Wardwork - Aq

WYLENGCO, Maria Constancia 2001-15366

Name: Antonita Quiñones (AQ) Location: W1 B24 Residence: Bayanan, Muntinlupa Civil Status: Single 2006

Age/Sex: 57/F Religion: Catholic Handedness: Right Date of Admission: (ER) December 6, (Ward) December 7, 2006

HISTORY CC: Facial and bipedal edema, anuria (nagmanas ang mukha at paa, at di maka-ihi) History of Present Illness 17 years PTA The patient was asked to undergo a medical clearance exam (for overseas work approval) and was incidentally found to have Diabetes. Medications prescribed were Diamicron and Glucophage (metformin), which she took irregularly from first administration to November 2006 (There were long intervals wherein the patient did not take her meds). 2 months PTA The patient went to Muntinlupa Medical Center (MMC) for a check-up. She complained of dizziness and cough, as well as to ask about her diabetes. Blood tests, urinalysis, urine culture, skin test and ECG were ordered. Blood sugar levels and cholesterol levels were interpreted to be high. Urinalysis and skin test findings were unrecalled. Results of urine culture pointed to presence of UTI (but the exact organisms were unrecalled). ECG results allegedly revealed a Left-sided enlargement of the heart. The patient’s blood pressure was interpreted as hypertensive. The patient was asked to return several times for continued check-ups and lab exams. 5 days PTA (December 3, 2006) AQ experienced epigastric pain, which she described to have felt like having gas accumulation in her stomach/intestines. This was accompanied by flatulence. She then went to Alabang Medical Clinic, where she was admitted and was confined for a day and a half. Discharge was on December 5, 2006. An X-ray was requested, and results allegedly revealed clear lung fields. An ultrasound was also performed because appendicits was suspected. UTZ findings revealed enlarged kidneys (“maga ang bato”). Urinalysis and blood tests were also done, results of which were unrecalled. An unrecalled medication was prescribed for the enlarged kidneys. 3 days PTA (December 5, 2006) The patient went to PGH-OPD (they decided to change hospitals due to financial restraints). They were asked to return on December 8, 2006 for urine testing. 1 day PTA (December 7, 2006) Bipedal edema, followed by facial edema, were noted. Anuria was also experienced, as well as hypogastric pain and chest tightness. All of these were reported to be of acute onset. Urine character and urination pattern prior to this day were described as: yellow color, but there were instances when the urine was red; nocturia (~3x/night); polyuria, polydipsia. The patient went to the PGH-ER. Blood tests and Xray were done. She stayed in the ER for one day. December 8, 2006 The patient was transferred to Ward 1. Course in the Wards Blood pressure and body temperature were regularly checked. Medications: Ferrous Sulfate and Calcium Carbonate, TID. Clonidine was prescribed to lower her BP. 3rd ward day (December 11, 2006): The patient underwent a dialysis and around 1 liter of fluids was drained. Marked reduction of edema was noted. ROS (+) cough with phlegm, difficulty of breathing, fatigue, chest tightness, nausea, diarrhea (2 days before the interview), difficulty of feeding (3x/day, 1Tbsp), weakness (-) fever, blurring of vision, tinnitus, asthma, allergy, seizure, tics

Past Medical History No other hospitalizations or previous surgeries. Family Medical History (+) TB and Lung Disease (father) (+) Diabetes (mother) and heart disease (-) cancer, kidney disease, stroke, hypertension, asthma Menstrual History The patient had her menopause when she was 45 years old. Menstruation prior to period cessation was described to be heavy. Personal/Social The patient worked as a domestic helper in Lebanon for 20 years. She lives with her siblings and has a good relationship with them. She is the 4th in a family of 6. PHYSICAL EXAM General: The patient is conscious, alert, awake, well developed and fairly nourished, not in cardiorespiratory distress. Vital Signs: BP 150/70 mmHg PR 80 bpm HR 72 bpm RR 30/min Temp: 37.2° C Skin Fair skin, smooth texture, good turgor. (-) jaundice (+) pallor HEENT Face: Symmetrical with appropriate affect; (-) paralysis Eyes: pale conjunctivae; anicteric sclerae; pupils equal, 2mm; (-) direct and consensual reflex; full EOM; (-) ptosis, exophthalmos Ears: (-) discharge, tenderness Nose; (-) alar flaring, septum not deviated; (-) discharge, tenderness Throat: pink buccal mucosa and tongue; lips pale; (-) dryness or lip sores, uvula midline Neck: (-) NVE Chest and Lungs (-) gross chest deformities Decreased breath sounds at both basal lung fields (+) rales (-) wheeze, stridor, adventitious breath sounds Cardiovascular (-) deformities, lifts, heaves PMI not noted Apex beat not appreciated Distinct S1, S2, (-) S3); normal hysiological splitting at 2nd L ICS MCL (-) murmurs, bruits Abdomen Globular, with bloating (-) scars, striae, hernias, lesions, masses Hyperactive bowel sounds (1.5 hrs, post-prandial) Deviated umbilicus (right) Extremities Warm extremities; (-) clubbing, cyanosis; full pulses

Neuro Exam Patient is alert, coherent and oriented to person, time and place. Able to follow commands and responds appropriately to questions. Equal and intact light touch and pain sensation Muscle Strength: 5 PATHOPHYSIOLOGY The proposed pathophysiology of diabetes and associated renal failure in AQ is depicted in the following algorithm.

Diabetes hyperglycemia  NO production ↑ Angiotensin II sensitivity

hyperlipidemia

↑ vascular permeability blood flow abnormalities ↑ blood flow ↑ intracapillary presssure

insulin resistance

hyperfiltration protein leakage (albumin)

 renal blood flow

progressive protein accumulation in vessel walls

endothelial dysfunction

 gfr

hypertension

vessel lumina occlusion oliguria/ anuria

↑ albumin excretion rate

hypoalbuminemia

proteinuria

 plasma oncotic pressure

↑ BUN/ crea metabolic waste products electrolyte imbalance

salt and water retention RAAS ADH SNS  effective circulating volume ascites / edema pulmonary congestion/ edema

DIAGNOSTIC WORKUP 1. Urinalysis- Check for glucosuria, proteinuria, urine sodium and osmolality.

2.

Blood Test-

a.

3.

4.

Glycated Hemoglobin A1 measurements – elevated in patients with chronic DM; to check if glycemic control is responsive to previously ingested anti-glycemic agents b. BUN/Crea c. ABG d. Cholesterol e. Plasma Electrolytes (Abnormalities of plasma sodium, potassium, bicarbonate, calcium, magnesium, and phosphate are common in acute renal failure, and their determination and monitoring are an integral part of the diagnosis and management of renal failure) Lipoprotein abnormalities Renal ultrasound provides an accurate means of measuring renal size (small kidneys are evidence of chronic renal disease)

5. MANAGEMENT PLAN 1. Blood pressure control. Multiple-drug therapy for hypertension include b-blockers, diuretics, and vasodilators, as well as angiotensin-converting enzyme inhibitors, which are used not only in established diabetic nephropathy but also in non-hypertensive patients with microalbuminuria. 2. Monitoring of diabetes control consists of the following. a. HbA1c provides an integrated measure of blood glucose profile over the preceding 2–3 months; it should be obtained approximately every 3 months. b. Self-monitoring of blood glucose is an important tool of diabetes management and is recommended for all patients. c. Urine glucose correlates poorly with blood glucose, is dependent on renal glucose threshold (150–300 mg/dl), and should only be used for monitoring diabetes therapy if self-monitoring of blood glucose is impractical.

d. Ketonuria grossly reflects ketonemia. All DM patients should monitor urine ketones using Ketostix or Acetest tablets during febrile illness or persistent hyperglycemia, or if signs of impending DKA (e.g., nausea, vomiting, abdominal pain) develop. 3. Patient education is integral to successful management of diabetes and its complications. Diabetes education should be reinforced at every opportunity, particularly during hospitalization for diabetes-related complications. 4. Dietary modification. A balanced diet that provides adequate nutrition and maintains a healthy weight is desirable. Caloric restriction is recommended for overweight persons. An allowance of 10–20% of total caloric intake as protein and less than 30% as total fat (less than 10% saturated fat) is appropriate. Patients with diabetic nephropathy usually are allowed a protein intake of 0.8 g/kg/day. With deterioration in renal function, further restriction in protein intake (0.6 g/kg) can be considered in selected patients. Carbohydrate allowance should be individualized based on glycemic control, plasma lipids, and weight goals. 5. Exercise improves insulin sensitivity, reduces fasting and postprandial blood glucose, and offers numerous metabolic, cardiovascular, and psychological benefits in diabetic patients. 6. Medications that are used for treating diabetes include insulin and oral agents. Type 2 DM patients respond initially to oral antidiabetic agents but may require insulin as the disease progresses. Medications for diabetes are most effective if instituted as part of a comprehensive management approach that includes dietary and exercise counseling (Carey, et. al,2001). Carey, CF., KF Woeltje and H Lee. (2001). The Washington manual (30th ed). USA: Lippincott Williams & Wilkins Davison, A.M, et. al. (1998). Oxford Textbook of Clinical Nephrology (2nd edition). New York: Oxford University Press Goldman, L., RL Cecil, and JC Bennett. (1999). Cecil textbook of medicine (21st ed). USA: W.B. Saunders Company. Larsen, P.R. et. al.(2003). Williams textbook of endocrinology (10th ed). Philadelphia: Saunders.