+AB

12 year old Male Cotabato Muslim Date of Admission: 8/20/2014 Transferred to Nephro service Chief complaint: polyuria

+History of Present Illness

2 years prior

• Noted to be able to drink 3 liters per day, with increased frequency of urination 3-4 times per night

• No dysuria, no hematuria• No headache, vomiting,

blurring of vision• (+) episode of fall, not

witnessed, 7 flight of stairs

+History of Present Illness

18 months

prior

• Consulted with a private physician due to persistence of polyuria.

• KUB ultrasound requested showed hydronephrosis. Further consult with a urologist advised

• Urologist requested VUR and renal perfusion study done

+History of Present Illness

12 months

prior

• (+)Consult at Davao Hospital done

• Repeat KUB UTZ, Renal perfusion study done:

• Spinal MRI: Normal

+History of Present Illness

4 months PTC

• Patient seen by pedia urologist

• Repeat KUB ultrasound, VCUG with normal results

• Advised consult with a nephrologist

+History of Present Illness

1 month prior

• Patient was seen at Nephro OPD

• Patient was prescribed with Hydrochlorthiazide

+Review of Systems

No headache No vomiting No Cough No difficulty of

breathing No chest pain No palpitations No dysuria, hematuria

No abdominal pain

+Birth and Maternal History

Born to a 39year old G5P5 5005, nonsmoker, non-alcoholic beverage drinker, with regular prenatal check-up at the Local Health Center since 3 months age of gestation (+) FeSO4, (-)MV/Folic Acid; No intake of teratogen, radiation exposure

Born full term via NSD at home delivered by traditional birth attendant. (-)fetomaternal complications, no NBS, no HS, BW ?

+Immunization History

c/o Local Health Center No booster

+Nutritional History

Exclusively breastfed until 1 years old Complimentary feeding started 6 months old Currently not a picky eater

+Developmental History

At par with age

+Past Medical History

No allergies to food and medication No previous hospitalization No trauma

+Family History

56 messenger 51 year old housewife

22 19

(-) Bronchial asthma , PTB, kidney disease;(+) DM, HPN,

23 20

+Physical Examination

Awake, weak-looking, ambulatory, coherent, not in cardiorespiratory distress

BP 90/60, HR 108, RR 22, T 36.7, Wt 27.5 kg Ht 110 cm Anicteric sclera, pink palbebral conjunctiva no cervical lymphadenopathy

+Physical Examination

Symmetric chest expansion, clear breath sounds Adynamic precordium, normal rate and regular rhythm,

no murmur Flat abdomen, normoactive bowel sounds, no

hepatosplenomegaly, no tenderness Full and equal pulses, no swelling, no joint deformities No nail changes

+Assessment

t/c Nephrogenic Diabetes Insipidus probably secondary to Chronic Obstructive Uropathy

Urinary Tract Infection

+S> O> P>

Awake, comfortable, not in distress(-) retractions, clear breath sounds(-) murmurSoft abdomen, non tenderFull and equal

CBCUrinalysisElectrolytesBUN, CreaTPAGUrince cultureUrine Na

DFAD5 0.9 NaCl (mtn)Hydrochlorthiazide

Cefuroxime (100)

Insert Foley Catheter

+

Hgb 115 Hct 0.33 Plt 366 Wbc 23.1 Seg .90 Lym 0.05 Mono 0.05 Randome Urine Na :

27

BUN 4.50 Crea 57 Na 132 K 2.70 Chl 82 Sosm: 276

Color: yellow Trans: turbid SG: 1.004 pH: 5.5 Glu: negative Prot: trace RBC: 17 WBC: 123 Leukocytes: +3 *Few yeast cells

with budding

+S>4rd HD O> P>

Awake, not in distress(-) retractions, clear breath sounds(-) murmurSoft abdomen, non tenderFull and equal pulses

I: 7860O: 10720FB -2860UO: 11.9 cc/kg/hr x32h

Na 156 K 2.2Chl 106 Ca 2.67

Na 129 K 1.7Chl 82 Ca 2.10USG: 1.003RBS: 6.7BUN: 2.6Sosm: 315.6

d/c IV fluidsd/c Hydrochlorthiazide

Kalium durule Minirin trial

TNaR= 243.8 D50.45 + 6mEqs KCL (KIR 0.3)

Refer to ICUHook to Cardiac MonitorFor ECG

+S>4th HD O> P>

Awake, not in distress(-) retractions, clear breath sounds(-) murmurSoft abdomen, non tender

I: 1910O: 1900FB: +10UO: 8.5 cc/kg

UO: 0.7cc/kg x8h

Na 129 K 1.7Chl 82 Ca 2.10

Na 128 K 2.60Chl 85 Ca 2.05

Central Line Insertion10mEqs KCL

Cefu D2+2Amik D1

D5LRS + 6mEqs KClCranial MRI

Hold Minirin for now

+S>5rd HD O> P>

Awake, not in distress(-) retractions, clear breath sounds(-) murmurSoft abdomen, non tenderFull and equal

I: 3745O: 5375FB -1630UO: 11.9cc/kg 18h

Na 130 K 3.2Chl 91 Ca 2.09

BUN 2.2Crea 43RBS 6.3sOs 268.5

UCS: Pseudomonas Aeurginosa 80, 000 col/ml

PLRS + 6mEqs KClKalium Durule

Cefuroxime Ceftazidime

Replace loses in excess of 115ml of urine (4cc/kg) w/ PLRS

+S>6rd HD O> P>

Awake, comfortable, not in distressC (-) retractions, clear breath sounds(-) murmurSoft abdomen, non tenderFull and equal pulses

I: 12197O: 15680UO: 24cc/kg

Na 130 K 3.5Chl 95 Ca 2.19

d/c urine volume/volume replacementfor Minirin

ENDO: Central DI unlikelyMay not give Minirin Resume HCTZ

+S>7th HD O> P>

Awake, not in distress(-) retractions, clear breath sounds(-) murmurSoft abdomen, non tenderFull and equal pulses

I: 5420O: 7810FB: -2390UO: 12.2cc/kg

Na 136 K 4.1Chl 94 Ca 2.46

d/c kalium durule

For repeat UCS

+S>9th HD O> P>

Awake, not in distress(-) retractions, clear breath sounds(-) murmurSoft abdomen, non tenderFull and equal pulses

I: 4420O: 4090FB +330UO: 6.95cc/kg

Na 136 K 3.5Chl 88 Ca 2.42

BUN 3.4RBS 5.3

Na 134 k 3.40 Chl 88 Ca 2.37BUN 4.4 RBS 6.5

Repeat UCS: Candida species 100,000 col/ml

Minirin tablet

High Potassium diet

Fluconazole tab

+S>10th HD O> P>

Awake, not in distressCR 92 RR 20 T 36.6(-) retractions, clear breath sounds(-) murmurSoft abdomen, non tenderFull and equal pulses

24hrs post MINIRIN

I: 8400O: 8760FB: -360UO: 14.31cc/kg

Pre minirinNa 136Sp gr: 1.004

Post minirinNa 134Sp gr: 1.003

Monitor I and O accurately

Start HCTZ

+S>12th HD O> P>

Awake, not in distressCR 92 RR 20 T 36.6(-) retractions, clear breath sounds(-) murmurSoft abdomen, non tenderFull and equal pulses

I: 4150O:2490FB:1660UO: 3.9cc/kg

KUB UTZ: Hydronephrosis, bilateral more on the leftCystitis with urine sediments

Continue HCTZ

Fluco D2/7

Ceftaz D8+2Ciprofloxacin (oral)

+S>14th HD O> P>

Awake, comfortableNo febrile episodes(-) retractionsClear breath soundsFull equal pulses

I: 2700O: 3860FB -1160UO: 6.12cc/kg

Transfer to Nephro service Continue HCTZContinue Cipro

+16th Hospital Day

Discharged with Hydrochlorthiazide and Kalium durule;

Ciprofloxacin and Fluconazole to complete for 2 more days

Follow-up at Nephro service