280 likes | 442 Views
AB. 12 year old Male Cotabato Muslim Date of Admission: 8/20/2014 Transferred to Nephro service Chief complaint: polyuria. History of Present Illness. History of Present Illness. History of Present Illness. History of Present Illness. History of Present Illness. Review of Systems.
E N D
AB • 12 year old Male • Cotabato • Muslim • Date of Admission: 8/20/2014 • Transferred to Nephro service • Chief complaint: polyuria
Review of Systems • No headache • No vomiting • No Cough • No difficulty of breathing • No chest pain • No palpitations • No dysuria, hematuria • No abdominal pain
Birth and Maternal History • Born to a 39year old G5P5 5005, nonsmoker, non-alcoholic beverage drinker, with regular prenatal check-up at the Local Health Center since 3 months age of gestation (+) FeSO4, (-)MV/Folic Acid; No intake of teratogen, radiation exposure • Born full term via NSD at home delivered by traditional birth attendant. (-)fetomaternal complications, no NBS, no HS, BW ?
Immunization History • c/o Local Health Center • No booster
Nutritional History • Exclusively breastfed until 1 years old • Complimentary feeding started 6 months old • Currently not a picky eater
Developmental History • At par with age
Past Medical History • No allergies to food and medication • No previous hospitalization • No trauma
Family History 56 messenger 51 year old housewife 22 20 23 19 (-) Bronchial asthma , PTB, kidney disease; (+) DM, HPN,
Physical Examination • Awake, weak-looking, ambulatory, coherent, not in cardiorespiratory distress • BP 90/60, HR 108, RR 22, T 36.7, • Wt 27.5 kg Ht 110 cm • Anicteric sclera, pink palbebral conjunctiva • no cervical lymphadenopathy
Physical Examination • Symmetric chest expansion, clear breath sounds • Adynamic precordium, normal rate and regular rhythm, no murmur • Flat abdomen, normoactive bowel sounds, no hepatosplenomegaly, no tenderness • Full and equal pulses, no swelling, no joint deformities • No nail changes
Assessment • t/c Nephrogenic Diabetes Insipidus probably secondary to Chronic Obstructive Uropathy • Urinary Tract Infection
BUN 4.50 • Crea 57 • Na 132 • K 2.70 • Chl 82 • Sosm: 276 • Color: yellow • Trans: turbid • SG: 1.004 • pH: 5.5 • Glu: negative • Prot: trace • RBC: 17 • WBC: 123 • Leukocytes: +3 • *Few yeast cells with budding • Hgb 115 • Hct 0.33 • Plt 366 • Wbc 23.1 • Seg .90 • Lym 0.05 • Mono 0.05 Randome Urine Na : 27
16th Hospital Day • Discharged with Hydrochlorthiazide and Kaliumdurule; • Ciprofloxacin and Fluconazole to complete for 2 more days • Follow-up at Nephro service