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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Buentipo, Ronaldo Address: 1607 Int. C F Varona St. Tondo, Manila Date of Admission: Feb.10, 2008 Admitting Diagnosis: CKD Stage V secondary to DM nephropathy in uremia DM type 2 with neuropathy Residents-in-charge: Drs. Esmero/Gregorio/Sarmiento CLINICAL ABSTRACT

Hospital#: 1737934 Age/Sex: 47 / M

This is a case of a 47 year old male from Tondo, Manila who came in due to vomiting History of Present Illness Patient is a diagnosed case of CKD Stage V secondary to DM nephropathy last Sept. 2007, s/p IJ catheter insertion, on maintenance hemodialysis 2x/week with poor compliance. Last hemodalysis was >1 week ago. Patient came in for blood transfusion but on blood chemistry, patient was noted to have increased creatinine with 1 episode of vomiting hence this admission. Past Medical History No hypertension, no allergies no goiter, no PTB DM – 12 years ; previously on Metformin BID and Gliclazide BID with poor compliance s/p AV fistula creation Feb.’08 Family History (+)DM-father (-)HPN (-)bronchial asthma Personal and Social History Patient is a smoker of 10pack/year, and previous alcoholic beverage drinker Review of Systems General: no fever, no chills, no night sweats, no weight loss, no anorexia. HEENT: no dizziness, no blurring of vision, no tinnitus, no discharge, no cough, no colds Cardiac: no chest pain, no palpitations Gastrointestinal: no nausea, no abdominal pain, no diarrhea, no constipation Genitourinary: no dysuria, no hematuria, (+) oliguria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no nocturia, no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no arthralgia, no myalgia Neurological: no seizures, no loss of consciousness Physical Examination General: conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 180 / 110 mmHg HR: 84 bpm RR: 20 cpm Temp: 36.7 °C Skin: (+)pallor, no cyanosis HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, (-)retractions, clear breath sounds th HEART: adynamic precordium, PMI at 5 ICS left anterior axillary line, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, nontender, no splenomegaly EXTREMITIES: (-) edema, (-) cyanosis, full and equal pulses Assessment: CKD Stage V secondary to DM nephropathy in uremia DM type 2 with neuropathy

Plan: For Admission

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Buentipo, Ronaldo Address: 1607 Int. C F Varona St. Tondo, Manila Date of Admission: Feb.10, 2008 Admitting Diagnosis: CKD Stage V secondary to DM nephropathy in uremia DM type 2 with neuropathy Residents-in-charge: Drs. Esmero/Gregorio/Sarmiento 24-HOUR HISTORY

Hospital#: 1737934 Age/Sex: 47 / M

This is a case of a 47 year old male from Tondo, Manila who came in due to vomiting History of Present Illness Patient is a diagnosed case of CKD Stage V secondary to DM nephropathy last Sept. 2007, s/p IJ catheter insertion, on maintenance hemodialysis 2x/week with poor compliance. Last hemodalysis was >1 week ago. Patient came in for blood transfusion but on blood chemistry, patient was noted to have increased creatinine with 1 episode of vomiting hence this admission. Past Medical History No hypertension, no allergies no goiter, no PTB DM – 12 years ; previously on Metformin BID and Gliclazide BID with poor compliance s/p AV fistula creation Feb.’08 Family History (+)DM-father (-)HPN (-)bronchial asthma Personal and Social History Patient is a smoker of 10pack/year, and previous alcoholic beverage drinker Review of Systems General: no fever, no chills, no night sweats, no weight loss, no anorexia. HEENT: no dizziness, no blurring of vision, no tinnitus, no discharge, no cough, no colds Cardiac: no chest pain, no palpitations Gastrointestinal: no nausea, no abdominal pain, no diarrhea, no constipation Genitourinary: no dysuria, no hematuria, (+) oliguria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no nocturia, no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no arthralgia, no myalgia Neurological: no seizures, no loss of consciousness Physical Examination General: conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 180 / 110 mmHg HR: 84 bpm RR: 20 cpm Temp: 36.7 °C Skin: (+)pallor, no cyanosis HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, (-)retractions, clear breath sounds th HEART: adynamic precordium, PMI at 5 ICS left anterior axillary line, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, nontender, no splenomegaly EXTREMITIES: (-) edema, (-) cyanosis, full and equal pulses Assessment: CKD Stage V secondary to DM nephropathy in uremia DM type 2 with neuropathy

Plan: For Admission Course in the Wards: Patient was admitted at room 422 under the service of Drs. Esmero/Gregorio/Sarmiento. Patient placed on DM diet wuth strict aspiration precaution. IJ catheter was maintained. Diagnostics included were: CBC with PC, BUN , Crea, Cl, Na, K, PO4, ABG, CXRPA, CBG, urinalysis, and ionized calcium.Mediations given were: Amlodipine 10mg/tab OD, Nifedipine 5mg 1 cap SL as needed for

BP>160/100, CaCO3 1 tab TID, NaHO3 1 tab TID, eO4 1 tab BID, EPO 4000 IU SQ 2x/week and Regular Insulin 5 units SQ for CBG >250 mg/dl. She was placed on moderate high back rest. Vital signs were monitored every 2 hours and CBG pre breakfast and 2 hours post prandial,

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Buentipo, Ronaldo Address: 1607 Int. C F Varona St. Tondo, Manila Date of Admission: Feb.10, 2008 Admitting Diagnosis: CKD Stage V secondary to DM nephropathy in uremia DM type 2 with neuropathy Residents-in-charge: Drs. Esmero/Gregorio/Sarmiento 48-HOUR HISTORY

Hospital#: 1737934 Age/Sex: 47 / M

This is a case of a 47 year old male from Tondo, Manila who came in due to vomiting History of Present Illness Patient is a diagnosed case of CKD Stage V secondary to DM nephropathy last Sept. 2007, s/p IJ catheter insertion, on maintenance hemodialysis 2x/week with poor compliance. Last hemodalysis was >1 week ago. Patient came in for blood transfusion but on blood chemistry, patient was noted to have increased creatinine with 1 episode of vomiting hence this admission. Past Medical History No hypertension, no allergies no goiter, no PTB DM – 12 years ; previously on Metformin BID and Gliclazide BID with poor compliance s/p AV fistula creation Feb.’08 Family History (+)DM-father (-)HPN (-)bronchial asthma Personal and Social History Patient is a smoker of 10pack/year, and previous alcoholic beverage drinker Review of Systems General: no fever, no chills, no night sweats, no weight loss, no anorexia. HEENT: no dizziness, no blurring of vision, no tinnitus, no discharge, no cough, no colds Cardiac: no chest pain, no palpitations Gastrointestinal: no nausea, no abdominal pain, no diarrhea, no constipation Genitourinary: no dysuria, no hematuria, (+) oliguria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no nocturia, no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no arthralgia, no myalgia Neurological: no seizures, no loss of consciousness Physical Examination General: conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 180 / 110 mmHg HR: 84 bpm RR: 20 cpm Temp: 36.7 °C Skin: (+)pallor, no cyanosis HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, (-)retractions, clear breath sounds th HEART: adynamic precordium, PMI at 5 ICS left anterior axillary line, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, nontender, no splenomegaly EXTREMITIES: (-) edema, (-) cyanosis, full and equal pulses Assessment: CKD Stage V secondary to DM nephropathy in uremia DM type 2 with neuropathy

Plan: For Admission Course in the Wards: Patient was admitted under the service of Drs. Esmero/Gregorio/Sarmiento. Patient placed on DM diet with strict aspiration precaution. IJ catheter was maintained. Diagnostics included were: CBC with PC, BUN , Crea, Cl, Na, K, PO4, ABG, CXR-PA, CBG, urinalysis, and ionized calcium.Mediations given were: Amlodipine 10mg/tab OD, Nifedipine 5mg 1 cap SL as needed for BP>160/100,

CaCO3 1 tab TID, NaHO3 1 tab TID, eO4 1 tab BID, EPO 4000 IU SQ 2x/week and Regular Insulin 5 units SQ for CBG >250 mg/dl. He was placed on moderate high back rest. Vital signs were monitored every 2 hours and CBG pre breakfast and 2 hours post prandial, st On the 1 hospital day, the patient was on DM diet with strict aspiration precaution. Heplock was maintained.The patient was for hemodialysis and ABG was ordered to be done after hemodialysis. Medications were continued. He was placed on moderate high back rest. Vital signs were monitored every 2 hours and CBG pre breakfast and 2 hours post prandial. nd On the 2 hospital day, the patient was on DM diet with strict aspiration precaution. Heplock was maintained.The patient was still for hemodialysis .Medications were continued. He was placed on moderate high back rest. Vital signs were monitored every 2 hours and CBG pre breakfast and 2 hours post prandial.

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Buentipo, Ronaldo Address: 1607 Int. C F Varona St. Tondo, Manila Date of Admission: Feb.10, 2008 Admitting Diagnosis: CKD Stage V secondary to DM nephropathy in uremia DM type 2 with neuropathy Residents-in-charge: Drs. Esmero/Gregorio/Sarmiento PATIENT’S DISCHARGE SUMMARY

Hospital#: 1737934 Age/Sex: 47 / M

This is a case of a 47 year old male from Tondo, Manila who came in due to vomiting History of Present Illness Patient is a diagnosed case of CKD Stage V secondary to DM nephropathy last Sept. 2007, s/p IJ catheter insertion, on maintenance hemodialysis 2x/week with poor compliance. Last hemodalysis was >1 week ago. Patient came in for blood transfusion but on blood chemistry, patient was noted to have increased creatinine with 1 episode of vomiting hence this admission. Past Medical History No hypertension, no allergies no goiter, no PTB DM – 12 years ; previously on Metformin BID and Gliclazide BID with poor compliance s/p AV fistula creation Feb.’08 Family History (+)DM-father (-)HPN (-)bronchial asthma Personal and Social History Patient is a smoker of 10pack/year, and previous alcoholic beverage drinker Review of Systems General: no fever, no chills, no night sweats, no weight loss, no anorexia. HEENT: no dizziness, no blurring of vision, no tinnitus, no discharge, no cough, no colds Cardiac: no chest pain, no palpitations Gastrointestinal: no nausea, no abdominal pain, no diarrhea, no constipation Genitourinary: no dysuria, no hematuria, (+) oliguria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no nocturia, no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no arthralgia, no myalgia Neurological: no seizures, no loss of consciousness Physical Examination General: conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 180 / 110 mmHg HR: 84 bpm RR: 20 cpm Temp: 36.7 °C Skin: (+)pallor, no cyanosis HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, (-)retractions, clear breath sounds th HEART: adynamic precordium, PMI at 5 ICS left anterior axillary line, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, nontender, no splenomegaly EXTREMITIES: (-) edema, (-) cyanosis, full and equal pulses Assessment: CKD Stage V secondary to DM nephropathy in uremia DM type 2 with neuropathy

Plan: For Admission Course in the Wards: Patient was admitted under the service of Drs. Esmero/Gregorio/Sarmiento. Patient placed on DM diet with strict aspiration precaution. IJ catheter was maintained. Diagnostics included were: CBC with PC, BUN , Crea, Cl, Na, K, PO4, ABG, CXR-PA, CBG, urinalysis, and ionized calcium.Mediations given were: Amlodipine 10mg/tab OD, Nifedipine 5mg 1 cap SL as needed for BP>160/100, CaCO3 1 tab TID, NaHO3 1 tab TID, eO4 1 tab BID, EPO 4000 IU SQ 2x/week and Regular Insulin 5 units SQ for CBG >250 mg/dl. He was placed on moderate high back rest. Vital signs were monitored every 2 hours and CBG pre breakfast and 2 hours post prandial,

On the 1 hospital day, the patient was on DM diet with strict aspiration precaution. Heplock was maintained.The patient was for hemodialysis and ABG was ordered to be done after hemodialysis. Medications were continued. He was placed on moderate high back rest. Vital signs were monitored every 2 hours and CBG pre breakfast and 2 hours post prandial. nd On the 2 hospital day, the patient was on DM diet with strict aspiration precaution. Heplock was maintained.The patient was still for hemodialysis .Medications were continued. He was placed on moderate high back rest. Vital signs were monitored every 2 hours and CBG pre breakfast and 2 hours post prandial. rd On the 3 hospital day, the patient had hemodialysis. He was then advised to go home with the following meds: 1. Amlodipine 10mg/tab OD 2. Nifedipine 5mg/tab, 1 tab SL PRN for BP>160/100 3. Ca CO3 tab TID 4. NaHCO3 tab TID 5. FeSO4 tab TID 6. Rythropoietin 4000 units SC 7. Intermediate insulin 10 units in the morning and 5 units in the evening The patient was advised to come back on Feb.18’08 (Mon) for follow up.
LABORATORY RESULTS AND OTHER ANCILLARY PROCEDURES Complete Blood Count WBC LYMF RBC HCT HGB EOS Mono BAso Reference Range 5.0 – 10.0 g/L 20.0 – 40.0 % 4.00 – 5.40 g/L 36.0 – 47.0% 120 – 160 g/L 1.0-4.0 2.0-6.0 0.0-0.1 Feb 10 16.2 18.4 3.24 26.6 8.8 0.1 5.8 0 Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphous Urates Bacteria Crystals Pus Cells Erythrocytes WBC Yeast cells Hyphal elements Casts February 10 Yellow Slightly turbid Occasional Occasional few --1-2 8-10 -----l

st

Blood Chemistry Normal Values 3.9 – 6.4 mmol/L 1.7 – 3.3 mmol/L 50 – 104 mmol/L (male) 45 – 84 mmol/L (female) 3.8 – 5.1 mmol/L 0.4 – 2.25 mmol/L 0.67 – 1.94 mmol/L 1.32 – 2.52 mmol/L 202 – 416.5 mmol/L (male) 142.8 – 239.2 mmol/L (female) 0 – 38 U/L (male) 0 – 32 U/L (female) 0 – 41 U/L (male) 0 – 35 U/L (female) 35 – 129 U/L 0 – 172 mmol/L 0 – 5.1 mmol/L 66 – 87 g/L 34 – 48 g/L 20 – 38 g/L 2.60 – 6.40 mmol/L 134 – 145 mmol/L 3.4 – 5.0 mmol/L 93 – 108 mmol/L Feb 9 41.62 1405 Feb 10 ABG(Feb.10’08) pH pCO2 pO2 HCO3 TCO2 BEb O2St

Glucose BUN Creatinine Cholesterol Triglyceride HDL – C LDL BUA SGOT SGPT Alk. Phos Total Bilirubin Direct Bilirubin Indirect Bilirubin Total protein Albumin S. globulin BUN Na K Cl

7.27 27.10 102 12.70 13.5 -11.9 97.10

140 5.4 109

4.7


				
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