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General Data R.G. 2 years 4 months (May 22, 2008) Male Filipino Roman Catholic Sampaloc, Manila Informant: Mother Reliability: Good.

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Presentation on theme: "General Data R.G. 2 years 4 months (May 22, 2008) Male Filipino Roman Catholic Sampaloc, Manila Informant: Mother Reliability: Good."— Presentation transcript:

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2 General Data R.G. 2 years 4 months (May 22, 2008) Male Filipino Roman Catholic Sampaloc, Manila Informant: Mother Reliability: Good

3 Chief Complaint

4 History of Present Illness 3 days PTA Decrease in frequency of urination No other symptoms noted No medications taken No consult done

5 History of Present Illness 2 days PTA Decrease in frequency of urination Decrease in the amount of urine Difficulty urinating Pain in the initial phase of urination Bilateral periorbital and facial edema No medications taken No consult done

6 History of Present Illness 1 day PTA Persistence of oliguria, dysuriam Progression of bilateral periorbital edema Difficulty of breathing Dry cough Wheezes No medication taken Consult was done Co-amoxiclav ml, 5ml Q8 (31.25mkd)

7 History of Present Illness Urinalysis Albumin++++ SugarNegatvie RBC2-4/hpf Pus cells0-2/hpf Hyaline casts0-1/hpf BacteriaModerate Mucus threadsModerate KUB Ultrasound Bilateral renal parenchymal disease with normal urinary bladder

8 Review of Systems No rashes, pruritus No headache, dizziness No aural discharge No cyanosis No chest pain No abdominal pain, vomiting, diarrhea, constipation No dysuria No muscle and joint pains No pallor, abnormal bleeding

9 Personal History Maternal History

10 Personal History Birth and Neonatal History

11 Personal History Feeding History

12 Personal History Developmental History

13 Personal History Past Illnesses – Bronchial Asthma – 2009 – Anergy

14 Immunization History

15 Family Profile FAMILY MEMBERAGESEXEDUCATIONAL ATTAINMENT OCCUPATIONHEALTH STATUS Father:MHealthy Mother:FHealthy Siblings: Healthy

16 Family History (+) HTN and DM – grandmother and grandfather (+) Bronchial Asthma – grandmother, maternal aunt, sibling

17 Socio-economic and Environmental History

18 Physical Exam BP: 130/90mmHg, HR: 104bpm, RR: 30bpm, T: 36.6°C Wt.: 15kg. () Ht.: 87.6cm. () BMI: 19 (above 2 = overweight) HC: 48.5cm, CC: 53cm, AC: 51cm Alert, awake, not in cardio-respiratory distress Warm moist skin, no active dermatoses, good skin turgor (+) periorbital and facial edema Pink palpebral conjunctivae, anicteric sclerae, no tragal tenderness, slightly hyperemic EAC, AU, no naso-aural discharge, moist buccal mucosa, non-hyperemic PPW, tonsils not enlarged

19 Physical Exam Supple neck, no palpable cervical lymph nodes Symmetrical chest expansion, no retractions, resonant on both lung fields, equal vocal fremiti, (+) coarse crackles on both lung fields, (+) expiratory wheeze Adynamic precordium, AB 5 th LICS MCL, no murmurs Globular abdomen, NABS, tympanitic, no tenderness, no palpable masses, no shifting dullness, no fluid wave, liver span=8cm, traube’s space not obliterated Pulses = full and equal Grade 1 bilateral pitting edema Neurologic exam essentially normal


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