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

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12 year old male cotabato muslim date of admission 8 20 2014 transferred to nephro service

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 illness1

History of Present Illness


History of present illness2

History of Present Illness


History of present illness3

History of Present Illness


History of present illness4

History of Present Illness


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


12 year old male cotabato muslim date of admission 8 20 2014 transferred to nephro service

  • 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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