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...
