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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Acabal, Rhodora Age/Sex: 51/F Address: 584 Int. 59 San Andres Bukid Manila Date of admission: August 16, 2007 Admitting Diagnosis: Acute Renal Failure on top of Chronic Renal Failure DM type 2 with nephropathy CAD HCVD LVH NSR II-B Residents in charge: Drs. Gonzales/Filio/Indon CIC: Palay/Rentillo/Roxas

Hospital #: 1723133

Clinical Abstract This is a case of a 51 year-old female who came in to IM-ER due to decrease in urine output History of Present Illness Patient is a diagnosed case of DM type 2 and hypertension, maintained on Imidapril + HCTZ, metformin, Glibenclamide. She was apparently well until… 2 days PTA, patient had loose watery stools of about ½ cup per bout x 6 bouts. No fever, no nausea, no vomiting no abdominal pain noted. 1 day PTA, there was persistence of above signs and symptoms with noted decrease in urine output. No medications taken. No consultation done. Persistence of decrease in urine output prompted consult hence the admission. Past Medical History No previous operations (+) HPN (+) DM No asthma No allegy Family History (+) HPN – mother Personal and Social History Nonsmoker, non alcoholic beverage drinker Review of Systems General: no weight loss, no anorexia HEENT: no blurring of vision, no tinnitus, no headache Cardio: no chest pain, no palpitation, no easy fatigability GIT: no abdominal pain, no diarrhea, no constipation GUT: (-) dysuria, (-) anuria Neuro: No seizure Hematologic: no easy brusability Physical Examination: Patient is conscious, coherent in respiratory distress Vital Signs: BP: 90/60 HR: 89 RR:Assisted Temp: 37oC HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, CHEST AND LUNGS: symmetrical chest expansion, no retraction, no lagging, clear breath sounds HEART: adynamic precordium, PMI at 5th ICS LMCL, NRRR, no murmur ABDOMEN: flabby, NABS, soft, nontender EXTREMITIES: grossly normal, with full equal pulse. (-) edema Assessment: Acute renal failure prob 2 to dehydration 2 to infectious diarrhea On top of CKD CKD rob 2 to DM nephropathy HCVD, LVH, NSR, NIF Morbidly Obese PLAN: For referral to surgery for tracheostomy

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Acabal, Rhodora Age/Sex: 51/F Address: 584 Int. 59 San Andres Bukid Manila Date of admission: August 16, 2007 Admitting Diagnosis: Acute Renal Failure on top of Chronic Renal Failure DM type 2 with nephropathy CAD HCVD LVH NSR II-B Residents in charge: Drs. Gonzales/Filio/Indon CIC: Palay/Rentillo/Roxas

Hospital #: 1723133

Date of referral: August 30, 2007 Referred to: Department of Surgery

Reason for referral: For tracheostomy

STAT:________ Routine:______

______________________________ Referring Physician

_______________________________ Receiving Physician


				
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