1. Lots of inconcistencies on dates. Best to check for consistency when the whole presentation has been compiled. Replies are in blue. There are 4 hospitalization days (days in the ward) + 1 day of admission (Sept. 16) of which labs are done and carried out until the discharge. The references for the values are the laboratory workups and the clinical abstract you sent.

2. Blood Chemistry* –BUN (29.4 mg/dL) - ↑- to check for kidney failure and explain the encephalopathy (if liver function due to leptospirosis is being considered, ammonia levels are better; kidney is not able to excrete ammonia in the form of urea…maybe elevated in Leptospirosis) –Creatinine (1.8 mg/dL) - ↑- more of routine for renal function and treatment management –Hyponatremia (134 meq/L)- ↓- this could be of a non- dilutional type; maybe diet; maybe something else… please ask pathophysio about this; try diarrheic episodes if any –Hypokalemia (3.3 meq/L)- ↓- try diarrheic episodes too, probably diet and probably non- dilutional; please ask pathophysio about this –Hypocalcemia (1.06 anong units ito? pero siguradong hypo siya kahit ano pa units) – units are in mmol/ L; check for its correlation with muscular tetany same as with other electrolytes, which may explain any muscular pains; check for diet and refer to pathophysio please… –Normal nga ba ang PT at aPTT niya noong September 18, 2009? (See tables at end of this section.) – PT is normal (11- 15 s) while aPTT is elevated (25- 35 s but range varies) CXR*: subsegmental atelectasis of the left lobe. *For all items with an asterisk: state why this test is indicated in this case. Kung routine yung test, sabihin ang findings expected kung leptospirosis. **For all items with two asterisks (subsequent slides), state why this treatment is indicated in this case.- di ba dapat pathophysiology or laboratory people ang sumasagot nito? ↑↓ - what is this? I don’t recall this on my slides Ward Management (1 st hospitalization day):

3. -IV Fluids**: pNSS- routine hydrating and infusion solution for medications and electrolytes as well as to correct any electrolyte problems -Antibiotics -Ceftriaxone IV antibiotic, 2 g, IV OD -(bakit ceftriaxone? ano na ba ang working diagnosis at this point?)- probably non- viral (bacterial or parasitic) hepatitis dahil may icterisia… the drug is used for empiric gram (±) coverage. -Analgesics -Paracetamol 500 mg/tab q4h -Tramadol HCl 37.5 mg + Paracetamol 325 mg ( Dolcet) tablet TID as needed  pwede ba to - what do you mean pwede? If the dosage… yes pwede. If the PK, a bit questionable considering baka may kidney and hepatic problem. But pain must always be managed. It should decrease the dosages of each substance in a fixed dose so baka okay lang naman. -Diet** -Renal diet with 35 kcal/kg/day, 60% HBV  what’s this divided into 3 meals & 2 snacks - I don’t know either but ito yung nakalagay… best to delete it but you do it… kumokopya lang ako ng notes ng clerk dito -MAT  what’s this- microscopic agglutination test (sero- specific assay of leptospiral serovars) -Confirmed leptospirosis -Ceftriaxone replaced with penicillin G 1.5 M u q6h

4. Ward Management (1 st hospitalization day): Behavioral ChangesUremic Encephalopathy? Nephrology Referral: Dialysis TCVS Referral for IJC insertion: 12 Lead ECG Sinus rhythm with left axis deviation and non-specific ST-T wave Changes BUN, Creatinine, PT, aPTT Not suggestive of Uremic Encephalopathy Aseptic Meningitis? Neurology Referral: Acute Confusional State Continue Ward Management

5. Ward Management (2 nd hospitalization day): Clinical –No more behavioral abnormalities –Neurologic exam unremarkable no meningeal or increased ICP signs –No signs of uremia Laboratory –Creatinine improving (1.6) – but still ↑ Medications For laboratory abnormalities found on the 1st day of admission CaCO 3 500 mg tab, 1 tab between meals Kalium durule, 1 durule TID x 2 days

6. Ward Management (4 th hospitalization day): Clinical –Afebrile –No behavioral changes Laboratory –BUN (21.3) – normal –Creatinine improved further – but still slightly ↑ (1.3) –Normonatremia (142) –Normokalemia (4.7) Medications: –Penicillin G was then shifted to Amoxicillin 500 mg/cap 1 cap QID.

7. CBC, Differential count and Anti HAV IgM (9/16/09) Hgb118 RBC5.63 Hct0.35 MCV61.60 MCH20.40 MCHC33.40 RDW15.20 MPV7.0 Plt234 WBC11.40 Neutro0.89 Bands0.02 Seg0.87 Lympho0.10 Eosino0.01 CHEMILUMINESCENT IMMUNOASSAY 09/16 Anti HAV IgM0.254 nonreactive

8. Urinalysis URINALYSIS09/16/09 Contradicts with 4 d PTA Hx- see notes above 09/17/09 ColorYellow TransparencySlightly turbid pH5.0 Specific Gravity1.0101.015 Albumin-- Sugar-- RBCs5-7/hpf0-1/hpf Pus cells3-6/hpf Squamous cellsFew Bacteria++ Amorphous urate++

9. Blood Chemistry Panel BLOOD CHEMISTRY09/16 Contradicts with 4 d PTA Hx- same 09/1809/1909/21 BUN41.629.421.3 Creatinine3.31.81.61.3 Alkaline phos166 Total bilirubin5.3 Direct bilirubin4.2 Indirect bilirubin1.1 Na130134142 K3.73.34.7 iPO42.8 iCa1.06

10. Hematology- addendum slide Particulars 09/18 Prothrombin time12.7 Normal control12.5 PT ratio1.0 INR1.0 aPTT45.6 Normal control36.3