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

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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
slide1
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
slide18

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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