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THIRD YEAR CPC PROTOCOL FOR SEPTEMBER 24, 2020
This case was submitted to the Department of Pathology as a special project in Pathology
B. Autopsy done in 2016.
General Data: This is a case of a 21 Female, single, unemployed, Roman Catholic, from
Bagong Silang, Caloocan City.
Chief Complaint: Difficulty of Breathing
History of Present Illness: Three days prior to admission, patient started to experience pro-
gressive difficulty of breathing, described as shortness of breath even at rest with no aggra-
vating or alleviating factors. This was associated with intermittent fever (Tmax: 39.0 C) re-
lieved by intake of Paracetamol 500 mg per tab. There were also noted 5 episodes of post-
prandial vomiting amounting to about half a cup, non-bloody and non-mucoid. Patient denies
cough, chest pain, orthopnea, edema, abdominal pain, rash, and diarrhea. No other medica-
tions taken, no consultation was done. In the interim, there was worsening of difficulty of
breathing and persistence of intermittent fever. No recurrence of vomiting.
Persistence of symptoms prompted consult and subsequent admission at this government hos-
pital.
Personal and Social History:

 Non-smoker
 Non-alcoholic beverage drinker
 Denies illicit drug use
 No history of recent travel
 High school graduate
 2nd born out of 7 children
 OBGYN history
✓ G0P0
✓ LMP not known
▪ M - 12 y/o
▪ I – 2 to 4 months
▪ D – 5 to 7 days
▪ A – 2 to 3 pads per day, mild to moderately soaked
▪ S – day 1 dysmenorrhea
Past Medical History:
 Juvenile Idiopathic Arthritis
 Known case since 2001 at a another government hospital presented as joint pains, was
on Ibuprofen 400mg TID from 2001 to 2015, lost to follow-up.
 July 2015 – consulted a private doctor, maintained on Dexamethasone 4mg/tab, 1 tab
BID, taken irregularly.
 No previous surgeries, hospitalizations, and no known allergies.
Physical Examination:
General: Awake, alert, coherent, ill-looking, in respiratory distress
Vital signs: BP: 90/60 HR: 150s RR: 40s, 98% at 2-3 LPM via nasal cannula, T: 40.0C
Skin: Flushed skin, no active dermatoses
HEENT: Anicteric sclerae, pink palpebral conjunctivae, (+) moon facie, moist buccal
mucosa, no tonsillopharyngeal congestion, no oral ulcers, no neck vein engorgement,
no palpable lymph nodes, no masses
Page 1 of 6
LUNGS: Equal chest expansion, no retraction, no tactile or vocal fremiti, coarse crack-
les – right lung, mid to base
HEART: Dynamic precordium, distinct heart sounds, tachycardic, normal rhythm, no
murmurs, no thrills, no heaves, apex beat at 5th ICS LMCL
ABDOMEN: Flabby globular abdomen, with purplish striae. Full and equal pulses, nor-
moactive bowel sounds, no bruit, tympanitic on all quadrants, Traube’s space not
obliterated, no hepatomegaly, no direct or rebound tenderness, no palpable masses
EXTREMITIES: no swelling of extremities, tenderness of joints, erythema, crepitus, (+)
contractures of elbows
COURSE IN THE WARD
1st hospital day

Patient was rushed to the emergency room due to difficulty of breathing. Physical examina-
tion was done and the patient was noted to have declining vital signs. The following laborato-
ry examinations were done:
Chest X-ray:
There is haziness in the right paracardiac region. Heart is magnified(enlarged). Aorta is
unremarkable. Hemidiaphragms, costophrenic sulci, and visualized bones are intact.
 Impression: removed for discussion purposes
Complete Blood Count

TEST RESULT NORMAL VALUE
HEMOGLOBIN 126 120-140gm/L
HEMATOCRIT 0.405 0.38-0.48x1012/L
PLATELET 162 150-450x109/L
WBC 19.0 5-10x109/L
NEUTROPHILS 0.87 0.45 – 0.65%
LYMPHOCYTES 0.10 0.25 – 0.50%
MONOCYTES 0.03 0.02 – 0.06%
Blood Chemistry

BUN 12.5 8 – 23mg/dl
CREATININE 387 50.4 – 98.1umol/L
Na+ 136.3 135-148mmol/L
K+ 2.86 3.6-5.2mmol/L
CL- 94.5 98-107mmol/L
Coagulation Studies

PT 20.4 9.9-12.9 seconds
% ACT 38.8
INR 1.84
CONTROL 11.9
APTT 36.9 25.1-33.1 seconds

CONTROL 28.5
Arterial Blood Gas

PH 7.47 7.35-7.45
PCO2 25.8 35-45mmHg
PO2 44.7 80-100mmHg
HCO3 18.2 22-26mEq/L
BE 5.5 +2
O2 SAT 84.4% 98-100%
 Interpretation: removed for discussion purposes
Urinalysis (Macroscopic)

COLOR Light yellow
TRANSPARENCY Slightly cloudy
SPECIFIC GRAVITY 1.015 1.005-1.030

Urinalysis (Chemistry)

PH 6.5 Range 4.6-8; Normal =
6
GLUCOSE NEGATIVE
PROTEIN TRACE
BLOOD +3
KETONE NEGATIVE
NITRATE NEGATIVE
BILIRUBIN NEGATIVE
UROBILINOGEN NORMAL
LEUKOCYTE NEGATIVE
Urinalysis (Microscopic)

RBC 45-50/HPF <3/hpf
WBC 1-2/HPF <5/hpf
EPITHELIAL CELLS MODERATE
MUCUS THREAD FEW
BACTERIA FEW
AMORPH. URATES FEW

Patient was admitted to Internal Medicine service. (admitting impression deleted for discus-
sion purposes)
2nd hospital day
Patient still had difficulty of breathing, joint pains, and fever. She was hooked with PNSS x
125 cc/hr. Her diet was soft diet with SAP. She was given the following medications: Ceftriax-
one 1 gm IV OD, Azithromycin 500mg/tab OD, Paracetamol 300mg IV q4 PRN for fever, and
Ibuprofen 400mg q6 PRN for joint pains. She was then referred to rheumatology service.
3rd hospital day

Patient was seen by the rheumatology service. Swollen knees were noted (assessment re-
moved). Additional medications were given: Piperacillin + Tazobactam 2.25gm IV q6, Hydro-
cortisone 25 mg IV q12, Vitamin K 1 amp IV q6 x 8 doses, Tramadol 50mg IV q8 for pain. 2D
echo was done and showed normal result with EF of 68%. Sodium was 142.9 and Potassium was
2.38
4th hospital day
Patient was conscious and coherent but spoke in short sentences. There was decreased crack-
les on both lung fields, decreased swelling on both knees and positive fluid balance.
Furosemide 40mg IV q2 x 2 doses was given. Creatinine improved from 387 to 197.4. Potassi-
um was corrected to 3.63.
5th hospital day
There was Improvement in the crackles on both lungs and swelling and tenderness on both
knees. Potassium level dropped from 3.63 to 2.7 and was corrected. WBC also dropped from
12.7 to 4.9. ESR was elevated. Dose of hydrocortisone was increased to 100mg IV q6 by the
endocrinology service.
6th-8th hospital day
Patient was ambulatory, not in cardiorespiratory distress. She has decreased crackles, no
febrile episodes and no joint tenderness and just minimal swelling on both knees. Creatinine
was normal. Post correction Potassium showed 2.15. Rheumatology requested for: HbsAg and
A-HCV- both non-reactive, Direct and Indirect Coomb’s test- both negative, C3- 1,790.0,
ANA- not done due to financial constraints.
9th hospital day
Patient was conscious, coherent, ambulatory, not in cardiorespiratory distress with no subjec-
tive complaints and with stable vital signs. Until later that day, while lying down on her bed,
patient experienced stiffening of extremities with peripheral and circumoral cyanosis associ-
ated with upward rolling of eyeballs lasting for 3-5 minutes. She was then referred to ER due
to sudden onset of decreased in sensorium. No eye opening to pain, no verbal output, does
not follow commands. Vitals signs were BP- 110/70, HR- 140s, RR- 30s rapid deep breathing,
Temp- 40.0 C, O2 sat- 60-70% room air. Equal chest expansion but with rales and coarse crack-
les. Assessment at that time (removed)
Patient was intubated and hooked to mechanical ventilator. ECG was done and showed sinus
tachycardia. Pre-intubation ABG showed primary metabolic acidosis with secondary respirato-
ry alkalosis. There was multiple electrolyte imbalance- severe hypokalemia and hypomagne-
sia. Fast correction was done. Troponin 1 was 0.64. Creatinine and BUN were normal at that
time. Chest x-ray was requested and revealed “faint haziness in both lower lungs. An endo-
tracheal tube is noted with its tip in the right main bronchus for which repositioning is sug-
gested. Gastric tube is in place.” Plain Cranial CT scan was also requested “Mild Cerebral At-
rophy, Mucus retention Cyst versus polyp, right maxillary sinus, and proptosis, bilateral.”
10th hospital day
In the evening, patient was referred due to hypotension of 80/90, HR 140s, temp 39.0 C,
bibasal crackles. Levophed was started. Post potassium correction was 2.66 and repeat Na
was 156.7. Corrections of both electrolytes were done. Patient eventually desaturated to 80%.
Suction was done and showed bloody mucoid aspirate per ET. O2 sat improved. BP at that
time was palpatory 40 with HR of 170s. Levophed was increased. ECG was done and showed
SVT with RBBB. Adenosine IV was ordered. Eventually, patient’s HR and BP went 0. CPR was
done for 12 minutes and 4 doses of epinephrine were given. Patient was pronounced dead.

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THIRD YEAR CPC PROTOCOL FOR SEPTEMBER 24, 2020

Chief Complaint: Difficulty of Breathing

Personal and Social History:

COURSE IN THE WARD

1st hospital day

Complete Blood Count

TEST RESULT NORMAL VALUE

TEST RESULT NORMAL VALUE

APTT 36.9 25.1-33.1 seconds

Arterial Blood Gas

TEST RESULT NORMAL VALUE

 Interpretation: removed for discussion purposes

TEST RESULT NORMAL VALUE

TRANSPARENCY Slightly cloudy

SPECIFIC GRAVITY 1.015 1.005-1.030

TEST RESULT NORMAL VALUE

TEST RESULT NORMAL VALUE

MUCUS THREAD FEW

AMORPH. URATES FEW

3rd hospital day

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