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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: BAUTISTA , ROBERTO Age/Sex: 65/m Address: Malate Manila Date of admission: July 11,2007 Admitting Diagnosis: CAD,HCVD,LVH, ST-NSR t/c CKD prob 2 to hypertensive nephrosclerosis r/o acute coronary syndrome Final Diagnosis: CKD stage 5 2 to hypertensive nephrosclerosis Residents in charge: Dr.Gonzales/Indon Intern-in-Chage: Maganda Clerk-in-Charge: Navarro/Ponelas/ Reyes

Hospital #: 1707869

Clinical Abstract
This is a case of a 65 year-old male who was admitted due to difficulty of breathing History of Present Illness 1 year PTA, week PTC, patient had productive cough with whitish sputum, no fever, with difficulty of breathing, with orthopnea, no chest pain, no palpitation, no consult done, no meds taken. 2 hrs PTC, there is persistence of the cough with difficulty of breathing while walking thereby prompting consult hence the admission. Past Medical History She was hypertensive for 1 year with unrecalled meds, poor compliance Family History + HPN maternal side - DM,CVD, CA, CKD, asthma Personal and Social History Previous smoker for 1 year stopped >12 years ago Non alcoholic beverage drinker Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Cardiac: (-) PND, + edema x 1 year 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:

CAD,HCVD,LVH, ST-NSR t/c CKD prob 2 to hypertensive nephrosclerosis r/o acute coronary syndrome
PLAN: For AV fistula creation


				
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