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
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: Patient was admitted under the service of Drs. De Leon/Sta. Maria/ De los Reyes/Filio/Indon. Consent for admission and management was secured. TPR q shift, I & O monitoring, DM diet. Labs requested were the ff: CBC c pc, CXR-PA,HBG’s, Na, K, Cl, FBS, RBS, KUB UTZ, UA, Bun Crea,HBsAg. Therapeutics include EPO 4000 SQ 2x/week, FeSO4 cap TID, NaHCO3 tab TID, CaCO3 tab TID, Ceftriaxone 1g TIV OD, Amlodipine 10mg tab OD, Nifedipine 5mg cap SL prn for BP > 160/100. Moderate to high back rest. For E hemodialysis. VS q1, UO monitoring, CBG AC/HS.
On the first hospital day, patient was placed on a DM diet, maintained on heplock, OFI limited to < 1 L/day. Previously requested labs were followed up. Patient scheduled for BT 1 u PRBC, O2 support via nasal canula at 3-4 ppm was maintained. VS q1, patient weighed daily, abdominal girth measured daily. On the 2nd HD, Patient was placed on a DM diet, OFI limited to < 1 L/day, maintained on heplock, scheduled for UTZ of whole abdomen, IFC was removed, meds were continued, VS q2, CBG AC/HS, UO monitoring. On the 3rd HD, Patient was placed on a DM diet, OFI limited to < 1 L/day, maintained on heplock, for repeat CBC c pc, UA, CXR PA, UTZ of KUB, Hemodialysis scheduled on Wednesday. All meds were continued, VS q2, CBG AC/HS On the 4th HD, the recommended diet was continued , heplock was maintained, Patient was scheduled for hemodialysis, referred to surgery for AV fistula creation, VS q2, CBG AC/HS. On the 5th HD, diet was continued, px maintained on heplock, px for hemodialysis today, for cbc c pc post dialysis. Moderate to high back rest. VS q2, CBG AC/HS. Patient was weigh daily. On the 6th HD, Patient underwent hemodialysis, and was advised to go home. Home medications are as follows Erythropoietin 4000 iu SQ 2x/week, FeSO4 1 tab TID, CaCO3 1 tab TID, NaHCO3 1 tab TID, Amlodipine 10g 1 tab OD, Nifedipine 5mg 1 cap SL PRN for BP > 160/100. Ff up at IM OPD, For hemodialysis 2x/week.
Summary of Laboratory Reports Radiological Findings June 16, 2007
Cardiomegaly with pulmonary congestive changes, pleural effusion left, parenchymal fibrosis R, IJ catheter at the level of T6 T7.
CBC with PC WBC RBC HGB HCT MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils HBSAg Anti HCV ABG pH July 15, 2007 3.5 10.3 30.8 89.2 30.0 33.6 May 30, 2007 9.4 3.4 10 29.9 88.4 30.0 34 306 80 11 6 3 0.3 Non reactive Non reactive
0.353 0.052 July 11, 2007 7.12
pCO2 pO2 HCO3 TCO2 BEb O2st
65.2 103.9 20.9 95 3.9 95.7