MAYO_PDS

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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: MAYO, JEROME Age/Sex: 25/M Address: 2252 Garrido St. Sta. Ana Manila Date of admission: August 5, 2007 2:10pm Admitting Diagnosis: Pneumonia, Community Acquired, Moderate Risk CKD stage 5 2 to CGN on Hemodialysis PTB V Residents in charge: Drs. Aguila.Receno/Dimaandal Intern-in-Charge: Ryan Escandor Clerk-in-Charge: Palay/Rentillo/Roxas

Hospital #: 1693696

PATIENT DISCHARGE SUMMARY This is a case of a 25 year-old male who came in due to fever History of Present Illness Patient is a diagnosed case of CKD stage 5 2 to CGN last June 2007, On maintenance hemodialysis 2x/wk, last was 2 days ago and with good compliance on meds: NaHCO3 1 tab TID, Calon 1 tab TID, EPO 4000 iu SQ. FeSO4 1 tab TID, Felopidine 5mg 1 tab OD. s/p IJ catheter right and AV fistula. Patient was apparently well until.. 2 wks PTA, patient had nonproductive cough no pleuritic chest pain, no dyspnea, no colds, no consult done. Still on medication with hemodialysis. 1 wk PTA, condition persisted with worsening of cough still nonproductive still with no fever, still with no consult done and continued medication. 2 days PTA, during hemodialysis, patient had chills but without fever patient had cough, no dyspnea and chest pain. Dialysis was terminated after 30 minutes due to chills. Patient was told that IJ catheter was infected. Still no consult was done. 1 day PTA, condition persisted with undocumented fever no dyspnea nor chest pain. Persistence of condition, prompted consult hence admission Past Medical History Denies illness like DM, CAD, HPN, BA (-) allergies s/p IJ catheter insertion and AV fistula. Family History (+) HPN - mother Personal and Social History nonsmoker and nonalcoholic beverage drinker, no illicit drug use Review of Systems Constitutional: (-) anorexia, (-) weight loss HEENT: (-) BOV, (-) headache, (-) dysphagia, (-) dizziness Respiratory: (-) chest pain, (-) DOB Cardio: (-) no chest pain, easy fatigability, no PND, orthopnea GIT: (-) abdominal pain, (-) vomiting, (-) melena (-) LBM GUT: no dysuria, (+) oliguria, (-) hematuria Endocrine: (-) no 3 P’s Neurologic: no loss of consciousness, no seizure Hematologic: no easy brusability MSS: no arthralgia, myalgia Physical Examination: Conscious, coherent, not in distress, ambulatory Vital Signs: BP: 140/90 HR: 90 RR: 20 Temp: 37 Skin: (-) pallor, no cyanosis, no jaundice HEENT: pink palpebral conjunctivae, anicteric sclerae, (-) alar flaring, no mass, no neck vein engorgement, no nasoaural discharge, no cervical lymphadenopathies CHEST AND LUNGS: symmetrical chest expansion, (-) retractions, (+) bilateral crackles L>R decreased breath sounds on right basal lung. HEART: adynamic precordium, PMI at 5th LICS MCL, normal rate regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: full equal pulses, (+) grade 3 edema, no cyanosis Assessment: Pneumonia, Community Acquired, Moderate Risk CKD stage 5 2 to CGN on Hemodialysis PTB V

PLAN: For Admission Patient was admitted under the service of Drs. Aguila/Receno/Dimaandal. Heplock was maintained. He was placed on a low salt, low fat low protein diet. Diagnostic procedure requested were CBC with platelet count, urinalysis, CXR-PA, ECG, ABGs, FBS, BUN, crea, Na, K, HDL, LDL, TG, Chole, BUA, Blood CS/ Sputum GS/CS, Sputum AFB. Medications were Ceftriaxone 1g TIV, Azithromycin 2g PO SD, Paracetamol 5oomg PO q4 if Temp ≥38C, NaHCO3 1 tab TID PO, FeSO41 tab BID PO, Amlodipine10 mg OD PO, Metoprolol, 50 mg BID PO, Nifedipine 5mg, SL PRN if BP ≥160/100, EDD 4,000 units, SQ 2x/wk, CaCO3 1 tab TID . For hemodialysis. He is on a moderate to high back rest. O2 was given at 2 lpm via nasal cannula. VS monitiored q1. Upon admission, BP 140/90 CR 90, RR 20. diet was continued, IVF maintained. Labs previously ordered were still requested. Mediactions were continued. He was scheduled for hemodialysis. Still on moderate to high back rest with VS monitored q2. WOF uremic ssx, dyspnea, cyanosis. On the 1st hospital day, vital signs were stable still with fine crackles on right basal fieldand grade 3 bipedal edema. He is still on a low fat low salt low protein diet. Heplock maintaine but IVF PNSS may be given during BT. Transfusion of 1unit PRBC properly typed and crossmatched. Medications were continued. He is scheduled for hemodialysis tomorrow. HE is still on a moderate to high back rest. To WOF uremic ssx dysnea and cyanosis. VS monitored q2 and CBG AC/HS with I and O monitoring with daily wound care. At around 6pm, he has stable vital signs. He was still on low fat, low salt diet, low protein diet, heplock maintained. Transfusion of 1 unit PRBC properly typed and crossmatched is still requested. Still for hemodialysis. Still on a moderate to high back rest. To watch out for uremic symptoms. SH, ACTH. Medications were continued. She is placed on a moderate to high back rest. VS and NVS monitored q1 CBG AC/HS with I and O monitoring with WOF chnge in sensorium and hypoglycemia. On the 2nd hospital day, vital signs were stable. He is still on a low fat low salt low protein diet with SAP. heplock was still maintained. Labs requested were followed up. Medications were continued. Blood transfusion was done. Post BT CBC was done q1, q2 and q6. He is still on a moderate to high back rest. VS monitored every 2 hours with UO monitoring. CBG AC/HS with daily wound care. To watch out for uremic ssx. He underwent hemodialysis On 3rd hospital day, vital signs were stable except BP which is 140/90. He is still on a low fat low salt low protein diet with SAP. heplock was still maintained. Labs requested were followed up. Medications were continued. He is still on a moderate to high back rest. VS monitored every 2 hours with UO monitoring. CBG AC/HS with daily wound care. To watch out for uremic ssx. TO e scheduled for hemodialysis.

Summary of laboratory results CBC WITH PC WBC RBC HGB HCT MCV MCH MCHC PLATELET NEUTROPHIL LYMHOCYTES MONOCYTES EOSINOPHILS BASOPHILS BLOOD CHEMISTRY FBS TG Cholesterol Potassium Urinalysis Physical Color: yellow Transparency: Slightly Turbid Microscopic Epith Cell moderate Mucus Thread few Amorph Urates few Pus Cells many /hpf Erythrocytes many/hpf Cast: Hyaline 1-2 /lpf Initial 17. x 109/L 2.7 x 1012/L 8.3 mg/dL 23 % 85.4 fL 30.9 36 288 x 109/L 81.1% 11.4 % 5.5 % 1.6 % 0.4% Post BT 1 hour 16.2 x 109/L 2.9 x 1012/L 9.2 mg/dL 24.2 % 82.9 fL 31.7 38.2 301 x 109/L 81.2% 8.4 % 6.7 % 3.2 % 0.5% Post BT 2 hours 17.1 x 109/L 3.0 x 1012/L 9.4 mg/dL 25 % 83.6 fL 31.5 38 309 x 109/L 82.8% 8% 5.9 % 2.9 % 0.4 Post BT 6 hours 16.3 x 109/L 3.1 x 1012/L 10 mg/dL 26.5 % 84.2 fL 31.3 37.2 313 x 109/L 85.4% 4.9 % 6.6 % 2.8 % 0.3

August 8, 2007 10.2 mmol/L 1.35umol/L 3.33 mmol/L 3.9 mmol/L

Sugar: negative Specific Gravity: 1.03 pH:7

Chemical Albumin: +4


				
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