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Macalagay___Clinical_Abstract

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Macalagay___Clinical_Abstract Powered By Docstoc
					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: MACALAGAY, EVA Age/Sex: 49/F Address: Tondo Manila Date of admission: July 12,2007 Admitting Diagnosis: CKD stage V 2 to DM Nephropathy DM 2 HCVD, CM, NSR, II-B Residents in charge: Dr. De Leon, Sta.Maria, de los Reyes, Filio, Indon Intern-in-Chage: Maganda Clerk-in-Charge: Navarro/Ponelas/ Reyes

Hospital #: 1709796

CLINICAL ABSTRACT
This is a case of a 49 year-old female who was admitted due to dyspnea History of Present Illness Patient is a known case of CKD stage V 2 to DM Nephropathy, DM2 poorly compliant to medication. Patient admitted at OMMC last June 2007. Patient was advised hemodialysisbut patient went HAMA. Patient still has anasarca and complains of occasional dyspnea. 2 days PTA, + dyspnea, no coughs, + edema, anasarca. Patient sought consult at Mary Johnston Hospital Dx: CKD 2 to HTN Nephrosclerosis, DM type2 with nephropathy, abscess left hand. Medications given were Furosemide, Felodipine, and Cefuroxime. Patient was advised admission but due to financial constraints chose to transfer at our institution, consult at OM ER. Persistence of symptom hence admission. Past Medical History June 2007- OMMC admitted CKD stageV went HAMA + DM, + HPN Family History - DM,CVD, CA, CKD, asthma Personal and Social History Non smoker, Non alcoholic beverage drinker Review of Systems Conscious, coherent, NICRD 140/70 96 26 36.9 HEENT: (-) dizziness, (-) blurring of vision, Respiratory: (-) colds, (-) hemoptysis Cardiac: (-) PND, Gastrointestinal: (-) abdominal pain, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Muscular: + general body weakness Physical Examination: conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 110/100-100/80 HR: 124-89 RR: 34-26 Temp: febrile HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (+) distended neckm veins CHEST AND LUNGS: symmetrical chest expansion, + retraction, (+) crakles , (-) wheezes HEART: adynamic precordium,PMI 6th ICS LMCL , no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: + pitting bipedal edema Assessment: CKD stage V 2 to DM Nephropathy

DM 2 HCVD, CM, NSR, II-B
PLAN: For AV fistula creation


				
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