History of Present Illness 9 months Terminal pain during urination UTI – cefuroxime 250mg/5mL BIDx7 days 6 months Fever and loss of appetite; U/A - WBC:

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Presentation transcript:

History of Present Illness 9 months Terminal pain during urination UTI – cefuroxime 250mg/5mL BIDx7 days 6 months Fever and loss of appetite; U/A - WBC: 20-25/hpf Recurrent UTI – same medication

5 months Fever and loss of appetite; U/A – WBC 18-20/hpf; C/S – no growth after 48 hours; UTZ – mild focal ectasia, left kidney Nephrologist referral; U/A – 2-3/hpf Urologist referral – for VCUG 1 month Went to nephrologist Procedure not done due tp GERD exacerbation Few days Persistence of terminal dysuria Consult

Review of Systems GENERAL: Undocumented weight loss, (+) decrease in appetite SKIN: No jaundice, no rashes HEENT: No eye pain, no blurring of vision, no ear discharge, no nasal discharge, no sore throat, no mucosal ulcers LUNGS: No dyspnea, no hemoptysis CARDIOVASCULAR: No cyanosis, no palpitations, no chest pain, no easy fatigability; GIT: No vomiting, no diarrhea, no constipation GUT: see HPI ENDOCRINE: No heat/cold intolerance, no polydipsia, no polyuria, no polyphagia HEMATOPOIETIC: no pallor, no bleeding manifestations, no easy bruisability EXTREMITIES: No muscle, bone and joint swelling, no limitation of range of motion, no joint pains NERVOUS: No convulsions, no mood/behavioral changes, no headache

Physical Examination General Survey: awake, alert, ambulatory, irritable, mild PEM, moderate wasting Anthropometric data: Wt 16.6 kg ;Ht 93 cm; BMI 19.2 ; BSA 0.65 Vital Signs: BP 90/50 PR 92 bpm, regular, RR 24cpm, T 37.0C Skin: warm, moist skin; no active dermatoses HEENT: Normocephalic head, no scalp lesions, closed fontanels; not sunken eyeballs, no swollen eyelids, no matted lashes, pink palpebral conjunctiva, anicteric sclera, 2-3mm ERTL, isocoric; no tragal tenderness, non-hyperemic external auditory canal, TM intact, AU (+) cerumen, AU; Midline nasal septum, turbinates not congested, no nasal discharge; Moist buccal mucosa, non- hyperemic posterior pharyngeal wall, tonsils not enlarged Neck: supple neck, thyroid gland not enlarged, (-) palpable lymph nodes Lungs/Chest: symmetric chest expansion, (-) retractions, clear breath sounds Cardiovascular: adynamic precordium, AB 4 th LICS left MCL, S1>S2 at apex, S1<S2 at base, (-) murmurs Abdomen: Globular, soft, no scars, no striae, normoactive bowel sounds, no palpable mass, non tender, no hepatomegaly, no splenomegaly GUT: (-) CVA tenderness; SMR Tanner stage 1 Extremities: pulses full and equal, no edema, no cyanosis, no clubbing

Please Read Medyo maraming inconsistencies. I collated all the records. Yung huling entry ay mod wasting with mild PEM pero BMI nya ay pasok sa normal. Yung mga data na pertinent, katulad na CVA tenderness, frequency, hesitancy, I assumed na wala kasi walang nakasulat. Yung regarding sa history nya ng GERD, walang nakalagay ng pertinent na data, katulad ng hypermic PPW, burning epigastric pain, etc… walang nakalagay na mga laboratory results ng mga DMSA scan, VCUG, EEG….