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CASE PRESENTATION

PGI NIKKI T. BARTOLOME


IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• FG
• 71 year old, Female
• Widow
• Roman Catholic
• Filipino
• Angeles CITY
• Source of information: patient, 95% reliability
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• Patient is a 71 yo female, known case of:


• DM Type 2 non-insulin requiring
• Hypertension stage II
• CKD secondary to obstructive uropathy secondary to bilateral staghorn calculi
• and
• s/p extracorporeal shockwave lithotripsy (ESWL), bilateral (Mt. Carmel, 2015-
2017)
• s/p DJ stenting left (February 2018, AUFMC) for obstructive uropathy left
secondary to proximal ureterolithiasis, staghorn calculus left
• s/p percutaneous nephrolithotomy right (2017, NKTI) for staghorn calculus,
right
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• Patient sought consult due to left flank pain which started a day
prior to consult. Other associated symptoms were undocumented
fever, dysuria, loss of appetite, and body malaise. Patient also
complained of productive cough with yellow sputum. No history of
fall or trauma, nausea, vomiting, chest pain, dyspnea, and gross
hematuria. Fever temporarily relieved by Paracetamol 500mg/tab.
• Persistence of symptoms prompted consult.
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

General Survey: conscious, conversant, responds appropriately


Vital Signs: BP: 130/80, RR: 22 cpm, PR: 87 bpm, Temp: 37.90C

PERTINENT PE FINDINGS:
Chest and Lungs: symmetrical chest wall expansion, no lagging and retractions
noted, no mass upon palpation, normal tactile fremitus, resonant upon
percussion, with crackles on bilateral basal lung field
Abdomen: Flabby, non-distended, normoactive bowel sounds, tympanitic, soft, (-)
direct and rebound tenderness, (+) kidney punch test left
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• Skin: fair skin complexion, no cyanosis, no pallor, no jaundice, warm to


touch, moist skin, good skin turgor
• Head: no lesions, no palpable masses, no tenderness
• Eyes: anicteric sclerae, pinkish palpebral conjunctiva, no discharges
• Ears: no discharge, no mastoid tenderness, no lesions
• Nose: no nasal discharges, no nasal turbinate congestion, no visible
bleeding
• Mouth and Throat: moist lips and buccal mucosa, no tonsillopharyngeal
wall redness/congestion
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• Neck: no cervical lymphadenitis, non-enlarged thyroid


• Chest and Lungs: symmetrical chest wall expansion, no lagging and
retractions noted, no mass upon palpation, normal tactile fremitus,
resonant upon percussion, with crackles on bilateral lung field.
• Heart: PMI at 5th ICS, heart rate normal in rate and regular in
rhythm, no heaves, no thrills, S1 heard best at the apex, S2 heard
best at the base, no murmurs appreciated
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• Abdomen: Flabby, non-distended, normoactive bowel sounds,


tympanitic, soft, (-) direct and rebound tenderness, (+) kidney
punch test left

• Extremities: no cyanosis, (-) deformities, full and equal peripheral


pulses, capillary refill of 1-2 seconds, (-) edema
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

NEUROLOGIC
• Awake, alert, oriented to 3 spheres
• Cranial Nerves
• CN I: not assessed
• CN II: pupils 2-3 mm ERTL (+) direct and consensual pupillary
• reflex
• CN III, IV, VI: pupils are equally round and reactive to light and
• accommodation, intact EOM
• CN V: intact sensation in the face, masseter strong bilaterally
• CN VII: no facial asymmetry, able to smile and frown
• symmetrically
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• CN VIII: hearing subjectively normal


• CN IX, X: able to swallow solid foods without difficulty, intact gag reflex
• CN XI: sternocleidomastoid strength full without resistance and
• symmetrical
• CN XII: no tongue deviation, no atrophy, able to protrude tongue

• Motor (muscle strength): 5/5 on both upper and lower extremity muscles
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

SUBJECTIVE OBJECTIVE
• 71yo female • Awake, conscious, coherent
• DM Type 2 non-insulin requiring • Oriented to 3 spheres
• Hypertension stage II • Vital Signs: BP: 130/80, RR:
• CKD secondary to obstructive uropathy secondary to 22 cpm, PR: 87 bpm, Temp:
bilateral staghorn calculi 37.90C
• s/p extracorporeal shockwave lithotripsy (ESWL), bilateral • crackles on bilateral lung field
(Mt. Carmel, 2015-2017) • (+) kidney punch test left
• s/p DJ stenting left (February 2018, AUFMC) for
obstructive uropathy left secondary to proximal
ureterolithiasis, staghorn calculus left
• s/p percutaneous nephrolithotomy right (2017, NKTI) for
staghorn calculus, right
• 1 day history of fever, loss of appetite, body malaise,
productive cough, left flank pain, dysuria
DIFFERENTIAL DIAGNOSIS
Complicated UTI Pneumonia-Moderate Musculoskeletal Strain
risk
RULE- -71/F -71F -left flank pain
IN: -with DM type 2 -with DM type 2
-Urinary tract -fever, productive
abnormality: history cough, loss of
of recurrent calculi appetie, body malaise
-flank pain -PE: crackles on BLF
-fever, dysuria
-PE: (+) kidney punch
left
RULE- (-) (-) -no history of trauma or
OUT: lifting of heavy objects
-presence of fever,
dysuria
DIFFERENTIAL DIAGNOSIS
Complicated UTI Pneumonia-Moderate Musculoskeletal Strain
risk
RULE- -71/F -71F -left flank pain
IN: -with DM type 2 -with DM type 2
-Urinary tract -fever, productive
abnormality: history cough, loss of
of recurrent calculi appetie, body malaise
-flank pain -PE: crackles on BLF
-fever, dysuria
-PE: (+) kidney punch
left
RULE- (-) (-) -no history of trauma or
OUT: lifting of heavy objects
-presence of fever,
dysuria
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• Assessment:
1. Complicated UTI r/o CAP-MR
2. CKD 4 secondary to obstructive uropathy
3. DM type 2 – NIR
4. Hypertension controlled
IDENTIFYING
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA

• Diagnostics:
CBC with PC
Na, K, Crea
Urine Culture
12L ECG
Chest X-Ray
KUB UTZ
• Therapeutics
1. Meropenem 1g/IV q 8
2. Start N-Acetylcysteine 600mg/tab, 1 tab BID
3. Paracetamol 300mg/IV
HEMATOLOGY
Examination Reference Values Result
Hemoglobin 123-153 g/L 110
Hematocrit 0.36 - 0.45 0.30
RBC Count 4.10 - 5.10 x1012/L 3.57
MCV 80.0 - 96.1 fL 84.0
MCH 27.5 - 33.2 pg 30.8
MCHC 33.4 - 35.5% 36.7
WBC Count 4.50 - 11 x 109/L 18.74
Neutrophils 0.18 - 0.70 0.85
Lymphocytes 0.10 - 0.48 0.06
Monocytes 0.00 - 0.04 0.09
Platelet count 150 - 400 x 109/L 218
URINALYSIS
Physical Examination
Color Light Yellow
Appearance Turbid
pH 6.0
Specific Gravity 1.010
Chemical Examination
Sugar Negative
Albumin 2+
Microscopic Examination
Pus cells More than 50/HPF
Red cells 4-6 HPF
Epithelial cells Few REMARKS:
Bacteria Few RBC Morphology:
Amorphous Urates - 100% normal
Amorphous Phosphates Few
Yeast Cells -
Casts -
ELECTROLYTES
Examination Result Reference Range Result Reference Range
Potassium 4.49 3.5 - 5.5 mmol/L 4.49 3.50 - 5.50 meq/L
Sodium 122.3 135.0 - 150.0 122.3 135.00 - 150.00
mmol/L meq/L
Creatinine 232.2 63.00 - 108.00 2.63 0.71 - 1.22 mg/dL
umol/L

eGFR= 19.1 ml/min/1.73m2

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