MARY JOHNSTON HOSPITAL

1221 Juan Nolasco Street, Tondo, Manila 1012

Tel Nos. (632) 245-4021 to 25 Fax No. (632) 245-4487
PhilHealth Accredited

Hospital Case No. 363226 Last Name: Marmiol Date Of Birth: 08-5-1970
Date of Admission: Dec. 22, 2017 First Name: Teddy Age/ Gender: 47/M
Attending Physician: Dr. M.Lim Middle Name: Carpio Civil status: Married

Chief Complaint: Joint Pains

History of Present illness:

1 week prior to admission patient had sudden onset of joint pains, he also claims that he had lost weight at estimate of 5kg. Patient
took Celecoxib but was not relieved. Persistence of symptoms prompted consult. Patient was subsequently admited

Past Medical History: Family Medical History: Personal & Social History:
(-) HPN (-) Heart fauilure (- ) Asthma PreviousSmoker: 20 years 10stk/day
(-) Dm (-) PTB (- ) Allergy (+) HPN Mother (-) Asthma (-) Dm both No Substance abuse history
(-) PTB (-) Allergy (-) Cancer Non Alcoholic Drinker

Review Of Systems:
(- ) Fever (-) Headache (-) Dizziness (- )SOB/DOB (-) Cough (-) Colds (-) Chest Pain (-) Orthopnea (- ) Easy Fatiguability
(-) Vomiting (-) LBM (- ) Abdominal Pain (-) Dysuria (-) Hematuria (- ) Melena (- ) Hematochezia
(- ) Body Weakness (- ) Edema (+) Weight Loss
Physical Examination: Course in the Ward:

Vital signs: BP: 140/80 HR: 90 RR: 20 Temp: 37.0 C Upon admission, patient placed on DM
Conscious, Coherent, Not in Distress GCS 15 (E4 V5 M6) Diet. Hooked to PNSS 1L x 16 hours.
Anicteric Sclerae, Pink palpebral Conjunctiva, Pink Oral Mucosa, (-) CLAD
Symmetrical chest Expansion (-)Retractions (+) Clear Breath Sounds R&L lung Medications on Board:
Adynamic Precordium, Normal Rate, Regular Rhythm ( -) Murmur 1. Omeprazole 40 mgTIV OD
Flabby, Normoactive Bowel Sounds, Soft, Nontender 2. Vitamin b complex OD
Full and Equal pulses, (+) Edema, (-) Cyanosis of Right Leg 3. EPO 4000 units SQ
4. TDL 50 mg TIV
Laboratory & Diagnostics Examination: 5. 3 units of PRBC transfused.

Hgb Hct Wbc Seg Lympho Mono Eo Plt Patient’s condition improved, Join pains became
12-22-17 64 .20 2.5 .36 .59 .02 0.0 164 minimal. Patient recuperated from Illness. Vital signs
12-24-17 89 .27 2.9 .32 .65 .02` .01 168 were stable. On the 3rd Hospital Day patient was
103 .30 3.0 .29 .68 .02 .01 150 discharged upon by request for MGH.
BUN NA K Crea HBA1c Gl Ica
141.8 4.06 .66 12.0 5.40 1.22
UA LY C 1.010 5.0
Gl- Pr - WBC RBC
0-2 0-1

ECG: Normal Sinus Rhythm, Left Atrial Abnormality

Ultra Sound: Normal sized Liver with Hepatic Cyst, Left Lobe.
Normal Sonogram of the gall bladder, pancreas, spleen, kidneys and urinary
Bladder.

Final Diagnosis: Aplastic anemia secondary to severe sepsis; Septic arthritis

Reminders:

To follow up at the OPD after 7 days. OPD clinic of Dr. M. LIM

Dr. M. LIM
Consultant- In-Charge Resident-In-Charge Date Accomplished

-NOT VALID FOR MEDICOLEGAL PURPOSE-

rev04.28.2016mjhform