29082017

A 10 /yr old girl presented in outpatient department with left flank pain of 2weeks duration,  progressive abdominal mass of a week duration and weight loss of a week duration.
Notable on examination are  evidences of weight loss and a tender,  nodular mass on the right flank,

a)  mention three diffential diagnosis for her condition.

B)  the girl was noticed to be unable  to use are lower limbs while being investigated  and the Abdominal Ultrasonography showed the mass to originate from the left kidney, what is your most likely diagnosis at this point?

C) Discuss four investigations  relevant to this diagnosis.

D) What are the risk factors to this condition?

E) Mention 5 prognostic factors in this condition.

F) What four complications may occur?

G) highlight  the stages of this condition.


A four year old girl was referred to you from a peripheral hospital  with history of Fever of ten days duration, vomiting and diarrhoea of week duration,  he was said to have had reduced urine output for two days though urine color was Amber, there was also facial and pedal edema.
Examination  revealed  an acutely ill looking child, Febrile (temperature  is 38.7centigrade) in mild respiratory distress, has pedal edema and facial puffiness, weight is 14kg.
Urine output is 0.3mls/kg/hr in the first 24hrs of admission
Serum  creatinine is is 6mg/dl.
Potassium  5.4mmol/l.
Urea 20mg/dl.

a)  What is your diagnosis?

b ) explain your initial fluid  regimen to your nurses.

c)  list ten causes of this condition.

d) Explain the pathophysiology of any three complications that may develop in this patient.

E)  what is the place dopamine in the management of this patient?

F)  Explain the term disequilibrum syndrome to your registrars.

MCQ 08/09/2017

1. A three -year old was brought to your specialist clinic with history to suggest severe mental retardation, special interest in water,  and always laughing, he has had several episodes of seizure.
Notable on examination include facial hypolasia,severe hypotonia and tremor.
The following are likely to be true about this patient.
a) This patient has a microdeletion on a  paternity derived  chromosome.
b) This patient has paternal uniparental disomy.
c) The prognosis is good.
d) this patient speech is expected to be affected.
e)  The patient has Down syndrome.

2. A twenty-day old baby was rushed into the special care baby unit unconscious,  he has being vomiting for three days,  has not being thriving since birth,  examination revealed a child who appeared small for age,  with sunken eye balls.
Random blood sugar was elevated with a value of 26mmol/l, urinalysis yielded ketonuria of +
The following are correct about this patient.
a).   He has a chance of spontaneous cure.
b). Abnormality of this type is mostly associated with mutation on chromosome  6p24.
c. Permanent diabetes may result in up to 60 percent of patients with this condition
d). Ketonuria is the hallmark of diagnosis
e) soluble insulin is of choice in active phase.

3. A 6yr old boy presented in OPD with history of progressive generalised body swelling of a month duration, urine output has reduced, bedside urinalysis yielded 4+ of protein, serum albumin was 1.8mg/dl
The following are likely to be correct of this patient and his condition.
A) Most patient with steroid responsive type have repeated relapses
B) A relapse is defined as proteinuria 3+ or 4+ for 3 consecutive days after initial remission.
c)immunenoflorescence microscopy is typically negative
D)children who continue to have proteinuria after 4 weeks of steroid therapy are considered steroid resistant.
E) in congenital type ,  cure rate is hundred percent after transplantation.

4. Concerning Proteinuria
A) Glomerular proteinuria should be suspected in any patient with a first morning urine protein : creatinine ratio >1.0.
B) microalbuminuria in children has been found to be associated with obesity and to predict, with reasonable specificity, the development of diabetic nephropathy in type 1 dmicroalbuminuria in children has been found to be associated with obesity and to predict, with reasonable specificity, the development of diabetic nephropathy in type 2 diabetes mellitus.
C. The dipstick may  be falsely positive in patients with highly concentrated urine.
d) orthostatic proteinuria occurs in less than 60% of patient with persistent proteinuria
E)Nephrotic range if greater than 960mg/metre square/ day.

5. Anti neutrophilic cytoplasmic antibody associated vasculitis include the following :
A). Kawasaki disease.
B) henoch schonlein purpura.
C.Takayasu disease.
D) churg Strauss syndrome.
E). Microscopic polyangitis.

Can it be diabetes?

I remember moving through the adult wards  in medical school and the sight of the interns checking the blood sugar of their patients,  from one bed to another without missing any ! Such is the place of diabetes in adult medicine, a very common condition among adults.
In children however, diabetes is not a very common occurrence such that doctors often miss the diagnosis when it occurs in children of resource poor countries. Diabetes in children may disguise as appendicitis, cerebral malaria,urinary tract infections, pneumonia or even typhoid enteritis.
A high index of suspicion is required for diagnosis of diabetes in children.One may need to routinely check the blood sugar of every child that present in the hospital for early diagnosis, treatment and prevention of complications of childhood diabetes.
I have made it a point of duty to bring this to the fore for this week because, it appears there is an increase in its occurrence amongst children seen in my facility in the last few years. This increase is such that in the last one year we have seen three cases, two of whom were initially managed as typhoid enteritis.
I hope to use this medium to educate us about this condition

What is Diabetes? 
Diabetes simply means high blood sugar. It occurs when the sugar in the body (sugar is the end product of almost every thing we eat) is not available for energy generation and also not converted to the storage form, usually the insulin in such a person is not available or insufficient for this conversion, making lack of insulin or insufficient insulin the reason for this excess blood sugar.

Why do people have diabetes? 
The reasons why people have diabetes is not entirely clear;  however, some of the reasons may include:
Genetic abnormalities, infection, and diet.

Family history: children of diabetic parents should be routinely checked as they are often at higher risk.

Infections: some infections are capable of destroying pancreas,  the insulin producing organ in the body, such infections include Mumps,  tuberculosis,  measles, other viral infections

Diet: western diet that predispose to Obesity may in turn predispose to a type of diabetes. Early exposure to "Canned" food with preservatives can trigger allergy/autoimmune reactions that may destroy insulin producing organ (this is hypothetical).

Here is a good news ;  Human breastmilk is protective, it is cheap and unadulterated. Vitamins such as C, D and E vitamins are also protective.
Minerals like zinc ,selenium are also protective .

What are the signs of diabetes in children?
Weight loss: This though not universal and may be subtle is a very common sign,  any unexplained weight loss in childhood must be investigated and the investigation  panel must include blood sugar,  please see your doctor or seek his or her opinion if your child is losing weight, you may even politely request for blood sugar check.

Frequent urination: if you notice that your child is urinating more frequently or too frequently please beckon  on your doctor,. Some of these children may even start to bed wet newly.

 Some children may start to drink water more often.

Some will eat more than before. !

Wounds on their body may not heal on time.

Some may have boil more often .

What to do if any of the above signs is seen?
See your doctor,  preferably  a paediatrician.,
 the complications( stroke,  blindness,  kidney damage to mention a few) of diabetes are serious and may be life long,  these complications are avoidable if diabetes is treated promptly.


To learn more..... Stay tuned.

Leave your questions,  comments or suggestions in the comments  box.

Daily assesment 18/08/17

1)  A mother presented with her 2 year old son who was left in care of her neighbour and was met watching television , he however has rash on the trunk, which was not there before leaving home.
Your registrar suspected physical Abuse and requested that you review before further plan.
Your examination shows widespread petechiae haemorrhage.

1. What four history will help you make diagnosis?
2. Mention Five of your differential diagnosis.
3. Mention three investigations that will help you make diagnosis.
4. The result of some of the investigations  are as shown below:
       WBC: 9000cells/ul.
       PCV: 34 Percent
       Platelet :52000cells/ul.
       Bleeding time : 17minutes.
       Prothrombin time: 12s.
       Activated plasma thromboplastin time: 40s.
a) what is the most likely diagnosis?
b)  Mention five causative agents.
C)  mention four treatment modalities.

2. Your Houseofficer has seen a 4year old boy with history of abdominal distention  of  a year duration,notable findings on  his examination include an abdominal mass extending from the right flank to the midline with smooth surface,   he could get above and below the mass, the child weighs 20kg and has a length of 78cm.

1) Mention four likely diagnosis.
2. Mention two investigations that are of outmost relevance in making diagnosis.
3. The chest radiograph reveal multiple well circumscribed opacities on the lung fields.
a).  What is your most likely diagnosis?
b). Mention four associations that may be expected.
c). What are the likely haematologic findings?
d).  Mention five clinical features expected?
e. Mention four prognostic factors in this patient.


     
   

14/08/17, Daily assessment.

1. You have been managing a twelve year old boy since age seven month, when he presented with history of progressive abdominal  distention , passage of large bulky stool and low weight of four kilograms, he developed  inability to make smooth coordinated movements at age ten.
Parents have no such history.
The peripheral blood film of this boy revealed numerous Acanthocytes.
Which of the following conclusions is/are correct?

(a) The boy may have retinal degeneration.
(B)  This condition is inherited as autosomal dominant.
(C) ricket is an early finding in this condition.
(d) Supplementation  with vitamin E may cure this condition.
(e)  This boy has hypobetalipoproteinaemia.

2. A  4 week old boy being managed by your resident doctors on outpatient basis for an extensive macular rash involving the scalp,  face and the trunk,was noticed to have irregular heart rate, the maternal immunoglobin profile obtained during pregnancy showed elevated anti la antibodies.
Which of the following  conclusions may be right?

(a)  This rash typically last three to four months.
(b) majority of patients with this condition develop progressive cardiomyopathy.
(c) The cardiac arrythmias  in this condition are permanent.
d) This rash is photosensitive.
(e) most feared complication of this condition is hepatitis.

3. expected findings in kwashiorkor include the following:

(a) increase cortisol and growth hormones level.
b)  increase thyroid stimulating hormone level.
(c) high plasma ferritin level.
(d) blood transfusion is indicated for persistent lack of appetite.
(e)  Apathy.

4. A 12yr old boy with recurrent passage of bloody urine since age four has now developed deafness, opthalmogical examination shows extrusion of the lens,  you make the following conclusions :

a)  anterior lenticonus is a pathognomonic feature of this condition.
b)  This patient is at risk of nephrotic syndrome.
C)  This condition can be inherited as autosomal dominant.
D)  The deafness in this condition is acquired.
E)  This condition  occurs as a result of defect in Type one collagen.

5. A two  year old girl whose mother is a vegan present with recurrent ulcer on the lips and tongue, you suspect the patient condition is due to :

a)  lack of enough calorie intake.
b) vitamin B1 deficiency.
c)  vitamin B5 deficiency.
d)  vitamin C deficiency.
e)  vitamin B12 deficiency.

Oral question:

A two year old boy who left the hospital  against medical advice while on chemotherapy  for retinoblastoma because the parent believed the eye swelling was due to spiritual attack,  presented last night with several episodes of convulsions and loss of consciousness  of about forty-five hours, the Glasgow coma score of three,  absent cornea reflex and  dilated and fixed pupils.

 1) what is your diagnosis?
ii) list Five confounders in making this diagnosis.
iii) mention three other reflexes that are likely to be absent.
iv ) mention two investigations that will enable a definitive diagnosis.
v)  describe  apnea  test?

Sustaining Breastfeeding together.

It was another breastfeeding  week  on 1st to 7th August, 2017. This year's theme challenged us to work together to make breastfeeding sustainable. It requested the support of every man, woman, manager, policy maker, NURSE, doctor, health attendant, Husband and everybody.
Breastfeeding is a BIG task, it drains energy, you may have witnessed or heard about women fainting after breastfeeding; such is the energy it consumes and this shows that the level of support needed by a breastfeeding woman is unquantifiable/ enormous.
If you did not talk to someone last week about breastfeeding , you didn't do too well, you still have the chance to do that before it is too late or better still forward this piece of information to them.
Can we have Breastfeeding celerebrated every week just to lay emphasis on the importance of breastfeeding?
I need not bore us on why breastfeeding or breast milk is important, its rich contents and the protections it offers are superior.
What I want us to pay attention to is helping the breastfeeding women around us do it well, any form of encouragement done properly will be appreciated; a thumbs up, a pat, money, food, space, breastfeeding leave with pay , a space in your establishment for brastfeeding mothers to breastfeed are just some of the supports that will make the breastfeeding mother do it well.
If you look around well enough this task is often left for the aged women in the community who themselves need support, they pass down traditional practices (big kudos to them), some of these practices are very helpful. That they are willing to help always is commendable. However, we are now in an era when we know better and our knowledge should set us free, set our community free also.
My major concern today are the challenges and myths of breastfeeding.
I have been in a nursery bay where HOT water was prescribed, to help uterus contracts and breast milk flows. Right in the hospital, even in labour wards you see people including healthcare practitioners prescribe bland PAP etc as a form of galactogogue. These are based on traditions and psychology; they have little scientific basis.
The challenges of breastfeeding are numerous, I will mention a few:

1. Milk not flowing: this is common in the first 3 days after birth, it is a normal finding in most mothers and will soon flow, as a mother, you need to relax, eat well and drink a lot fluids, be happy, ensure you are not in any form of pain as this can cause delay in milk flow.
Please my fellow doctors, DO NOT PRESCRIBE HOT WATER FOR THESE WOMEN, doing so has no established basis ,tell me how much hot water can a woman who should be well hydrated drink? The breastfeeding mother should take about 3litres of water daily, normal (water at room temperature) will do. If the lack of milk flow extends beyond the 3rd day with all the above mentioned stuffs clearly addressed pleas see your doctor (pregnant woman doctor (Obstetrician) or babies doctor (Paediatrician)).
Palm wine is not a special fluid, if you are not interested don't drink, don't blame your inability to produce enough milk on lack of palm wine, a lot of people get unneccessarily worried because of this temporary problem to the extent that such worry inhibit their milk flow.
Pregnant women and breastfeeding mothers need GOOD FOOD,simple well prepared meal, No mandatory Pap .
The list below is a well illustrated 10  steps to
SUCCESSFUL BREAST-FEEDING
  Every facility providing maternity services and care for newborn infants should accomplish the following:
  1   Have a written breast-feeding policy that is routinely communicated to all health care staff.
  ii Train all health care staff in the skills necessary to implement this policy.
  iii   Inform all pregnant women about the benefits and management of breast-feeding.
  iv    Help mothers initiate breast-feeding within a half hour of birth.
  v    Show mothers how to breast-feed and how to maintain lactation even if they should be separated from their infants.
  vi    Give newborn infants no food or drink other than breast milk unless medically indicated., please babies do not need water while breastfeeding exclusively, herbal concoction is not needed, brestmilk is all in all in the right proportions.
  vii   Practice rooming-in (allow mothers and infants to remain together) 24 hr a day.
  viii   Encourage breast-feeding on demand.
  ix   Give no artificial teats or pacifiers (also called dummies or soothers) to breast-feeding infants.
  x    Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.


2. Pain while breastfeeding , this could be a normal finding initially but breast feeding  should soon be itch free, free flowing , if the pain is disturbing lasting more than few hours after delivery,  please prescribe pain killer for these women also encourage them to breastfeed more often during this period, yes the reasons for this pain may inlude
A) Breast engorgement.....  Breast is overfilled, overstretched and painful, mother will need to Breastfeed more often to prevent this very painful challenge, give pain killer if one develops , other treatment modalities include warm compress, warm shower etc
B) Breast abscess.... Please never allow it get to this level, if this develops see a doctor fast. The woman will have pains, fever and may have chills.

C) Sores on the  nipple(s)..this should not be, it is usually due to bad techniques of breastfeeding, the technique is about the most important thing , if the nipples have sores, the treatment is more breastfeeding to avoid engorgement and one can also express the milk and give through cup till the sores heal, the proper techniques must be emphasized. These techniques are usually taught during the antenatal vists and in the post natal ward after delivery (make it a point of duty to learn the proper technique, such that you can help yourself and people around you).
The technique is illustrated below properly.
Babies are designed to breastfeed and every mother is built to provide beast milk but the techniques must be right, everything must come together at the point baby attaches to the breast.
 Get in a comfortable chair with great back support to feed your baby. Using a stool to rest your feet on will help with good posture and prevent you from straining your neck and shoulders.
Use your breastfeeding support pillow if you have one. (And if you don’t, use whatever kind of pillows you can find to help support you and the baby). A good breastfeeding pillow can make a huge difference in getting the baby in a proper position to latch on well.
Make sure your baby is tummy-to-tummy with you at all times.
Make sure you bring your baby to you, and do not try to lean onto the baby. Not only will this cause severe strain on your neck and shoulders, but it can affect the baby’s position.
Remember to keep your baby’s ear, shoulder, and hip in alignment, which will make swallowing easier.
The baby’s nose should be opposite the nipple.
You might need to hold your breast to help guide the nipple to your baby’s mouth. Grasp the breast on the sides, using either a “C” hold or “U” hold. Make sure you keep your fingers far from the nipple so you don’t affect how baby latches on.
Aim the nipple toward the baby’s upper lip/nose, not the middle of the mouth.You might need to rub the nipple across the top lip to get your baby to open his/her mouth.
The baby’s head should be tilted slightly back. You do not want his chin to his chest.
When he opens his mouth wide with the chin dropped and tongue down, he should latch on to the nipple. If he does not open wide, do not try to shove the nipple in and wiggle the mouth open. It is best to move back, tickle the lip again with the nipple and wait for a wide open mouth.
Try to get as much of the lower portion of the areola (the area around the nipple) in the baby’s mouth.
The baby’s chin should indent the lower portion of your breast.
Look to see if the baby’s bottom and top lip are flanged out like fish lips. If they are not, you may use your finger to pull the bottom one down and open up the top one more.
Positioning your baby to feed

There are many different positions that can work while breastfeeding. It is important to find one that is comfortable for both you and your baby. Make sure to utilize the tips in the above list to help ensure your position is correct.
Cross-Cradle Hold:
This position is often the most helpful for moms right after birth and until they get more confident in getting their baby latched on correctly. It feels awkward for many moms at first, but once they see how it allows them to use both their hands more effectively, moms get more comfortable with it.
You will use the arm on the opposite side you will be feeding from to hold and support your baby, while you use the hand on the side you are feeding from to support your breast.
Lay your baby next to you, tummy-to-tummy, with your opposite hand supporting the back of his head. You want to make sure you are holding at the neck, so you are just guiding the head. You will use the other hand (on the same side the baby is feeding from) to hold and navigate your breast and nipple. Once the baby is securely latched on, you can move your arms to the cradle hold.
Numerous other methods exist, check and learn.

3.Lastly for today, is a 3rd challenge
 Breast leakage: innocuous, the milk overflows , stain wears and can be smelly, More hygiene needed, it resolves on its own.

The myth are numerous and challenges enormous the scope of today's blog can not exhaust them all. We shall revisit some other ones later .
 Here I rest my case for this week, help mothers breastfeed, give the needed support.




Leave your comments , questions and suggestions in the box below.

Febrile convulsion : Prevention and care

Scary as it goes, convulsion or fits (seizure) is the commonest scary experience for mother to witness a child have, they chant all sorts of names. Jesus, Jehovah, doctor, Yepa, Oh! Ha! Just to mention a few.

I have witnessed them pee themselves but that is fine. What bothers me and affect these children more than the convulsion are the wrong interventions  and the insults we inflict on them during this process.

This brings us to today's blog tittle.

"Care and Prevention of Febrile Convulsion in Children"

What is Febrile convulsion?

It is a convulsion (fit) or seizure in children when they are having fever, occurs usually in children between the age 6 months  and  60 months (5yrs).

Convulsion may be characterized (but not restricted to) by abnormal movement of any part of the body usually jerking, pedaling, abnormal blinking of the eyes, upward rolling of the eyes, stiffening of the body, etc.
It is quite a common place in children.

Fever is defined as elevated body temperature, subjectively and rather unreliably checked by placing the back of the palm on the forehead in this part of the world.

The reliable method is by using a thermometer, a specimen is shown below.

Off mode

Default value when switched on.

Reading after measurement

Temperature greater than  37.5 Celsius measured from the armpit (there are other places one can check) is referred to as fever.


What are the causes?

The causes are mostly from infections, that may affect any part of the body except the brain. These include but not limited to :

Malaria
Catarrh and cough (flu, pneumonia)
Infection in the throat (tonsillitis and pharyngitis)
Infection in the passage for urine (urinary tract infections)
Infection in the ear (Otitis)
Like I said, infection anywhere in the body except the brain may be a cause . If the infection is in the brain, the outcome is worse and the associated fit is not called febrile convulsion.

What to do during a febrile illness to avoid febrile convulsion?

1. Have a thermometer to measure your children temperature. This can be done by anybody and everybody.A digital thermometer displays the temperature of the body on its screen.

Switch on the thermometer and simply put in the ampit for 2 minutes or till it alarms, Check the number displayed thereafter,If lesser than 37.5 Celcius, no problem, Values greater than 38 Celsius are particularly disturbing and requires care that may include

a) Complete exposure of the child
b) Fanning
c) Bathing with lukewarm water
d) Toweling with wet napkins (wet with warm water)
e) Administration of Paracetamol (only if the above methods fail and temperature is greater than 38 Celsius).
   Paracetamol should not be used routinely in any child to prevent fever (it damages the liver and the kidney if used excessively).
Such child should at least be reviewed by a family physician or a paediatrician(babies doctor)

What to do during convulsion

Convulsion for one minute is like eternity to an helpless mother, so any form of intervention will do. Anything done to stop the convulsion is usually welcomed and appreciated though most of these interventions are needless and harmful as we shall soon see , the following are recommended steps of interventions

1. Remove all clothing and allow proper ventilation

2. Put to lie on the left side

3.Follow steps a to e of prevention written above

4. If available, insert a rectal diazepam. This is a gel that can be placed in the body through the anus and hastens abating the seizure

4. It is also Paramount to see a doctor (babies doctor)

May I quickly add that febrile convulsion usually does not leave a child damaged, There is no long term outcome. It is our wrong interventions during this period that damage these children.

What not to do.

1. Do not pee on the child. This is rather a common practice. Please, do not do it. The  danger is the child run a greater risk of aspirating the urine(breathing in urine) and suffer lung infections and may even die from choking.

2. Do not give COW Urine,sounds funny or you say barbaric, people do it, and it is a very common practise.
The first problem here is cow urine, the second is that it is used alongside onion and garlic making a concoction that potentially lowers the blood sugar making the child to have more convulsions and subsequently suffer permanent brain damage.

3. Do not put their leg(s) in fire, Yes, people do it,in the last one month, I have seen a couple of cases.

The fact here is that fire can only worsen convulsion, It does not stop it,the child is then left with a damaged foot, prolonged hospital stay, more psychological effect the extent of which can not be quantified.

4. Do not insert spoon, or anything in their mouth while convulsing,  you may remove their teeth , injure the mouth structures and the child may choke.

5. Don't give anything by mouth while a patient is convulsing or sleeping after convulsion, It is dangerous.

Most of the above interventions are instituted by Neighbours, grandparent, friends etc but not by the mother who is at the time of event practically " brain dead".
This is a case where doing nothing ( if u do not know what to do )is far better than doing useless stuff.

Please share this information , it will definitely help some poor children somewhere.

Leave your comments , suggestions , additions and questions in the comment box below.

MCQ2/8/17

1 . A 5yr old girl  referred to you on account of Vaginal bleeding noticed following development of breast about 4month prior, she deny use of oestrogen containing creams, she has genus vagum and an irregular sharp edged rash on the the trunk , her pulse rate is fast and bounding.
The following conclusions are likely to be true of this condition

A). The average age of affectation in girls is 3yrs
B). In patients with associated cushing syndrome the      ACTH level is low
C). Clinical hyperthyroidism is uncommon in this condition
D). Phosphaturia is the commonest extra glandular manifestation
E). A missense mutation occured in this patient.

2.Growth hormone is indicated in the following conditions
A) Turner syndrome
B)Prader Willis syndrome
C)End stage renal disease
D)Growth hormone deficiency
E) intra uterine growth restriction

3. The mother of a new born(1hr old) has called your attention to teeth in her baby's mouth , she knows this is unusual and wants an explanation, some of the valid points  you told her include

A) This is an abnormal condition and the teeth as a rule must be extracted.
B) her child's condition is called neonatal teeth
C) cleft palate must be ruled out
D). Usually occur on the mandible
E) attachment of the teeth is deep rooted

4. A 6mo old boy seen at the out patient department with nasal discharge of few days to which the care giver procured decongestant from OTC, the attending resident noticed the heart rate to be 210bpm despite normal Temperature and respiratory rate , child is otherwise normal , you are invited to review and corroborate the above findings

A) This condition is likely not to need treatment.
B). This condition may rapidly progressed to heart failure
C) The over the counter decongestant may have a role in development of this condition
D)deep intranasal suctioning may reduce the heart rate
E) Digitization may be needed.

5.The result below was obtained from a 4yr old boy with Loss of consciousness.
Sodium ion:152mmol/l
Potassium ion : 3.8mmol/l
Random blood sugar,: 162mg%
BUN: 6mmol/l
Bicarbonate : 17mmol/l
Chloride ion :118mmol/l
The following conclusion is/are true

A) he has metabolic acidosis
B)plasma osmolality is 425Mosmol/l
C.) The anion gap is normal
D) Has renal tubular acidosis
E).May have diabetes insipidus