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, patients 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; 2 nd 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 neck
CHEST 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 Diet
To start on IV PNSS x 60cckw
To hook on 2L/w via nasal canula