Case Presentation

Case Presentation

Maria Febi C. BillonesJanuary 13, 2010

General Data

• R.Q.• 61 y/o• Female• Married• Bicutan

Chief Complaint

• Dyspnea

Patient Profile

• Known diabetic x 15 years

• Initially presented with 3 P’s & weight loss

• Prescribed with Glibenclamide 5mg BID

however with poor compliance

Patient Profile

• Known hypertensive x 5 years

• HBP 150/100

• UBP 120/90

• No medications taken

History of Present Illness

• 1 year PTC patient noticed easy fatigability

usually after simple household chores associated

with dyspnea on exertion

• She also experienced occasional chest heaviness

lasting almost the whole day aggravated by work

and relieved temporarily by rest

History of Present Illness

• 3 months PTC noted worsening of symptoms

hence had herself an ECG and Chest Xray in a

nearby laboratory clinic

• However, results revealed “within normal limits”

on ECG and “Atheromatous Aorta” on Xray hence

decided not to seek medical consult

History of Present Illness

• Persistence of dyspnea as well as easy

fatigability prompted consult.

• (-) cough, colds, orthopnea, PND, edema

• (-)

Review of Systems

• (-) weight loss• (-) dizziness• (+) headache, occasional• (+) nape pains, occasional• (-) blurring of vision• (-) nausea• (-) vomiting• (-) abdominal pain• (-) diarrhea• (-) constipation

(+) polyuria (+) polydipsia (+) nocturia (-) oliguria (-) paresthesias (-) fever

Past Medical History

• s/p Total Hysterectomy for multiple myoma,

1978 at UDMC

• s/p breast cyst excision, 1972

• (-) asthma, allergy, PTB

Family Medical History

DiabetesPTBHypertensionSchizophreniaBrain Tumor

Personal Social History

• previous smoker 1-2 sticks/day x 1 yr (1978)• occasional alcoholic beverage drinker• College Graduate, previously worked in a bank• Eventually lost her job and currently on

financial crisis

OB-GYN History

• Nulligravid• Underwent total hysterectomy for multiple

myomas at 28 y/o• Menarche at 16 y/o, monthly regular interval,

5 days duration, moderate amount, (-) dysmenorrhea

PHYSICAL EXAMINATION

Physical Examination

• General Survey– Conscious, coherent, not in respiratory distress

• Vital Signs– BP 150/90– HR 58– RR 22– Temp 37.1

• Wt 70.3kg Ht 161cm BMI 27

Physical Examination

• HEENT– pink conjunctivae, anicteric sclerae, no nasoaural

discharge, no tonsillopharyngeal congestion

• Neck– No anterior neck mass, no cervical

lymphadenopathy, no neck vein engorgement

Physical Examination

• Chest/Lungs– Equal chest expansion, no retractions, clear breath

sounds• Heart– Adynamic precordium, bradycardic, regular rhythm,

distinct heart sounds, apex beat at 5th ICS LMCL, no murmur

• Abdomen– Flabby, (+) incision scar, infraumbilical area,

normoactive bowel sounds, soft, non-tender

Physical Examination

• Extremities– Full and equal pulses, pink nailbeds, no edema, no

cyanosis, no jaundice

• Neuro Exam– Awake, alert, follows commands, oriented– Cranial Nerves• 1 – N/A; 2 – pupils 3mm EBRTL; 3,4,6 – full & equal

EOMs; 5 – brisk corneals; 7 – no facial asymmetry; 8 – intact gross hearing; 9,10 – good gag, 11 – good shoulder shrug, 12 – tongue midline

Physical Examination

• Neuro Exam– MMT – 5/5 all extremities– Sensory – 100% intact– DTRs - ++– Cerebellars: no dysmetria– Meningeals: supple neck, no incontinence

AssessmentAssessment

t/c Chronic Stable Angina Pectoris

DM Type 2, non-insulin requiring, Obese I

t/c DM nephropathy

Hypertension Stage 1, uncontrolled

Plan

• Diagnostic– FBS, BUN, Crea, Na, K, Cl, Ca, Mg– Urinalysis– 12-L ECG

• Therapeutics– Metformin 500mg BID– Losartan 50mg OD

Plan

• Lifestyle Modification– Low salt low fat diet, low protein high fiber diet

• Daily BP monitoring, sugar monitoring• Refer to Ophtha

Diagnostic Dillemma

• Among diabetic patients, what is the

sensitivity and specificity of 24 hr urine

albumin vs urine micral test in early detection

of DM nephropathy?

Diagnostic Dillemma

• P – patients with diabetes

• I –24 hr urine albumin vs urine micral test

• O – in early detection of DM nephropathy

• M – cross sectional studies

Therapeutic Dillemma

Among long term diabetic patients, which is

more effective between ACE-inhibitor and

Angiotensin-receptor blocker in delaying the

progression of diabetic nephropathy?

Therapeutic Dillemma

• P – patients with long term diabetes (>10yrs)• I – ACE inhibitor vs ARB• O – in delaying the progression of diabetic

nephropathy• M – randomized control trial

Thank you...