncomplicated appendicitis remains controversial. Currently, appendectomy remains the standard of
care. Laparoscopic appendectomy has a slight benefit over open appendectomy.

ALVARADO SCORE POINTS

Migratory right iliac fossa pain 1

Anorexia 1

Nausea and vomiting 1

Tenderness: right iliac fossa 2

Rebound tenderness right iliac fossa 1

Fever >= 36.3c 1

Leukocytosis 2

Shift to the left of neutrophils 1

Score: <3: Low likelihood of appendicitis

4–6: Consider further imaging
≥7: High likelihood of appendicitis

CASE 5: INGUINAL HERNIA

abnormal protrusion of an organ or tissue through a defect in its surrounding wall. Approximately 75% of abdominal wall hernias occur in the
groin. The lifetime risk of inguinal hernia is 27% in men and 3% in women. Inguinal hernias are five times more common than femoral hernias.
The most common subtype of groin hernia in men and women is the indirect inguinal hernia.4

GENERAL DATA:This is a case of a Patient L.S, a 43 years old male from pili who came to ER with a chief complaint of abnormal bulge in inguinal
area, left.

RELIABILITY: 98%

HISTORY OF PRESENT ILLNESS:

3 months PTC, patient noticed a palpable mass,non tender in the inguinal area, left with no associated symptoms. No consult done. 2 months
PTC , the above symptoms persisted now accompanied with pain 8\10 which is aggravated when doing heavy works. Consult was done at
surgery OPD and ultrasound was requested which revealed Inguinal Hernia, Left. Patient was scheduled for surgery. Few hours PTA patient
came in to ER for the admission for elective surgery.

Past Medical History: No history of illnesses,previous hospitalization, no previous surgery.

Family History:
(+) Hypertension
(-) DM
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Allergies: None

Personal and Social History: non smoker, non alcoholic drinker

REVIEW OF SYSTEMS:

General (-) loss of apetite, (+) easy fatigability, (+) weight change

Skin (-) rashes, (-) itching, (-) dryness, (-) changes in hair or nails

HEENT (-) headache, (-) dizziness, (-) lightheadedness, (-) pain, (-) redness, (-) excessive tearing, (-) minimal eye
tears, (-) blurred vision and use of glasses or contact lenses, (+) nasal discharge, (-) bleeding gums, (-) sore
tongue, (-) sore throat, (-) hoarseness

Neck (-) pain, (-) stiffness in the neck, (-) nuchal rigidity

Respiratory (-) dry cough, (-) dyspnea, (-) presence of sputum, (-) increased work of breathing

Gastrointestinal (-) vomiting, (-) change in bowel movement

Cardiovascular (-) cyanosis, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitation

Urinary (-) dysuria, (-) change in color of urine, (-) abnormal discharge, (-) burning or pain on urination.

Peripheral vascular (-) pallor, (-) ecchymosis, (-) cyanosis, (-) edema

Musculoskeletal (-) stiffness, (-) limping, (-) history of trauma

Neurologic Can move all extremities with ease, (-) history of convulsions, (-) tremors, (-) mental deterioration

Endocrine (-) heat and cold intolerance, (-) excessive sweating, (-) changes in urine frequency and amount

PHYSICAL EXAMINATION:

BP: 110/80
HR: 82
RR: 20
TEMP: 36.5
O2: 99%

General :awake, conscious, coherent, not in distress

SKIN :no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor

HEENT :Anicteric sclerae, pink palpebral conjunctiva, no. cervical lymphadenopathy

CHEST/LUNGS :symmetric chest expansion, no retractions, clear breath sounds

CVS :adynamic precordium, normal rate regular rhythm, no murmur, PMI is at the left 5th ICS MCL

ABDOMEN :flat, soft, non ditended, palpable mass in the inguinal area, left, non tender.

EXTREMITIES :no edema,full equal pulse, CRT <2secs

Neurological Examination
Mental Status The patient is awake, GCS 15

CN I. : No Anosmia
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.
CN III, IV &VI: Extraocular muscles are all intact
CN V. : equal facial sensation to pinprick.
CN VII. : face symmetry withnormal eye closure ans smile
CN VIII. : Intact gross hearing
CN IX & X. : (+) gag reflex
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

Motor: 5/5 in all extremities

Sensory: intact bilaterally, 100%

ADMITTING DIAGNOSIS:
INGUINAL HERNIA INDIRECT, REDUCIBLE, LEFT.

DISCUSSION:

INGUINAL HERNIA

Inguinal hernias are generally classified as indirect, direct, and femoral based on the site of herniation relative to surrounding structures.
Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior
epigastric vessels, within Hesselbach’s triangle. The borders of the triangle are the inguinal ligament inferiorly, the lateral edge of rectus sheath
medially, and the inferior epigastric vessels superolaterally. Femoral hernias protrude through the small and inflexible femoral ring. The borders
of the femoral ring include the iliopubic tract and inguinal ligament anteriorly, Cooper’s ligament posteriorly, the lacunar ligament medially, and
the femoral vein laterally. The Nyhus classification categorizes hernia defects by location, size, and type.

Pathogenesis: Inguinal hernias may be congenital or acquired. Most adult inguinal hernias are considered acquired defects in the abdominal
wall although collagen studies have demonstrated a heritable predisposition. A number of studies have attempted to delineate the precise
causes of inguinal hernia formation; however, the best-characterized risk factor is weakness in the abdominal wall musculature. Congenital
hernias, which make up the majority of pediatric hernias, can be considered an impedance of normal development, rather than an acquired
weakness. During the normal course of development, the testes descend from the intra-abdominal space into the scrotum in the third
trimester. Their descent is preceded by the gubernaculum and a diverticulum of peritoneum, which protrudes through the inguinal canal and
becomes the processus vaginalis. Between 36 and 40 weeks of gestation, the processus vaginalis closes and eliminates the peritoneal opening
at the internal inguinal ring. Failure of the peritoneum to close results in a patent processus vaginalis (PPV), hence the high incidence of indirect
inguinal hernias in preterm babies. Children with congenital indirect inguinal hernias will present with a PPV; however, a patent processus does
not necessarily indicate an inguinal hernia. In a study of nearly 600 adults undergoing general laparoscopy, bilateral inspection revealed that
12% had PPV. None of these patients had clinically significant symptoms of a groin hernia. In a group of 300 patients undergoing unilateral
laparoscopic inguinal hernia repair, 12% were found to have a contralateral PPV, which was associated with a fourfold 5-year incidence of
inguinal hernia.

Treatment: Surgical repair is the definitive treatment of inguinal hernias; however, operation is not necessary in a subset of patients. When the
patient’s medical condition confers an unacceptable level of operative risk, elective surgery should be deferred until the condition resolves, and
operations reserved for life threatening emergencies. Although the natural history of untreated inguinal hernias is poorly defined, the rates of
incarceration and strangulation are low in the asymptomatic population. As a result, nonoperative management is an appropriate consideration
in minimally symptomatic patients. Prospective studies and meta-analyses have demonstrated no difference in intent-to-treat outcomes,
quality of life, or cost-effectiveness between nonoperative management and elective repair among healthy inguinal hernia patients. A 2012
systematic review found that 72% of asymptomatic inguinal hernia patients developed symptoms (mostly pain) and had surgical repair within
7.5 years of diagnosis. 26 Nevertheless, the complication rates of immediate and delayed elective tension-free repair are equivalent. A
nonoperative strategy is safe for minimally symptomatic inguinal hernia patients, and it does not increase the risk of developing hernia
complications.

Nonoperative inguinal hernia treatment targets pain, pressure, and protrusion of abdominal contents in the symptomatic patient population.
The recumbent position aids in hernia reduction via the effects of gravity and a relaxed abdominal wall. Trusses externally confine hernias to a
reduced state and intermittently relieve symptoms in up to 65% of patients; however, they do not prevent complications, and they may be
associated with an increased rate of incarceration. The risks of incarceration and strangulation appear to decrease over the first year, likely
because gradual enlargement of the abdominal wall defect facilitates spontaneous reduction of hernia contents. The sheer volume of
protruding tissue in an inguinal hernia does not necessarily signify severe morbidity.

CASE 6:CHOLECYSTITIS

GENERAL DATA: This is a case of a 61 year old patient from Iriga City who came in to the ER with a chief complaint of Abdominal Pain
RELIABILITY: 90%

HISTORY OF PRESENT ILLNESS:

2 months PTA, patient had onset of intermittent Epigastric pain, radiating to back, with a pain scale of 6/10, no aggrevating factor, no relieving
factors. No consult done. No meds taken. 2 weeks PTA, patient noted yellowish discoloration of skin. There is also noted increase in the
abdominal pain. Few hours PTA, noted with increased intensity of abdominal pain 9/1o associated with tea colored urine which prompted
consult.

Past Medical History: No history of illnesses,no previous hospitalization, no previous surgery.

Family History:
(+) Hypertension
(+) DM
(-) PTB
(-) Asthma
(-) HPN
(+) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Personal and Social History: (+) smoker, (-) alcoholic dinker

REVIEW OF SYSTEMS:

General (-) loss of apetite, (-) easy fatigability, (-) weight change

Skin (+)jaundice (-) rashes, (-) itching, (-) dryness, (-) changes in hair or nails

HEENT (-) headache, (-) dizziness, (-) lightheadedness, (-) pain, (-) redness, (-) excessive tearing, (-) minimal eye
tears, (-) blurred vision and use of glasses or contact lenses, (+) nasal discharge, (-) bleeding gums, (-) sore
tongue, (-) sore throat, (-) hoarseness

Neck (-) pain, (-) stiffness in the neck, (-) nuchal rigidity

Respiratory (-) dry cough, (-) dyspnea, (-) presence of sputum, (-) increased work of breathing

Gastrointestinal (-) vomiting, (+) change in bowel movement (diarrhea)

Cardiovascular (-) cyanosis, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitation

Urinary (-) dysuria, (-) change in color of urine, (-) abnormal discharge, (-) burning or pain on urination.

Peripheral vascular (-) pallor, (-) ecchymosis, (-) cyanosis, (-) edema

Musculoskeletal (-) stiffness, (-) limping, (-) history of trauma

Neurologic Can move all extremities with ease, (-) history of convulsions, (-) tremors, (-) mental deterioration

Endocrine (-) heat and cold intolerance, (-) excessive sweating, (-) changes in urine frequency and amount

PHYSICAL EXAMINATION:

BP: 120/80
HR: 68
RR: 20
TEMP: 36.5
O2: 99%

General :awake, conscious, coherent, not in distress

SKIN :no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor

HEENT :Anicteric sclerae, pink palpebral conjunctiva, no. cervical lymphadenopathy

CHEST/LUNGS :symmetric chest expansion, no retractions, clear breath sounds

CVS :adynamic precordium, normal rate regular rhythm, no murmur, PMI is at the left 5th ICS MCL

ABDOMEN :flat, soft, non distended, non tender, normal bowel sounds

EXTREMITIES :no edema,full equal pulse, CRT <2secs

Neurological Examination

Mental Status The patient is awake, GCS 15

CN I. : No Anosmia
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.
CN III, IV &VI: Extraocular muscles are all intact
CN V. : equal facial sensation to pinprick.
CN VII. : face symmetry with normal eye closure ans smile
CN VIII. : Intact gross hearing
CN IX & X. : (+) gag reflex
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

Motor: 5/5 in all extremities

Sensory: intact bilaterally, 100%

ADMISSION DIAGNOSIS:
OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLECYSTITIS

DISCUSSION:

CHOLEYCYSTITIS

Pathogenesis: Acute cholecystitis is secondary to gallstones in 90% to 95% of cases. Acute acalculous cholecystitis is a condition that typically
occurs in patients with other acute systemic diseases. In <1% of acute cholecystitis, the cause is a tumor obstructing the cystic duct. Obstruction
of the cystic duct by a gallstone is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall.
Why inflammation develops only occasionally with cystic duct obstruction is unknown. It is probably related to the duration of obstruction of
the cystic duct. Initially, acute cholecystitis is an inflammatory process, probably mediated by the mucosal toxin lysolecithin, a product of
lecithin, as well as bile salts and platelet-activating factor. Increase in prostaglandin synthesis amplifies the inflammatory response. Secondary
bacterial contamination is documented in 15% to 30% of patients undergoing cholecystectomy for acute uncomplicated cholecystitis. In acute
cholecystitis, the gallbladder wall becomes grossly thickened and reddish with subserosal hemorrhages. Pericholecystic fluid often is present.
The mucosa may show hyperemia and patchy necrosis. In severe cases, about 5% to 10%, the inflammatory process progresses and leads to
ischemia and necrosis of the gallbladder wall. More frequently, the gallstone is dislodged and the inflammation resolves.

When the gallbladder remains obstructed and secondary bacterial infection supervenes, an acute gangrenous cholecystitis develops, and an
abscess or empyema forms within the gallbladder. Rarely, perforation of ischemic areas occurs. The perforation is usually contained in the
subhepatic space by the omentum and adjacent organs. However, free perforation with peritonitis, intrahepatic perforation with intrahepatic
abscesses, and perforation into adjacent organs (duodenum or colon) with cholecystoenteric fistula occur. When gas-forming organisms are
part of the secondary bacterial infection, gas may be seen in the gallbladder lumen and in the wall of the gallbladder on abdominal radiographs
and CT scans, an entity called an emphysematous gallbladder.
Clinical Manifestations: About 80% of patients with acute cholecystitis give a history compatible with chronic cholecystitis. Acute cholecystitis
begins as an attack of biliary colic, but in contrast to biliary colic, the pain does not subside; it is unremitting and may persist for several days.
The pain is typically in the right upper quadrant or epigastrium and may radiate to the right upper part of the back or the interscapular area. It
is usually more severe than the pain associated with uncomplicated biliary colic. The patient is often febrile, complains of anorexia, nausea, and
vomiting, and is reluctant to move, as the inflammatory process affects the parietal peritoneum. On physical examination, focal tenderness and
guarding are usually present in the right upper quadrant. A mass, the gallbladder and adherent omentum, is occasionally palpable; however,
guarding may prevent this. A Murphy’s sign, an inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute
cholecystitis.
Treatment: Patients who present with acute cholecystitis will need IV fluids, antibiotics, and analgesia. The antibiotics should cover gram-
negative aerobes as well as anaerobes. A third generation cephalosporin with good anaerobic coverage or a second-generation cephalosporin
combined with metronidazole is a typical regimen. For patients with allergies to cephalosporins, an aminoglycoside with metronidazole is
appropriate. Although the inflammation in acute cholecystitis may be sterile in some patients, more than one half will have positive cultures
from the gallbladder bile. It is difficult to know who is secondarily infected; therefore, antibiotics have become a part of the management in
most medical centers.

Cholecystectomy is the definitive treatment for acute cholecystitis. In the past, the timing of cholecystectomy has been a matter of debate.
Early cholecystectomy performed within 2 to 3 days of the illness is preferred over interval or delayed cholecystectomy that is performed 6 to
10 weeks after initial medical treatment and recuperation. Several studies have shown that unless the patient is unfit for surgery, early
cholecystectomy should be recommended, as it offers the patient a definitive solution in one hospital admission, quicker recovery times, and an
earlier return to work.

Laparoscopic cholecystectomy is the procedure of choice for acute cholecystitis. The conversion rate to an open cholecystectomy is higher
(10%–15%) in the setting of acute cholecystitis than with chronic cholecystitis. The procedure is more tedious and takes longer than in the
elective setting. However, when compared to the delayed operation, early operation carries a similar complication rate.

CASE 7: ABNORMAL UTERINE BLEEDING

GENERAL DATA: This is a case of a 44 year old patient S.J.R, female, married , filipino from canaman, Camarines Sur who came in to the ER with
a chief complaint of Heavy menstrual Bleeding.

RELIABILITY: 97%

HISTORY OF PRESENT ILLNESS:

5 Years PTA, patient noted with gradually enlarging mass, non tender in the Hypogastric area. No consult done. No meds taken. 8 months PTA,
noted with prolonged menstrual bleeding for 15 days consuming 6-7 pads fully soaked and 3 large baby diaper per day accompanied with
dysmenorrhea. Consult was done at a private MD and utz was taken which revealed a large mass to consider myoma uteri and was referred to
our institution for further evaluation and management. Consult was done at BMC, the patient was given iron tablets and tranexamic acid and
was sent home. Bleeding resolved after 5 days. 6 months PTA, patient sought consultation at bmc opd for follow up check up imcp clearance
and was scheduled for surgery. 1 months PTC, biopsy was done which revealed Endometrial Polyp. FHPTC, patient came in to ER for admission
the elective surgery.

MENSTRUAL HISTORY:
Menarche: 13 years
Interval: irregular
Duration: 10-15 days
Quantity: 6-7 pads fully soaked
Symptoms: dysmenorrhea

OB HISTORY:
Coitarche: 27 years
Gravida: 1
Parity: 1
Pregnancy Age: 29
Outcome: live, term baby girl
Mode of delivery: NSD

PAST MEDICAL HISTORY: No history of any illnesses.

Family History:
(-) Hypertension
(-) DM
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Personal and Social History: (-) smoker, (-) alcoholic drinker

REVIEW OS SYSTEMS:

General (-) loss of apetite, (+) easy fatigability, (+) weight change

Skin (-) rashes, (-) itching, (-) dryness, (-) changes in hair or nails

HEENT (-) headache, (-) dizziness, (-) lightheadedness, (-) pain, (-) redness, (-) excessive tearing, (-) minimal eye
tears, (-) blurred vision and use of glasses or contact lenses, (+) nasal discharge, (-) bleeding gums, (-) sore
tongue, (-) sore throat, (-) hoarseness

Neck (-) pain, (-) stiffness in the neck, (-) nuchal rigidity

Respiratory (-) dry cough, (+)shortness of breadth, (-) presence of sputum, (-) increased work of breathing

Gastrointestinal (-) vomiting, (-) change in bowel movement

Cardiovascular (-) cyanosis, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitation

Urinary (-) dysuria, (-) change in color of urine, (-) abnormal discharge, (-) burning or pain on urination.

Peripheral vascular (-) pallor, (-) ecchymosis, (-) cyanosis, (-) edema

Musculoskeletal (-) stiffness, (-) limping, (-) history of trauma

Neurologic Can move all extremities with ease, (-) history of convulsions, (-) tremors, (-) mental deterioration

Endocrine (-) heat and cold intolerance, (-) excessive sweating, (-) changes in urine frequency and amount

PHYSICAL EXAMINATION:

BP: 130/80
HR: 95
RR: 20
TEMP: 362
O2: 99%
Ht: 157 cm
Wt: 84 kg
BMI: 34.1

General :awake, conscious, coherent, not in distress

SKIN :no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor

HEENT :Anicteric sclerae, pink palpebral conjunctiva, no. cervical lymphadenopathy

CHEST/LUNGS :symmetric chest expansion, no retractions, clear breath sounds

CVS :adynamic precordium, normal rate regular rhythm, no murmur, PMI is at the left 5th ICS MCL
 ABDOMEN : globular, enlarged to a size of 20 weeks AOG and with a mass measuring 20cm x 24cm in hypogastric area with noted
tenderness

EXTREMITIES :no edema,no cyanosis,full equal pulse, CRT <2secs

Neurological Examination

Mental Status The patient is awake, GCS 15

CN I. : No Anosmia
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.
CN III, IV &VI: Extraocular muscles are all intact
CN V. : equal facial sensation to pinprick.
CN VII. : face symmetry with normal eye closure ans smile
CN VIII. : Intact gross hearing
CN IX & X. : (+) gag reflex
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

Motor: 5/5 in all extremities

Sensory: intact bilaterally, 100%

ADMITTING DIAGNOSIS:
GRAVIDA 1 PARA 1 (1001) ABNORMAL UTERINE BLEEDING; LEIOMYOMA; POLYP

DISCUSSION:

ABNORMAL UTERINE BLEEDING

1. Heavy menstrual bleeding: formerly menorrhagia, defines prolonged or heavy cyclic menstruation.
Objectively, menses lasting longer than 7 days or exceeding 80 mL of blood loss are determining values.
2. Intermenstrual bleeding: replaces metrorrhagia,
3. Breakthrough bleeding: informal term for intermenstrual bleeding that accompanies hormone
administration.
4. Hypomenorrhea: diminished flow or shortening of menses.
5. Oligomenorrhea: cycles with intervals longer than 35 days.
6. Withdrawal bleeding: predictable bleeding that results from an abrupt decline in progesterone levels.
7. Postcoital bleeding: prompted by vaginal bleeding.

Abnormal uterine bleeding is common, and etiologies include anatomic changes, hormonal dysfunction, in ection,
system disease, medications, and pregnancy complications.

Causes of AUB: are subdivided into nine main categories arranged according to the acronym PALM-COEIN

1. Polyp
2. Adenomyosis
3. Leiomyoma
4. Malignancy and hyperplasia
5. Coagulopathy
6. Ovulatory dysfunction
7. Endometrial
8. Iatrogenic
9. Not yet classified

CASE 8: PREMATURE RUPTURE OF MEMBRANE

GENERAL DATA:
This is a case of 21 years old patient A.N.M, female, married filipino, from Miloar, Camarines Sur who came in to the ER with a chief complaint
of Labor Pain.
RELIABILITY: 99%

HISTORY OF PRESENT ILLNESS:

6 hours PTA, patient BOW ruptured accompanied by passage of clear mucus discharge, contractions and hypogastric pain 6/10. Patient was
taken to a lying in were IE revealed 2cm dilation and presence of blood in examining finger then the patient was referred to BMC for further
evaluation and management.
Gravida: 1
LMP: JUNE 29,2021
EDC: APRIL 4, 2022
AOG: 38 WEEKS

MENSTRUAL HISTORY:

Menarche: 12 years
Interval: 26-28
Duration: 4-5 days
Quantity: 3 pads, moderately soaked
Symptoms: dysmenorrhea

PAST MEDICAL HISTORY: No history of any illnesses.

Family History:
(+) Hypertension
(-) DM
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Personal and Social History: (-) smoker, (-) alcoholic drinker

REVIEW OS SYSTEMS:

General (-) loss of apetite, (+) easy fatigability, (+) weight gain

Skin (-) rashes, (-) itching, (-) dryness, (-) changes in hair or nails

HEENT (-) headache, (-) dizziness, (-) lightheadedness, (-) pain, (-) redness, (-) excessive tearing, (-) minimal eye
tears, (-) blurred vision and use of glasses or contact lenses, (+) nasal discharge, (-) bleeding gums, (-) sore
tongue, (-) sore throat, (-) hoarseness

Neck (-) pain, (-) stiffness in the neck, (-) nuchal rigidity

Respiratory (-) dry cough, (-)shortness of breadth, (-) presence of sputum, (-) increased work of breathing

Gastrointestinal (-) vomiting, (-) change in bowel movement

Cardiovascular (-) cyanosis, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitation

Urinary (-) dysuria, (-) change in color of urine, (-) abnormal discharge, (-) burning or pain on urination.

Peripheral vascular (-) pallor, (-) ecchymosis, (-) cyanosis, (+) edema

Musculoskeletal (-) stiffness, (-) limping, (-) history of trauma

Neurologic Can move all extremities with ease, (-) history of convulsions, (-) tremors, (-) mental deterioration

Endocrine (-) heat and cold intolerance, (-) excessive sweating, (-) changes in urine frequency and amount
PHYSICAL EXAMINATION:

BP: 130/90
HR: 94
RR: 20
TEMP: 36.7
O2: 99%
Ht: 157 cm
Wt: 79.2kg
BMI: 32.1
FH: 132bpm
FH: 31cm

General :awake, conscious, coherent, not in distress

SKIN :no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor

HEENT :Anicteric sclerae, pink palpebral conjunctiva, no. cervical lymphadenopathy

CHEST/LUNGS :symmetric chest expansion, no retractions, clear breath sounds

CVS :adynamic precordium, normal rate regular rhythm, no murmur, PMI is at the left 5th ICS MCL

ABDOMEN : globular, linea nigra present with striae gravidarum

GENITAL : IE:
Dilation: 3cm
Effacement: 50%
BOW: intact
Presentation: cephalic
Station: -2

EXTREMITIES : edema in the lower extremities, ,no cyanosis,full equal pulse, CRT <2secs

Neurological Examination

Mental Status The patient is awake, GCS 15

CN I. : No Anosmia
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.
CN III, IV &VI: Extraocular muscles are all intact
CN V. : equal facial sensation to pinprick.
CN VII. : face symmetry with normal eye closure ans smile
CN VIII. : Intact gross hearing
CN IX & X. : (+) gag reflex
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

Motor: 5/5 in all extremities

Sensory: intact bilaterally, 100%

ADMITTING DIAGNOSIS:
GRAVIDA 1 PARA 0 PREGNANCY UTERINE 38 WEEKS AOG CEPHALIC IN BEGINNING LABOR ; PREMATURE RUPTURE OF
MEMBRANE BY 6 HOURS.

DISCUSSION:
PREMATURE RUPTURE OF MEMBRANE

Membrane rupture at term without spontaneous uterine contractions complicates approximately 8 percent of pregnancies. Until recently,
management generally included labor stimulation if contractions did not begin after 6 to 12 hours. This intervention evolved more than 50
years ago because of maternal and fetal complications due to chorioamnionitis (Calkins, 1952). Such routine intervention was the accepted
practice until challenged by Kappy and colleagues (1979). These investigators reported excessive cesarean delivery in term pregnancieswith
ruptured membranes managed with labor stimulation compared with those expectantly managed. Subsequent research included that of
Hannah (1996) and Peleg (1999) and their associates, who enrolled a total of 5042 pregnancies with ruptured membranes in a randomized
investigation. They measured the effects of induction versus expectant management and also compared induction using intravenous oxytocin
with that using prostaglandin E2 gel. There were approximately 1200 pregnancies in each of the four study arms. They concluded that labor
induction with intravenous oxytocin was the preferred management. This determination was based on significantly fewer intrapartum and
postpartum infections in women whose labor was induced. There were no significant differences in cesarean delivery rates. Subsequent
analysis by Hannah and coworkers (2000) indicated increased adverse outcomes when expectant management at home was compared with in-
hospital observation. Mozurkewich and associates (2009) reported lower rates of chorioamnionitis, metritis, and NICU admissions for women
with term ruptured membranes whose labors were induced compared with those managed expectantly. At Parkland Hospital, labor is induced
soon after admission when ruptured membranes are confirmed at term. The benefit of prophylactic antibiotics in women with ruptured
membranes before labor at term is unclear (Passos, 2012).

CASE 8: CEREBROVASCULAR DISEASE

GENERAL DATA: This is a case of a 60 years old patient, nale,married, filipino from Tinambac, Camarines Sur who came. In with a chief
complaint of left sided body weakness

RELIABILITY: 90%

HISTORY OF PRESENT ILLNESS:

1 day PTA, patient had feeling of dizziness, no headache, no chest pain hence sought consult at private cilic where noted with increased BP and
was given amlodipine as maintenance medicine. On the way home patient felt left sided weakness body weakness was brought to ER.

PAST MEDICAL HISTORY: known hypertensive with maintenance on Amlodipine 10mg tab taken once a day.

Family History:
(+) Hypertension
(+) stroke
(-) DM
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Personal and Social History: (-) smoker, (-) alcoholic drinker

REVIEW OS SYSTEMS:

General (-) loss of apetite, (+) easy fatigability, (+) weight gain

Skin (-) rashes, (-) itching, (-) dryness, (-) changes in hair or nails

HEENT (-) headache, (-) dizziness, (-) lightheadedness, (-) pain, (-) redness, (-) excessive tearing, (-) minimal eye
tears, (-) blurred vision and use of glasses or contact lenses, (-) nasal discharge, (-) bleeding gums, (-) sore
tongue, (-) sore throat, (-) hoarseness

Neck (-) pain, (-) stiffness in the neck, (-) nuchal rigidity

Respiratory (-) dry cough, (-)shortness of breath , (-) presence of sputum, (-) increased work of breathing

Gastrointestinal (-) vomiting, (-) change in bowel movement

 Cardiovascular (-) cyanosis, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitation

Urinary (-) dysuria, (-) change in color of urine, (-) abnormal discharge, (-) burning or pain on urination.

Peripheral vascular (-) pallor, (-) ecchymosis, (-) cyanosis, (+) edema

Musculoskeletal (-) stiffness, (-) limping, (-) history of trauma

Neurologic Can move all extremities with ease, (-) history of convulsions, (-) tremors, (-) mental deterioration

Endocrine (-) heat and cold intolerance, (-) excessive sweating, (-) changes in urine frequency and amount

PHYSICAL EXAMINATION:

BP: 160/80
HR: 65
RR: 20
TEMP: 36.7
O2: 99%
Ht: 155cm
Wt: 53kg
BMI: 22.1

General :awake, conscious, coherent, not in distress

SKIN :no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor

HEENT :Anicteric sclerae, pink palpebral conjunctiva, no. cervical lymphadenopathy

CHEST/LUNGS :symmetric chest expansion, no retractions, clear breath sounds

CVS :adynamic precordium, normal rate regular rhythm, no murmur, PMI is at the left 5th ICS MCL

ABDOMEN : soft , flat, no tenderness,normal bowel sounds

EXTREMITIES :no edema, ,no cyanosis,full equal pulse, CRT <2secs

Neurological Examination

Mental Status The patient is awake, GCS 15

CN I. : No Anosmia
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.
CN III, IV &VI: Extraocular muscles are all intact
CN V. : equal facial sensation to pinprick.
CN VII. : face symmetry with normal eye closure ans smile
CN VIII. : Intact gross hearing
CN IX & X. : (+) gag reflex
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

Motor: 5/5 in upper and lower right extremities, ⅖ in ULE, ⅗ in LLE

Sensory: 1OO% in RUE and RLE. 50% in LUE and LLE

ADMITTING DIAGNOSIS:
ACUTE CEREBROVASCULAR DISEASE PROBABLY INFARCT ,RIGHT MCA NIHSS 6; HPN STAGE 2
DISCUSSION:

CEREBROVASCULAR DISEASE

Cerebrovascular diseases include some of the most common and devastating disorders: ischemic stroke and hemorrhagic stroke. Stroke is the
second leading cause of death worldwide, with 6.2 million dying from stroke in 2015, an increase of 830,000 since the year 2000.
A stroke, or cerebrovascular accident, is defined as an abrupt onset of a neurologic deficit that is attributable to a focal vascular cause. Thus, the
definition of stroke is clinical, and laboratory studies including brain imaging are used to support the diagnosis. The clinical manifestations of
stroke are highly variable because of the complex anatomy of the brain and its vasculature. Cerebral ischemia is caused by a reduction in blood
flow that lasts longer than several seconds. Neurologic symptoms are manifest within seconds because neurons lack glycogen, so energy failure
is rapid. If the cessation of flow lasts for more than a few minutes, infarction or death of brain tissue results. When blood flow is quickly
restored, brain tissue can recover fully and the patient’s symptoms are only transient: this is called a transient ischemic attack (TIA). The
definition of TIA requires that all neurologic signs and symptoms resolve within 24 h without evidence of brain infarction on brain imaging.
Stroke has occurred if the neurologic signs and symptoms last for >24 h or brain infarction is demonstrated. A generalized reduction in cerebral
blood flow due to systemic hypotension (e.g., cardiac arrhythmia, myocardial infarction, or hemorrhagic shock) usually produces syncope .

CASE 10: COMMUNITY ACQUIRED PNEUMONIA

GENERAL DATA: This is a case of a patient 82 years old , female , married, filipino who came in with a chief complaint of Difficulty of Breathing

RELIABILITY:85%

HISTORY OF PRESENT ILLNESS:

3 months PTA, patient had easy fatigability, dyspnea on exertion, on and off bipedal edema. No consultation done. No meds done. On interim,
still with symptoms until 1 week PTA, patient had 3 pillow orthopnea and cough, ocassionally blood streaked. Consult was done at a private
cardio MD and was given heart failure meds. 3 days PTA, patient had increased frequency of cough. FHPTC, persistence prompted consult and
hence admission.

PAST MEDICAL HISTORY: (+) hypertension (+) HF

Family History:
(-) Hypertension
(-) stroke
(-) DM
(-) PTB
(-) Asthma
(-) HPN
(-) Heart dIsease
(-) Blood Disorders
(-) Allergy
(-) Others

Personal and Social History: (-) smoker, (-) alcoholic drinker

REVIEW OS SYSTEMS:

General (+)fever, (-) loss of apetite, (+) easy fatigability, (-) weight gain

Skin (-) rashes, (-) itching, (-) dryness, (-) changes in hair or nails

HEENT (-) headache, (-) dizziness, (-) lightheadedness, (-) pain, (-) redness, (-) excessive tearing, (-) minimal eye
tears, (-) blurred vision and use of glasses or contact lenses, (-) nasal discharge, (-) bleeding gums, (-) sore
tongue, (-) sore throat, (-) hoarseness

Neck (-) pain, (-) stiffness in the neck, (-) nuchal rigidity

Respiratory (+) cough, (+)shortness of breath , (-) presence of sputum, (+) increased work of breathing

Gastrointestinal (-) vomiting, (-) change in bowel movement

Cardiovascular (-) cyanosis, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitation
 Urinary (-) dysuria, (-) change in color of urine, (-) abnormal discharge, (-) burning or pain on urination.

Peripheral vascular (-) pallor, (-) ecchymosis, (-) cyanosis, (+) edema

Musculoskeletal (-) stiffness, (-) limping, (-) history of trauma

Neurologic Can move all extremities with ease, (-) history of convulsions, (-) tremors, (-) mental deterioration

Endocrine (-) heat and cold intolerance, (-) excessive sweating, (-) changes in urine frequency and amount

PHYSICAL EXAMINATION:

BP: 140/80
HR: 97
RR: 20
TEMP: 38.2
O2: 99%
Ht: 155cm
Wt: 53kg
BMI: 22.1

General :awake, conscious, coherent, not in distress

SKIN :no lesions, no rashes or birthmarks, no cyanosis, warm to touch with good skin turgor

HEENT :Anicteric sclerae, pink palpebral conjunctiva, no. cervical lymphadenopathy

CHEST/LUNGS :symmetric chest expansion, no retractions, presence of bilateral crackles

CVS :adynamic precordium, normal rate regular rhythm, no murmur, PMI is at the left 5th ICS MCL

ABDOMEN : soft , flat, no tenderness,normal bowel sounds

EXTREMITIES :no edema, ,no cyanosis,full equal pulse, CRT <2secs

Neurological Examination

Mental Status The patient is awake, GCS 15

CN I. : No Anosmia
CN II. : Pupils are equally reactive to light at 2-3 mm in diameter.
CN III, IV &VI: Extraocular muscles are all intact
CN V. : equal facial sensation to pinprick.
CN VII. : face symmetry with normal eye closure ans smile
CN VIII. : Intact gross hearing
CN IX & X. : (+) gag reflex
CN XI. : able to turn head side to side
CN XII. : toungue is in midline

Motor: 5/5 in all extremities

Sensory: intact bilaterally, 100%

ADMITTING DIAGNOSIS:
COMMUNITY ACQUIRED PNEUMONIA- HIGH RISK WITH HYPOXIA; HYPERTENSIVE ARTERIOSCLEROTIC CARDIOVASCULAR DISEASE;
CONGESTIVE HEART FAILURE, FUNCTIONAL CLASS III

DISCUSSION:

COMMUNITY ACQUIRED PNEUMONIA

Pneumonia is an infection of the pulmonary parenchyma. Despite being the cause of significant morbidity and mortality, it is often
misdiagnosed, mistreated, and underestimated. Pneumonia historically was typically classified as community-acquired (CAP), hospital-acquired
(HAP), or ventilator-associated (VAP). A fourth category, health care associated pneumonia (HCAP), was introduced recently. This category was
meant to encompass those cases of CAP that were caused by multidrug-resistant (MDR) pathogens typically associated with HAP.
The extensive list of potential etiologic agents in CAP includes bacteria, fungi, viruses, and protozoa. Newly identified pathogens include
metapneumoviruses, the coronaviruses responsible for severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome
(MERS), and community-acquired strains of MRSA. Most cases of CAP, however, are caused by relatively few pathogens. Although
Streptococcus pneumoniae is most common, other organisms must also be considered in light of the patient’s risk factors and severity of
illness. Separation of potential agents into “typical” bacterial pathogens or “atypical” organisms may be helpful. The former category includes S.
pneumoniae, Haemophilus influenzae, and (in selected patients) S. aureus and gram-negative bacilli such as Klebsiella pneumoniae and
Pseudomonas aeruginosa. The “atypical” organisms include Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species as well
as respiratory viruses such as influenza viruses, adenoviruses, human metapneumovirus, and respiratory syncytial viruses.
Complications of severe CAP include respiratory failure, shock and multiorgan failure, coagulopathy, and exacerbation of comorbid illnesses.
Three particularly noteworthy conditions are metastatic infection, lung abscess, and complicated pleural effusion. Metastatic infection (e.g.,
brain abscess or endocarditis) is very unusual and will require a high degree of suspicion and a detailed workup for proper treatment. Lung
abscess may occur in association with aspiration or with infection caused by a single CAP pathogen, such as CA-MRSA, P. aeruginosa, or (rarely)
S. pneumoniae.