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12 year old Male Cotabato Muslim Date of Admission: 8/20/2014 Transferred to Nephro service - PowerPoint PPT Presentation


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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.

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Presentation Transcript
AB

  • 12 year old Male

  • Cotabato

  • Muslim

  • Date of Admission: 8/20/2014

  • Transferred to Nephro service

  • Chief complaint: polyuria







Review of systems
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
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
Immunization History

  • c/o Local Health Center

  • No booster


Nutritional history
Nutritional History

  • Exclusively breastfed until 1 years old

  • Complimentary feeding started 6 months old

  • Currently not a picky eater


Developmental history
Developmental History

  • At par with age


Past medical history
Past Medical History

  • No allergies to food and medication

  • No previous hospitalization

  • No trauma


Family history
Family History

56 messenger

51 year old housewife

22

20

23

19

(-) Bronchial asthma , PTB, kidney disease;

(+) DM, HPN,


Physical examination
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 examination1
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
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


16 th hospital day
16th Hospital Day

  • Discharged with Hydrochlorthiazide and Kaliumdurule;

  • Ciprofloxacin and Fluconazole to complete for 2 more days

  • Follow-up at Nephro service


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