Case # 1

Case # 1

Patient Profile

• N.F. is a 55 year-old Filipino female, married housewife, Roman Catholic, from Makati City

• Admitted last December 3, 2011

Patient Profile• Land lady and owns general merchandise

w/c is the family’s primary source of income• Lives in a bungalow (mixed concrete and

wood), located along the road, with 5 occupants, 3 rooms, 1 CR, w/ electricity, MAYNILAD as source of water, garbage collected everyday

• Sleeping habit– sleeps from 10PM-6AM and 12NN- 3PM

• Food preference:– Rice, vegetables and fish

• Water intake >1L/day• Urine 4-5x/day, around 2.5L/day?• Exercise:– Walking 1 block

Chief Complaint

• Body weakness of 1 week duration

History of Present Illness

• 9 days prior to admission (+) fever (38°), relieved by Bioflu

• 8 days prior to admission(+) body weakness described as feeling of

fatigue, advised bed rest by her daughter, avoided her usual activities

History of Present Illness

• 6 days prior to admission(+) decrease appetite, from the usual 1 cup of

rice/meal 3x a day + snacks in between to 2-3 glasses of milk + 2-3 pieces of crackers + 1 glass water

History of Present Illness

• 2 days prior to admissionPersistence of weakness & decreased appetite +

vague epigastric pain (feeling of hunger) , 5-6/10, on PS, prompted consult at a private physician

Given Omeprazole, Mefenamic Acid and Iselpin w/c relieved epigastric pain

Advised to drink Ensure but did not complySeries of laboratory examinations done

History of Present Illness

• Day of admissionFollow-up consult for laboratory results

showed elevated BUN, Creatinine, FBS, total cholesterol, triglycerides, HDL, LDL, SGPT, uric acid, K, and WBC?

(+) bipedal edema noted by the physicianAdvised admission

Temporal Profile

10 9 8 7 6 5 4 3 2 1 0

FeverGeneralized body weaknessAppetiteEpigastric pain

PTA (Days)

Inte

nsity

of s

ympt

om

Past Medical History• (+) UTI – 1997, treated for 1 month, became recurrent though no

laboratories done to support the impression (frequency?), self medicated with Bactrim 1-2 doses per episode

• Diagnosed with Hypertension (2005)– Losartan 50mg OD– Poor compliance– BP: 130-140/80-90

• Diagnosed with Diabetes Mellitus Type 2 (2005)– Gliclazide 80mg BID– Good compliance

• Use of Herbal supplements– Taheebo for 6 months (2005)

• (-) hx of nephrolithiasis, chronic use of NSAIDS?

Family History

• Hypertension• Diabetes Mellitus – both sides

Social History

• Non-smoker• Non-alcoholic drinker

Review of Systems

• (-) fever, dizziness, nausea/vomiting, decreased sensorium

• (-) cough/colds• (-) changes in BM• (-) flank pain, LUTS

Admitting Physical Examination

• Vital Signs– BP = 140/80– HR = 93– RR = 17– Temperature = 36.4

• Head and Neck– Dirty sclerae– Pink palpebral conjunctivae

Admitting Physical Examination

– No cervical lymphadenopathies– No tonsillo-pharyngeal congestion

• Chest and Lungs– Symmetric chest expansion– Clear breath sounds– No retractions

Admitting Physical Examination

• Heart– Adynamic precordium– Distinct S1 and S2– Normal rate– Regular rhythm– No murmur

• Abdomen– Flabby abdomen

Admitting Physical Examination

– Soft– Non-tender upon palpation

• Extremities– Full and equal pulses– Bipedal edema– No cyanosis

DiagnosticspH PCO2 PO2 HCO3 BE O2 sat Total

Co2

7.33 25 86 13.40 -12.70 96.00 14.20

CBCCBC 12/4/2011

Hemoglobin 102

Hematocrit 29

RBC 3.7

WBC 15.2

Neutrophils 94

Stabs

Lymphocytes 5

Monocytes 1

Eosinophils

Basophils

Platelet 681

CBCCBC 12/10/2011

Hemoglobin 96

Hematocrit 28

RBC 3.4

WBC 10.9

Neutrophils 67

Stabs

Lymphocytes 28

Monocytes

Eosinophils 4

Basophils 1

Platelet Slightly increased

Urinalysis 12/4/2011

Color yellow

Turbidity cloudy

Reaction acidic

Specific Gravity 1.015

Protein negative

Sugar trace

RBC 3-5/hpf

WBC many

Casts none

Bacteria few

Epithelial Cells none

Mucus Threads none

Crystals none

Yeast Cells none

12/4/2011

HbA1c 12.5

12/4/2011

BUN 15.4

Creatinine 761

Sodium 129

Potassium 5.7

Chloride 99

12/4/2011

Urine Culture Negative after 48 hours

12/5/2011Creatinine 718

Sodium 132

Potassium 5.7

12/5/2011Random Urine TP/Creatinine Ratio

0.51

12/10/2011

Creatinine 633

Uric Acid 418

12/8/2011

Creatinine 679

Sodium 134

Potassium 4.7

12/6/2011

Creatinine 565

Uric Acid 416

Sodium 136

Potassium 4.3

Calcium 1.6

Phosphorous 1.7

12/4/11 Impression:

ECG Sinus Tachycardia

12/4/11 Impression:

KUB Ultrasound Enalrged right kidney. Early changes of nephritis is considered.Normal left kidney and urinary bladder.