Cagayan

State University
College of Medicine
Oral Revalida
Dec. 12 & 13, 2020
IM Case # 1

General Data:
J. B., 45 years old male, married, Born Again Christian, born on May 29, 1975, presently
residing at Piat Cagayan, admitted for the first time at CVMC last November 5, 2020.

Chief complaint: Abdominal pain

History of Present Illness:
Patient is apparently well until 2 days PTA when he experienced abdominal pain located
at the upper abdomen and periumbilical that radiates to the back, characterized as rapid onset,
steady moderate to severe pain that improves when sitting up or leaning forward. No consult
was done but self medicated with Maalox tablet affording no relief. Until 1 day PTA, the
abdominal pain progresses now accompanied by undocumented fever with nausea, vomiting 2x
and generalized body weakness prompted consult to a nearby hospital and subsequently
referred to CVMC hence was admitted.

Past Medical History
Unremarkable
Family Medical History
(+) Cancer- paternal side
(-) Hypertension
(-) Diabetes
(-) Heart disease

Personal, Social And Environmental History
High school graduate
Employed at a private institution
Smoker consuming 5 sticks/day for 15 years
Alcohol beverage drinker 3x a week

Review of System
(+) fever (-) chest pain (+) Body weakness
(+) epigastric pain (+) vomiting (-) cough/colds
(-) loss of appetite (-) dysuria (-) dysphagia
(-) difficulty of breathing (-) weight loss (-) diarrhea




Physical Examination
General Survey: Anxious, coherent, oriented to 3 spheres, weak looking, wheel chair borne, in
mild cardiopulmonary distress
Vital Signs:
BP 90/60 CR 120 RR 24
Temp 38.6 C 02 sat 92% at room air
Skin: Poor skin turgor, warm to touch, no active lesions
HEENT: Icteric sclera, pinkish palpebral conjunctiva, dry lips and mucosa, no tonsillopharyngeal
wall congestion, no cervical lymphadenopathy
Chest and Lungs: Symmetrical chest wall expansion, no lagging, no retraction, (+) rales on left
lower lung field, no wheezes
Heart: Adynamic precordium, tachycardic regular rhythm, PMI 5th ICS left mid clavicular line,
no murmur
Abdomen: Distended with bluish discoloration at the umbilical area, hypoactive bowel sounds,
soft, (+) direct tenderness epigastric area
Extremities: full and equal pulses on both upper and lower extremities, no edema
Neurologic Exam: Mental status, cranial nerves, motor and sensory are all normal


Laboratory Results
CBC Results Normal Values
Hgb 122 120-160 g/L
Hct 0.49 0.380-0.470
Platelet 245 150-400
WBC 16 4.5-11.00
Neutrophils 64 35.0-65.0
Lymphocytes 30 20.0-40.0
Monocytes 4.6 2.0-8.0
Eosinophils 0.4 0.0-5.0
Basophils 0.8 0.0-1.0

Results Normal Values

Na 140 135-145
K 3.2 3.5-5.5
Amylase 1,045 30-110 U/L
Lipase 956 23-300 U/L
BUN 65 1-17 mg/dl
Creatinine 184 53-115
SGOT/AST 112 14-36
SGPT/ALT 125 9-52
LDH 495 95-195

Arterial Blood Gas (ABG) -

pH 7.29
PaCO2 45
PaO2 55
SaO2 86%
HCO3 22
Interpretation: Uncompensated Respiratory Acidosis with moderate hypoxemia

Abdominal Utrasound: The gallbladder id normal in size and the wall is not thickened. A echogenic focus
with posterior acoustic shadowing is seen within the lumen measuring 2.6 cm. The pancreas is diffusely
enlarged. Normal Liver, Spleen, and Kidneys

Chest X Ray AP view

Lung fields are clear
The trachea is in the midline
The heart is not enlarged
Diaphragm are intact
Blunting of the costophrenic angle left
Other chest structures are intact

Impression: Mild Pleural effusion left


DIAGNOSIS:
ACUTE PANCREATITIS SECONDARY TO GALLSTONE


Guide Questions

1. What is your primary impression?
What are your bases for your impression? (Salient features)
2. What are your differential diagnosis? How do you rule in and rule out those differential
diagnosis?
1. Acute Peritonitis
2. Perforated viscus
3. Acute Mesenteric ischemia
4. Cholecystitis

3. What are the Common etiologies of Pancreatitis?
1. Gallstone
2. Alcohol
3. Hypertriglyceridemia
4. ERCP (Endoscopic retrograde cholangiopancreatography)
5. Trauma
6. Postoperative
 7. Sphincter of Oddi dysfunction
4. What is the pathogenesis of Pancreatitis?
5. What laboratory tests will you request for the patient?
1. Amylase – more than 3 fold increase
2. Lipase (more preferred)- more than 3 fold increase
3. CBC- leucocytosis, hemoconcentration
4. Renal Function – azotemia with BUN >22 mg/dl
5. AST and ALT- elevated
6. UTZ of hepatobiliary tree
7. Abdominal CT scan
8. ABG-hypoxemia
6. How do you manage the patient?
1. Fluid resuscitation – initial IVF plain LR or PNSS 15-20 cc/kg bolus
2. Analgesics for pain (Meperidine)
3. Oxygen via nasal cannula
4. NPO
5. Prophylactic Antibiotic have no role unless if with established intra abdominal
infection
6. Cholecystectomy to prevent recurrence
7. What is the scoring system used that is associated with increased risk for in hospital
mortality if with >/= 3/5?
BISAP score
B-BUN >25 mg/dl
I-Impaired mental status (GCS <15)
S-SIRS (Systemic Inflammatory Response syndrome) >/=2 of 4 present
A- Age >60 years old
P- Pleural effusion

















 Cagayan State University
College of Medicine
Oral Revalida
Dec. 12 & 13, 2020
IM Case # 2

General Data:
R.S. 54/F, widow, born on June 26, 1966, from Baggao, Cagayan admitted for the 1st
time at CVMC last October 5, 2020.

Chief complaint: Palpitation

History of Present Illness:
Patient is apparently well until, 5 days PTA when she experienced cough productive of
yellowish phlegm associated with undocumented fever and pleuritic chest pain. She went for
consult at a nearby district hospital and was given Cefuroxime 500 mg capsule BID and
N acetylcysteine 600 mg effervescent tablet once a day both for 7 days. Paracetamol 500 mg
tablet every 4 hours as needed for fever. She noted lysis of the fever and relief of the chest pain
but still with cough. Until few hours PTA, the productive cough persisted now with associated
abdominal pain and palpitation this prompted consult at CVMC hence was admitted.

Past Medical History
(+) Hyperthyroidism maintained on methimazole 5 mg tab BID for almost 1 year now
but non compliant
(-) Hypertension
(-) Coronary Artery Disease
(-) Diabetes Mellitus
(-) Asthma
(-) Allergies to food and drugs

OB History: G3 P3 (2-1-0-3)- all delivered via NSD

Family Medical History
(+) Heart Disease on maternal side
(-) DM
(-) cancer

Personal, Social And Environmental History
(-) smoker
(-) alcoholic beverage drinker
Online seller

Review of System
 (+) palpitation (+) cough
(-) difficulty of breathing (-) weight loss
(+) fever (+) pleuritic chest pain
(-) easy fatigability (+) abdominal pain
(-) headache (-) dizziness
(-) body weakness (-) vomiting
(-) chills (-) muscle and joint pain

Physical Examination
General Survey: conscious, coherent, ambulatory, not in cardiopulmonary distress
Vital Signs: BP 120/70 CR 128 RR 26
Temp 38.4 C 02 sat 94 % at room air
Skin: good skin turgor, diaphoretic
HEENT: Anicteric sclera, pinkish palpebral conjunctiva, no cervicalymphadenopathy
(+) approximately 6 x 6 cm non movable mass anterior neck area
Chest and Lungs: Symmetrical chest wall expansion, fine crackles bibasal , no
wheezes
Heart: Adynamic precordium, tachycardic regular rhythm, PMI 5th ICS left mid clavicular line,
no murmur
Abdomen: flat, normoactive bowel sounds, soft, non tender
Extremities: full and equal peripheral pulses on both upper and lower extremities,
no edema

Laboratory Results
CBC Results Normal Values
Hgb 129 120-160 g/L
Hct 0.45 0.380-0.470
Platelet 350 150-400
WBC 24.5 4.5-11.00
Neutrophils 95.0 35.0-65.0
Lymphocytes 5.0 20.0-40.0
Monocytes 2.0 2.0-8.0
Eosinophils 3.5 0.0-5.0
Basophils 0.5 0.0-1.0

Results Normal Values

Na 130 135-145
K 4.2 3.5-5.5
Calcium 6.4 8.4-10.2
Creatinine 105 53-115
BUN 6.3 3.3-6.7
Chest X Ray AP view
 The trachea is in the midline
The heart is not enlarged
Diaphragm intact
Reticular infiltrates both parahilar area
Blunted right costophrenic angle
Other chest structures are intact

Impression: Pneumonia both hilar areas
Mild Pleural effusion Right

12 Lead ECG
Sinus Tachycardia

DIAGNOSIS:
THROID STORM
COMMUNITY ACQUIRED PNEUMONIA LOW RISK, PARAPNEUMONIC EFFUSION RIGHT

Guide Questions

1. What is your primary impression?
What are your bases for your impression? (Salient features)
2. What are your differential diagnosis? How do you rule in and rule out those
differential diagnosis?
1. Anxiety disorder
2. Sepsis
3. Arrhythmia
4. Anticholinergic or Adrenergic Drug Intoxication

3. In Diagnosing Thyroid Storm, what do you call the criteria that we use?
BURCH AND WARTOFSKY’S
1. Cardiovascular dysfunction (Tachycardia)
2. Thermoregulatory dysfunction
3. CNS effects
4. GI-Hepatic dysfunction
5. CHF or AF
6. Precipitant history
Interpretation:
<25 points- Thyroid storm unlikely
25-44 – Impending storm
>/= 45 – Highly suggestive of thyroid storm
*** the score of the patient is 50
4. What are the precipitants of thyroid storm?
a. Pre existing thyrotoxicosis
b. Conditions associated with rapid rise in hormone levels such as withdrawal
with anti thyroid medication
 c. Conditions associated with non thyroidal illnesses such as infection
(Pneumonia)
5. What laboratory tests will you request? And what are the expected results?
1. TSH (decreased), FT4, FT3 (increased)
2. CBC - leukocytosis
3. Liver function test - elevated
4. Serum electrolytes (hypocalcemia)
5. Chest X Ray
6. 12 Lead ECG
For the cough – sputum GS/CS

6. What emergency measures/medications will you give at the Emergency Room?
1. Inhibit new hormone production – PTU or Methimazole
2. Inhibit release of preformed hormones – SSKI, Lugol’s solution
3. Control of adrenergic symptoms – propranolol, atenolol, metoprolol
4. Supportive management – acetaminophen for fever or pain
For the cough if secondary to Bacterial pneumonia give Antibiotics



























 Cagayan State University
College of Medicine
Oral Revalida
Dec. 12 & 13, 2020
IM Case # 3

General Data:
A.C. 23/M, single, born on November 1, 1996 from Lallo, Cagayan and presently
working at San Fernando Pampanga as call center agent came in for consult for the 1st time at
the OPD last September 23, 2020.

Chief complaint: Skin rashes

History of Present Illness:
Patient is apparently well until 6 weeks PTA when he experienced low grade fever
associated with headache and myalgia. No consult was done however he self medicated with
Paracetamol 500 mg tablet every 4 hours affording temporary lysis of fever. Until 3 days PTA,
the above condition recurred now with maculopapular erythematous rashes initially noted on
the chest and back, non pruritic, and gradually progresses on the face, neck, abdomen and both
extremities that prompted him to seek consult.

Past Medical History
Unremarkable

Family Medical History
(+) Cancer - maternal side
(+) DM and HPN - paternal side

Personal, Social And Environmental History
(+) cigarette smoker (5 pack/day since 16 y/o)
(+) occasional alcoholic beverage drinker
Denies any history of illicit drug use

Sexual History: He had 4 previous male sexual partners

Review of System
(+) Rashes (+) Headache
(+) fever (-) vomiting
(+) body weakness (-) dizziness
(+) anorexia (+) weight loss
(-) chest pain (-) easy fatigability
(-) cough (-) difficulty of breathing


Physical Examination
General Survey: conscious, coherent, ambulatory, not in cardiorespiratory distress
Vital Signs: BP 110/70 CR 110
RR 18 Temp 37.8 C
Skin: generalized patchy erythematous maculopapular rashes
HEENT: (+) whitish greasy scales on the scalp, anicteric sclera, pale palpebral conjunctiva,
(+) white patches on the tongue, no tonsillopharyngeal wall congestion, no cervical
lymphadenopathy
Chest and Lungs: Symmetrical chest wall expansion, clear breath sounds bilateral
Heart: Adynamic precordium, tachycardic regular rhythm, PMI 5th ICS left mid clavicular line,
no murmur
Abdomen: flat, normoactive bowel sounds, soft, non tender
Extremities: full and equal pulses on both upper and lower extremities, no edema
Neurologic Exam: unremarkable

Laboratory Results
CBC Results Normal Values
Hgb 105 120-160 g/L
Hct 0.36 0.380-0.470
Platelet 156 150-400
WBC 14 4.5-11.00
Neutrophils 40.0 35.0-65.0
Lymphocytes 55.0 20.0-40.0
Monocytes 3.0 2.0-8.0
Eosinophils 1.5 0.0-5.0
Basophils 0.5 0.0-1.0

ELISA – Positive
Western Blot – Positive
CD4+ T cell – 100/uL (low)

DIAGNOSIS
HUMAN IMMUNODEFICIENCY VIRUS DISEASE
IMMUNOCOMPROMISED HOST

Guide Questions

1. What is your primary impression?
What are your bases for your impression? (Salient features)
2. What are your differential diagnosis?
How do you rule in and rule out those differential diagnosis?
1. Infectious Mononucleosis
2. Cytomegalovirus infection
3. Candidiasis
 3. What is the Hallmark of HIV Disease?
4. How does HIV transmitted?
5. What diagnostic tests will you request for the patient?
1. Screening ELISA
2. Western blot – confirmatory test
3. CD4+ T cell count
4. CBC

6. How do you manage this patient?
A. Anti retroviral therapy
1. NRTI (Nucleoside Reverse Transcriptase Inhibitor) - Zidobudine, Lamivudine
2. NNRTI (Non-nucleoside Reverse Transcriptase Inhibitor)- Nevirapine, Efavirenz
3. PI (Protease Inhibitor) - Ritonavir boosted Iopinavir

B. Prophylaxis for Opportunistic Infection such as Pneumocystis jiroveci pneumonia
- Trimethoprim sulfamethoxazole




























 Cagayan State University
College of Medicine
Oral Revalida
Dec. 12 & 13, 2020

IM Case # 4

General Data:
F.T., 22 years old female, single, Roman Catholic, born on May 5, 1997, presently
residing at Golden harvest Subd. Tuguegarao City, admitted for the first time at CVMC last
December 1, 2020

Chief complaint: Fever

History of Present Illness:
Patient is apparently well until 7 days PTA when she experienced intermittent low grade
fever with associated body malaise and headache. She self medicated with Paracetamol 500 mg
tablet every 4 hours as needed for fever affording temporary relief. 3 days PTA, she still had
fever now with associated loss of appetite and burning epigastric pain. No consultation was
done. Until 1 day PTA, the condition persisted now with vomiting of previously ingested food
(8x) and generalized body weakness prompted consult hence was admitted.

Past Medical History
Unremarkable

Family Medical History
(+) Cancer - Paternal side

Personal, Social And Environmental History
College graduate but unemployed
Non-cigarette smoker
Occasional alcohol beverage drinker

OB History
Menarche - 12 years old
Regular monthly menstruation, 5 days duration consuming 3 pads per day
On her 2nd day of menstruation
Review of System
(+) fever (+) joint pains (-) nose/gum bleeding
(+) body malaise (+) headache (-) rashes
(+) epigastric pain (+) vomiting (-) cough/colds
(+) loss of appetite (+) body weakness (-) dysphagia
(-) difficulty of breathing (-) dysuria (-) diarrhea
(-) chest pain
Physical Examination
General Survey: Conscious, coherent, weak looking, ambulatory not in cardiopulmonary distress
Vital Signs: BP 100/60 CR 94 RR 20 Temp 38.3 C 02 sat 96% at room air
Skin: Poor skin turgor, warm to touch, no lesions
HEENT: Anicteric sclera, pink palpebral conjunctiva, dry lips and mucosa, no tonsillopharyngeal
wall congestion, no cervical lymphadenopathy
Chest and Lungs: Symmetrical chest wall expansion, no lagging, no retraction, no crackles,
no wheezes
Heart: Adynamic precordium, normal rate regular rhythm, PMI 5th ICS left mid clavicular line,
no murmur
Abdomen: flat, normoactive bowel sounds, soft, non tender
Extremities: full and equal pulses on both upper and lower extremities, no edema
Neurologic Exam: Mental status, cranial nerves, motor and sensory are all normal


Laboratory Results
CBC (12/1/20 10:00 AM) Results Normal Values
Hgb 136 120-160 g/L
Hct 0.418 0.380-0.470
Platelet 35 150-400
WBC 3.90 4.5-11.00
Neutrophils 38.7 35.0-65.0
Lymphocytes 45.2 20.0-40.0
Monocytes 4.7 2.0-8.0
Eosinophils 0.7 0.0-5.0
Basophils 0.6 0.0-1.0
MCV 82.3 80.0-100.0
MCH 26.8 26.0-32.0
MCHC 3.25 4.50-11
CBC (12/1/20 6:00 PM) Results Normal Values
Hgb 134 120-160 g/L
Hct 0.414 0.380-0.470
Platelet 42 150-400
WBC 4.12 4.5-11.00
Neutrophils 37.8 35.0-65.0
Lymphocytes 43.7 20.0-40.0
Monocytes 7.3 2.0-8.0
Eosinophils 0.6 0.0-5.0
Basophils 0.5 0.0-1.0
MCV 82.4 80.0-100.0
MCH 27.0 26.0-32.0
MCHC 3.28 4.50-11
CBC (12/2/20 4:00 AM) Results Normal Values
Hgb 127 120-160 g/L
Hct 0.398 0.380-0.470
Platelet 59 150-400
WBC 4.00 4.5-11.00
Neutrophils 50.7 35.0-65.0
Lymphocytes 33.7 20.0-40.0
Monocytes 5.2 2.0-8.0
Eosinophils 0.5 0.0-5.0
Basophils 0.2 0.0-1.0
MCV 82.6 80.0-100.0
MCH 26.3 26.0-32.0
MCHC 3.18 4.50-11

12/1/20 Results Normal Values

Na 140 135-145
K 3.2 3.5-5.5
Creatinine 71 53-115
SGOT/AST 158 15-37
SGPT/ALT 95 30-65

Bleeding Parameters Results Normal Values

Prothrombin time 13.8 10-15 seconds

INR 1.07
% Activity 86.8%

APTT 35.9 24-36 seconds

Dengue NS1 (ICT/Rapid) – Positive

Chest X Ray AP view

Lung fields are clear
The trachea is in the midline
The heart is not enlarged
Diaphragm and sulci are intact
Other chest structures are intact

Impression: No radiographic abnormalities within the chest


Urinalysis

Physical Exam

Color Yellow

Transparency Cloudy

Chemical Analysis

Ph 6.0

Specific gravity 1.015

Protein Negative

Glucose Negative

Ketones Negative

Blood +++

Leukocyte Negative

Bilirubin Negative

Urine flow cytometry

WBC 2/UL (0-17)

RBC 197/uL (0-11)

Epithelial cells 4/uL (0-17)

Cast 0/uL (0-0.28)

Bacteria 241/uL

Mucus threads 0

DIAGNOSIS:
# DENGUE FEVER WITH WARNING SIGNS, TRANSAMINITIS SECONDARY
# HYPOKALEMIA SECONDARY TO GASTROINTESTINAL LOSSES (Vomiting)
# MODERATE SIGNS OF DEHYDRATION


Guide Questions

1. Based on the history and physical examination, what is your primary impression?
What are your basis for your impression?
 2. What are your differential diagnosis? How do you rule in and rule out those differential
diagnosis?
3. What laboratory tests will you request for the patient?
4. After you saw the results of the tests, how will interpret the results?
5. How do you manage the patient? What IVF do you give, regulation and how long?
6. What medications will you give the patient and why?
7. How do you monitor the patient? What are the things to watch out for this patient?
8. What is your Final Complete Diagnosis?
9. Discuss briefly the etiology and pathophysiology of the disease
10. Before you discharge the patient, what advise will you give?