PAY WARD

General Data

M.M, 31 y/o, Male, Single, Filipino, Iglesia ni Cristo, works as Service crew, born on February 28, 1984 in Sta. Cruz,Manila, presently residing at Brgy. Bagong Silang, admitted for the 1std time at FEU-NRMF Medical Center on December 1, 2015

Chief Complaint

Headache

History of Present Illness

• The history of present illness started 7 days prior to admission when patient experienced neck stiffness, starting at occiput radiating upwards to temporal area with palpable pulsations after taking his TB medication of Rifampicin/INH/Pyrazinamide/Ethambutol (Quadtab) . No other associated signs and symptoms were noted like fever, dizziness, numbness or vomiting. No other medications were taken and no consultation was done.

• 6 days PTA, patient had undocumented fever. No medications taken and no consultation was done

• 5 days PTA, still with the persistence of signs and symptoms but now left cervical lymphadenopathy. They sought consult to the Medical City and was given Co-Amoxiclav 625mg 3x a day.

• 4 days PTA, patient had persistence of headache with strong, bounding temporal pulsations. They sought consult at FEU-NRMF Medical Center Emergency Department and was advised discontinuation of Co-Amoxiclav and was shifted to Cefuroxime 500mg 2x a day for 1 week. Patient was advised to home and still took Quadtab.

• 3 days PTA, patient had itchy, red rashes starting at the dorsal forearm radiating upward to the chest, going distally to his bilateral ankles. Patient still took Quadtab.

• 2 days PTA, patient’s blood pressure was noted to be 140/90 and still took Quadtab. No other medications were taken.

• 1 day PTA, still with the persistence of signs and symptoms of headache and temporal pulsations, sought consult to our institution hence this admission

Past Medical History

• (+) chicken pox, measles and mumps• Immunizations were unrecalled• November 4, 2015: diagnosed with Primary PTB

and was medicated on Quadtab 5x a day and • December 2014: diagnosed with Lumbar lordosis

and had undergone physical therapy rehabilitation for 8 sessions and was on Celecoxib 400 mg.

• 2011: Right Appendectomy at Sampaloc Hospital• Allergic to black beans (Tausi)

Family History

• Father: 64 years old, has TB and HPN • Mother: deceased at 52 years old due to DM• He was the eldest among 6 siblings.• 2nd sibling- had PTB, Appendicitis and DM• 3rd sibling- had Appendicitis• 4th- Anemic and have PCOS• 5th- has PCOS and HPN

Personal and Social History• College graduate• Married for 8 years to a wife who has HPN and PCOS.• Has 2 children, eldest son had Bronchial Pneumonia; 2nd daughter

apparently healthy• Food preferences include 2 cups of rice, pork or chicken, rarely

vegetables and fish.• Alcoholic beverage drinker (2 bottles of beer per night) since 2001. • 13 pack year smoker.• He lives with his wife and children in a bungalow type of house that has

1 room and 3 windows and is well-ventilated.• Normal urination and defacation• Drinking water is from from a purifier• Waste is properly segregated and collected twice a week.

Laboratory Work-ups

Review of Systems

Physical Exam

SKIN: Whole body rashes prominent at extensors, and bilateral extremities, sparing the neckCHEST AND LUNGS: Decreased breath sounds

DIAGNOSIS

• Hypersensitivity reaction secondary to TB Drug

MEDICATIONS

• Hydrocortisone 200 mg • Cetirizine (Alnix) 10mg/tab• Diphenhydramine 50mg/tab• Paracetamol 500mg/tab, 1 tablet every 4 hrs

PLAN OF CARE

• Diet– Hypoallergenic DietTo start on IV PNSS x 60cckwTo hook on 2L/w via nasal canula