OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: PINEDA, MARIBETH Hospital Number: 1719102 Age/sex: 33/F Address: 1208 Sagat St. Paco, Manila Date of Admission: September 6, 2007 Admitting Diagnosis: CKD Stage V probably secondary to CGN in Anemia Final Diagnosis: CKD Stage V probably secondary to CGN HCVD, NSR, II-B HCVD, NSR, II-B Bronchial Asthma, intermittent Bronchial Asthma, intermittent Residents-in-charge: Drs. Sta. Maria/Delos Reyes-Gonzales /Roxas /Estrada S/P IJ Catheter Insertion Clerks-in-charge: Ocampo /Reloj /Rosarito Clinical Abstract GENERAL DATA This is a case of a 33 y/o female from Paco, Manila who was admitted due to pallor.
HISTORY OF PRESENT ILLNESS Patient was recently diagnosed to have Hypertension and was maintained on Captopril (25mg TID PO). Patient was also noted to have an increase in Serum Creatinine of 400mg/dl. 1 month PTA, patient had easy fatigability, with no chest pain, palpitation, orthopnea, PND. There was also no cough, nor hemoptysis. No consult was done and no other medications besides Captopril 25mg were given. 1 week, patient had increased severity of fatigability with occasional dyspnea and 2-pillow orthopnea. No consult was done and medications given. Persistence of symptoms prompted consult and subsequent admission. PAST MEDICAL HISTORY: Has Asthma, since childhood, last attack: May 2007 Has HPN: July 2007 maintained on Captopril (25mg TID PO) NO DM, Heart disease, Goiter, PTB FAMILY MEDICAL HISTORY: (+) HPN on paternal side. PERSONAL and SOCIAL HISTORY: Non-smoker; Non-alcoholic beverage drinker 1 bottle of beer/day x 3 months REVIEW OF SYSTEMS: General: no weight loss, no loss of appetite HEENT: no blurring of vision, no tinnitus GIT: no abdominal pain, no changes in bowel movement GUT: no dysuria, no hematuria, no oliguria Endocrine: no polyphagia, no polydipsia, no polyuria PHYSICAL EXAMINATION: General Survey: conscious, coherent, not in cardio-respiratory distress. Vital signs: BP: 160/90mmHg HR: 98 beats/minute RR: 23 cycles/minute Temp: 36.9º C (axillary)
HEENT: anicteric sclera, pale palpebral conjunctiva, no naso-aural discharge, supple neck, palpable cervical lymph nodes, no mass Chest: Symmetric chest expansion, no retractions, (+)bibasal crackles, L>R th Heart: Adynamic precordium, AB at 5 ICS LMCL, normal rate, regular rhythm, no murmurs Abdomen: flat, normoactive bowel sounds, soft, non-tender, no organomegaly
Extremities: Grossly normal, no cyanosis, no jaundice, full and equal pulses, no edema, pale palms and nail beds Neuro: MOTOR Conscious, oriented to time, place, person CN I – intact CN II – Pupils equally reactive to light and accommodation 2-3 mm CN III, IV, VI – intact EOMs 5/5 5/5 CN V – (+) bicorneal reflex CN VII – No facial assymetry CN VIII – can hear CN IX, X – good gag CN XI – can shrug both shoulders CN XII – tongue at midline (-) Babinski, left No clonus, no nuchal rigidity SENSORY DTR
100% ++ ++
ASSESSMENT: CKD Stage V probably secondary to CGN HCVD, NSR, II-B Bronchial Asthma not in Acute Exacerbation PLAN: Low salt, low fat diet; Decrease OFI to < 1L/day IVF was shifted to Heplock Patient was for BT of 1 ‘u’ PRBC, and was hooked to PNSS 500cc x KVO Diagnostics: Serum Ca, PO4, Mg and post BT CBC Therapeutics: Furosemide 80mg IV now Course in the Wards: Upon admission, patient’s vital signs were stable: BP: 160/100; CR: 88; RR: 20; T: 37