DEMOGRAPHIC PROFILE

NAME: XY

ADDRESS: Turod Sur Cordon Isabela

GENDER: Male

AGE: 82

WEIGHT: 65kg

STATUS: Widowed

BIRTHDAY: January 5, 1929

NATIONALITY: Filipino

DATE OF ADMISSION: January 22, 2011

TIME OF ADMISSION: 23:15

ADMITTING DIOAGNOSIS: Hypertension, Diabetes Mellitus

Type II, Diabetic Nephropathy Secondary to End-Stage Renal

Disease

Attending Physician: XO
COURSE IN THE WARD

DATE/TIME/SHIFT DOCTOR’S ORDER SIGNIFICANCE

11/22/11 Please admit to ROC and For further management and care. Consent serve as an
BP: 200/100 secure consent for agreement that patient is willing to undergo such therapies
RBS: 195 admission offered by the hospital
TPR q shift BP q 1 till For comparative baseline data
stable then q 4
Diabetic diet Recommended diet for diabetic patients with high glycemic
index. Diets include high fiber, low carbohydrates and fats
IVF: PNSS IL x KVO The only Isotonic and non-glycemic solution
Lab: CBC, RBS, For quantitative exploratory procedure and supportive diagnosis
Creatinine, U/A, Serum
Electrolytes
Meds: Alpha Adrenergic Agonist indicated for Hypertensive patient
Clonidine 75 mg 1tab SL
NOW
Lantus 10 “U” SC OD Long-Acting Insulin in controlling blood sugar for full 24h
I&O q shift, weight q AM Comparative baseline data in determining the function of kidney
daily to excrete nitrogenous waste moreover it is also serve as data in
assessing fluid overload
Save Left Arm To prevent damage to fistula
11/23/11 Norvasc 10mg OD Calcium channel blocker acts by relaxing cardiac muscle by
BP: 180/100 inhibiting calcium influx
HGT before meals For comparative baseline data in monitoring episodes of
hyperglycemia
CaCO3 500mg TID Calcium supplement in treating severe hypocalcemia
IVF TF: PNSS x SR The only Isotonic and non-glycemic solution

CLINICAL DIAGNOSTIC RESULTS

CBC RESULTS: DATE: 1/22/11

PARAMETERS QUANTITATIVE RESULT IMPRESSIONS
VALUE
WBC 5-10 x109/L 18.6 Associated with infection U/A shows presence of pus
RBC 4-5 x 1012/L 2.13 Anemia associated with malerythropoietin synthesis
secondary to hemolytic uremic syndrome (HUS)
HGB 110-180g/dl 98 A deficient RBC synthesis predisposes inadequate O2
binding to RBC for transport to collateral circulation
HCT 27-54% 36.5 Normal
PLT 150-400 x109/L 126 Associated with uremia induced platelet dysfunction
secondary to hemolytic uremic syndrome (HUS)

CHEMISTRY RESULTS: DATE: 1/22/11

PARAMETERS QUANTITATIVE RESULT IMPRESSIONS
VALUE
RBS 68 - 128 mg/dL 195 Associated with mal catabolic glucose pathway due
to insulin resistant to cell receptor site secondary to
DMT2
CREATININE 53-115 mmol/L 437 Associated with protein pathway metabolism by the
myocytes resulting to formation of creatinine
metabolites due to inadequate glucose pathway
metabolism, moreover it also reflects on the GFR in
the kidney hence there is a direct relationship
between creatinine level and GFR.
ELECTROLYTES RESULTS:
PARAMETERS QUANTITATIVE RESULT IMPRESSIONS
VALUE
SODIUM 135-145mmol/L 167 A decrease tissue perfusion due to damage to the kidneys
will result to activation of RAAS allowing reabsorption of
Na++ in the distal tubule
POTASSIUM 3.6-5.5mmol/L 2.7 Associated with drug induce antidiuretic medication
CALCIUM 1.05-1.30mmol/L 0.7 Associated with the inability of kidney to activate Vit D for
the absorption of Ca++ on the GI system, moreover there is
an inverse relationship between Phosphate and Ca++ level
CHLORIDE 96-106mmol/L 98 Normal

I&O
11/23/11
TOTAL INPUT 24HRS TOTAL OUTPUT 24HRS WEIGHT
1540 1150 65.3kg
11/24/11
TOTAL INPUT 8HRS TOTAL OUTPUT 8HRS WEIGHT
420 260 65.8kg

URINALYSIS RESULTS
PARAMETERS QUANTITATIVE RESULT IMPRESSIONS
VALUE
COLOR AMBER YELLOW DARK Associated with amorphous crystals and pus precipitation
BROWN causing changes in color
CONSISTENCY CLEAR TURBID Associated with amorphous crystals and pus precipitation
resulting to sedimentation
PH 4.5-8 8.0 Alkalinic urine, risk for candida infection
SPECIFIC GRAV. 1.015-1.025 1.010 Suggested for renal failure and fluid retention
PROTEIN - +++ Associated with damage to the glumerulus allowing large
molecules to pass through the filtration
GLUCOSE - ++ Associated with damage to the glumerulus allowing large
molecules to pass through the filtration secondary to osmotic
diuretic effect due to hyperglycemia
RBC - TNTC Indicates damage to the surrounding tissues of the glumerulus
most especially in the present of dysmorphic RBC in urine
PUS CELLS - 5-6 Associated with
EPITHELIAL C. - - Normal
MUCUS - Rare Normal
THREADS
BACTERIA - - Normal
CRYSTALS - Amorpho Alkalinic urine induces crystal formation. Moreover due to
us alkalinity of the urine GU tract are prone for infection a
phosphat medium for bacterial and yeast formation
e crystals

Candida
Introduction
 Diabetes Mellitus Type II/NIDDM/Adult-onset Diabetes
 Metabolic disorder characterized by insulin resistance, relative insulin deficiency and hyperglycemia associated
with microvascular, macrovascular and neuropathic complications.
 Prevented with proper exercise and diet high in fiber and low fat intake and sugar.
Causes/Predisposing and Risk Factors
 Sedentary lifestyle
 Obesity
 Exotoxins: bisphenol-A
 Medical Condition (HPN, Cushings, Thyrotoxicosis, Pheochromocytoma)
 High cholesterol and TG level, low HDL in relation to high LDL.
 Long term Glucocorticoid therapy
 Genetics: 1ST degree relatives
 Race: Hispanic, African American, Asia-Pacific Islanders
 Gender: Male>Female
 Age: Young 40
 BMI of more than 25
 Waist of 40 inches in men and 35 inches in women
 Fatty liver atherosclerosis related

Anatomy of the Pancreas

 Pancreas is a gland organ in the digestive and endocrine system. It is both and endocrine (hormones directly on
the bloodstream) and exocrine gland (directly into the external environment) made up of approximately million of
clustered cell called islets of Langerhans.
 Location: lies transversely across the posterior wall of the abdomen, at the back of the epigastric and left
hypochondriac region.
 Size: length varies from 12.5-15cm
 Weight: 60-100 grams.
 Functions:
 As to endocrine function it secretes the following by the cells:
alpha glucagon, beta insulin and gama somatostatin (regulatory function), PP pancreatic polypeptides
 As to exocrine function it secretes pancreatic enzymes passing the small intestine for further metabolism.
Sign and Symptoms
Diagnosis Criteria of Diabetes Mellitus Type II According to American Diabetes Association (ADA)
 Classical symptoms of polyphagia, polydipsia, polyuria and weight loss.
 Random Plasma Glucose: >200mg/dl
 Fasting Plasma Sugar: > 126mg/dl (no caloric intake for 8 hours)
  Two hour post glucose load (75mg) plasma glucose >200mg/dl and confirmed by repeat test

Clinical Laboratory Examination

 Glycosylated Hemoglobin (HbA1c)
A form of hemoglobin used primarily to identify the average plasma glucose concentration over a prolonged
periods of time. This reflects on the normal 120-day life span of the red blood corpuscle.
ADA: > 6.5%
 Random Plasma Glucose: >200mg/dl
 Fasting Plasma Sugar: > 126mg/dl (no caloric intake for 8 hours)
 Two hour post glucose load (75mg) plasma glucose >200mg/dl and confirmed by repeat test
 Urine Microalbumin Level
24hour urine collection (>30mg/dl)
 C- Peptide
Serve as marker for insulin secretion. In a standard meal absence of C-Peptide in response to CHO ingestion
indicates beta cell failure
 Self Monitoring Of Blood Glucose (SMBG)
Normal range of 70-120mg/dl pre meal and under 140mg/dl 2hour post meal.
 Oral Glucose Tolerance Test
3days before the test the person should have eaten a diet high in CHO (200-300g/day). Fast for 8-12hours a day
before the exam, and receives 75g of glucose (100g for pregnant).
 Normal: 2hour glucose level is less than 140mg/dl and all values between 0 and 2hours are less than 200mg/dl.
 Impaired glucose tolerance: FPG >126mg/dl and a 2hour glucose level is between 140-199mg/dl.
 Diabetes: When two diagnostic test done on different days show that the blood glucose is high.
 Gestational Diabetes: FPG: >95mg/dl, 1hour glucose level of more than 180mg/dl, a 2hour glucose level more
than 155mg/dl, or a 3hour glucose level of more than 140mg/dl

Introduction
Chronic renal failure also known as End-stage renal disease is a progressive loss in renal function over a period of months
or years.

Stages
Stage I: slightly Diminish Function: Kidney damage with normal or relative high GFR >90mL/min/1.73m2
Stage II: Mild Reduction in GFR 60-89mL/min1.73m2 with kidney damage
Stage III: Moderate reduction in GFR 30-59 mL/min1.73m2
Stage IV: Severe reduction in GFR <15-29mL/min1.73m2. Preparation for renal replacement therapy
Stage V: Established kidney failure GFR<15mL/min1.73m2. Permanent renal replacement therapy

Causes/Predisposing and Risk Factors

 DM
 Chronic upper urinary tract infection
 Chronic hydronephrosis
 Kidney disease - obviously ESRD starts as early kidney disease.
 Diabetic nephropathy - 43.2% (NIDDK) of kidney failure is due to diabetes; most common cause; 35.9% of cases
(NHWIC).
 Chronic kidney failure - ESRD is by definition the last state of chronic kidney failure
 Hypertension - 23% of cases (NIDDK); 28.8% cases (NWHIC)
 Glomerulonephritis - 12.3% of cases (NIDDK); 11.4% cases (NWHIC)
 Polycystic kidney disease - 2.9% of cases (NIDDK, NWHIC)
Anatomy of the Kidney

The kideys are organs with several functions. They are an essential part of the urinary system and also serve homeostatic
functions such as the regulation of electrolytes, maintenance of acid-base balance, and regulation of blood pressure. They
serve the body as a natural filter of the blood, and remove wastes which are diverted to the urinary bladder. In producing
urine, the kidneys excrete wastes such as urea and ammonium; the kidneys also are responsible for the reabsorption of
water, glucose, and amino acids. The kidneys also produce hormones including calcitriol, renin, and erythropoietin.

Blood supply

The kidneys receive blood from the renal arteries, left and right, which branch directly from the abdominal aorta. Despite
their relatively small size, the kidneys receive approximately 20% of the cardiac output.

Each renal artery branches into segmental arteries, dividing further into interlobar arteries which penetrate the renal
capsule and extend through the renal columns between the renal pyramids. The interlobar arteries then supply blood to the
arcuate arteries that run through the boundary of the cortex and the medulla. Each arcuate artery supplies several
interlobular arteries that feed into the afferent arterioles that supply the glomeruli.

Functions

Excretion of wastes

The kidneys excrete a variety of waste products produced by metabolism. These include the nitrogenous wastes urea,
from protein catabolism, and uric acid, from nucleic acid metabolism.

Acid-base homeostasis

Two organ systems, the kidneys and lungs, maintain acid-base homeostasis, which is the maintenance of pH around a
relatively stable value. The kidneys contribute to acid-base homeostasis by regulating bicarbonate (HCO3-) concentration.
The kidneys have two important roles in the maintaining of the acid-base balance: to reabsorb bicarbonate from and to
excrete hydrogen ions into urine
Osmolality regulation

Any significant rise in plasma osmolality is detected by the hypothalamus, which communicates directly with the
posterior pituitary gland. An increase in osmolality causes the gland to secrete antidiuretic hormone (ADH), resulting in
water reabsorption by the kidney and an increase in urine concentration. The two factors work together to return the
plasma osmolality to its normal levels.

ADH binds to principal cells in the collecting duct that translocate aquaporins to the membrane allowing water to leave
the normally impermeable membrane and be reabsorbed into the body by the vasa recta, thus increasing the plasma
volume of the body.

Blood pressure regulation

When the extracellular fluid compartment is expanded and blood pressure is high, the delivery of these ions is increased
and renin secretion is decreased. Similarly, when the extracellular fluid compartment is contracted and blood pressure is
low, sodium and chloride delivery is decreased and renin secretion is increased in response.

Hormone secretion

The kidneys secrete a variety of hormones, including erythropoietin, and the enzyme renin. Erythropoietin is released in
response to hypoxia (low levels of oxygen at tissue level) in the renal circulation. It stimulates erythropoiesis (production
of red blood cells) in the bone marrow. Calcitriol, the activated form of vitamin D, promotes intestinal absorption of
calcium and the renal reabsorption of phosphate. Part of the renin-angiotensin-aldosterone system, renin is an enzyme
involved in the regulation of aldosterone levels.

Nephron

Nephron is the basic structural and functional unit of the kidney. Its chief function is to regulate the concentration of
water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as
urine. A nephron eliminates wastes from the body, regulates blood volume and blood pressure, controls levels of
electrolytes and metabolites, and regulates blood pH. Its functions are vital to life and are regulated by the endocrine
system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.[1] In humans, a normal kidney
contains 800,000 to 1.5 million nephrons.[2]

Anatomy
Renal corpuscle

Composed of a glomerulus and the Bowman's capsule, the renal corpuscle (or Malpighian corpuscle) is the beginning of
the nephron. It is the nephron's initial filtering component.

The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole of the renal circulation. The
glomerular blood pressure provides the driving force for water and solutes to be filtered out of the blood and into the
space made by Bowman's capsule. The remainder of the blood (only approximately 1/5 of all plasma passing through the
kidney is filtered through the glomerular wall into the Bowman's capsule) passes into the narrower efferent arteriole. It
then moves into the vasa recta, which are collecting capillaries intertwined with the convoluted tubules through the
interstitial space, in which the reabsorbed substances will also enter. This then combines with efferent venules from other
nephrons into the renal vein, and rejoins the main bloodstream.

The Bowman's capsule, also called the glomerular capsule, surrounds the glomerulus. It is composed of a visceral inner
layer formed by specialized cells called podocytes, and a parietal outer layer composed of a single layer of flat cells called
simple squamous epithelium. Fluids from blood in the glomerulus are filtered through the visceral layer of podocytes, and
the resulting glomerular filtrate is further processed along the nephron to form urine.

Renal tubule

The renal tubule is the portion of the nephron containing the tubular fluid filtered through the glomerulus.[4] After passing
through the renal tubule, the filtrate continues to the collecting duct system, which is not part of the nephron.

The proximal tubule as a part of the nephron can be divided into an initial convoluted portion and a following straight
(descending) portion.[5] Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the peritubular
capillaries, including approximately two-thirds of the filtered salt and water and all filtered organic solutes (primarily
glucose and amino acids).

The loop of Henle, also called the nephron loop, is a U-shaped tube that extends from the proximal tubule. It consists of a
descending limb and ascending limb. It begins in the cortex, receiving filtrate from the proximal straight tubule, extends
into the medulla as the descending limb, and then returns to the cortex as the ascending limb to empty into the distal
convoluted tubule. The primary role of the loop of Henle is to concentrate the salt in the interstitium, the tissue
surrounding the loop.

Considerable differences distinguish the descending and ascending limbs of the loop of Henle. The descending limb is
permeable to water and noticeably less impermeable to salt, and thus only indirectly contributes to the concentration of
the interstitium. As the filtrate descends deeper into the hypertonic interstitium of the renal medulla, water flows freely
out of the descending limb by osmosis until the tonicity of the filtrate and interstitium equilibrate. Longer descending
limbs allow more time for water to flow out of the filtrate, so longer limbs make the filtrate more hypertonic than shorter
limbs.

Unlike the descending limb, the ascending limb of Henle's loop is impermeable to water, a critical feature of the
countercurrent exchange mechanism employed by the loop. The ascending limb actively pumps sodium out of the filtrate,
generating the hypertonic interstitium that drives countercurrent exchange. In passing through the ascending limb, the
filtrate grows hypotonic since it has lost much of its sodium content. This hypotonic filtrate is passed to the distal
convoluted tubule in the renal cortex.

The distal convoluted tubule has a different structure and function to that of the proximal convoluted tubule. Cells lining
the tubule have numerous mitochondria to produce enough energy (ATP) for active transport to take place. Much of the
ion transport taking place in the distal convoluted tubule is regulated by the endocrine system. In the presence of
parathyroid hormone, the distal convoluted tubule reabsorbs more calcium and excretes more phosphate. When
aldosterone is present, more sodium is reabsorbed and more potassium excreted. Atrial natriuretic peptide causes the
distal convoluted tubule to excrete more sodium. In addition, the tubule also secernates hydrogen and ammonium to
regulate pH.
After traveling the length of the distal convoluted tubule, only about 1% of water remains, and the remaining
salt content is negligible.

Collecting duct system

Each distal convoluted tubule delivers its filtrate to a system of collecting ducts, the first segment of which is the
collecting tubule. The collecting duct system begins in the renal cortex and extends deep into the medulla. As the urine
travels down the collecting duct system, it passes by the medullary interstitium which has a high sodium concentration as
a result of the loop of Henle's countercurrent multiplier system.

Though the collecting duct is normally impermeable to water, it becomes permeable in the presence of antidiuretic
hormone (ADH). ADH affects the function of aquaporins, resulting in the reabsorption of water molecules as it passes
through the collecting duct. Aquaporins are membrane proteins that selectively conduct water molecules while preventing
the passage of ions and other solutes. As much as three-fourths of the water from urine can be reabsorbed as it leaves the
collecting duct by osmosis. Thus the levels of ADH determine whether urine will be concentrated or diluted. An increase
in ADH is an indication of dehydration, while water sufficiency results in low ADH allowing for diluted urine.

Lower portions of the collecting organ are also permeable to urea, allowing some of it to enter the medulla of the kidney,
thus maintaining its high concentration (which is very important for the nephron).

Urine leaves the medullary collecting ducts through the renal papillae, emptying into the renal calyces, the renal pelvis,
and finally into the urinary bladder via the ureter.

Because it has a different origin during the development of the urinary and reproductive organs than the rest of the
nephron, the collecting duct is sometimes not considered a part of the nephron. Instead of originating from the
metanephrogenic blastema, the collecting duct originates from the ureteric bud.

Sign and Symptoms

Systemic sign: malaise, weakness and fatigue
Gastrointestinal signs: anorexia, nausea, vomiting, GI bleeding
Neurological signs: peripheral neuropathy, seizure, restless leg syndrome
Hematologic signs: anemia, abnormalities in wbc, platelet
Dermatologic signs: pruritus
Metabolic/Endocrine signs: hyperkalemia, hypocalcemia, hypermagnesemia, estrogen, testosterone, LH abnormalities
Cardiac signs: hypertension, pericarditis
Vascular signs: local Or DIC, vessel occlusion

Clinical Laboratory Examination

 Serum electrolytes
 BUN
 Creatinine
 Total creatinine phosphokinase
PAST MEDICAL HISTORY
As told by his daughter, he was hospitalized thrice at Callang General Hospital. It was then on the month of June last year
when he was rushed to the hospital due to difficulty of breathing and was diagnosed with kidney failure under the service
of his private physician and suggested to undergo dialysis. Several months later, on the month of August again
hospitalized for the second time with same symptoms but more seriously worse accompanied by blood tinged when
coughing. He had completed his vaccination when he was a child and no allergies have been reported from the patient. He
is also taking maintenance drug at home for his hypertension, antacids and diuretic medications. Moreover he also has
blood glucose monitoring at home and do self administration of Lantus insulin.

PRESENT MEDICAL HISTORY

At present on January 24,2011 he was admitted for the third time to continue his dialysis and monitor his condition
closely while on hospitalization. As told by his daughter his father is undergoing dialysis for almost 9mos, 4 times a
month.

FAMILY HISTORY OF ILLNESSES

As told by his daughter his wife died 14 years ago due to uncontrolled hypertension, making him widowed early.
Moreover one of his brothers also has heart disease when he was a child while his second son is also diabetic as well. No
other history has been reported on both parties of their paternal and maternal side.

HEALTH PERCAPTION AND MANAGEMENT PATTERN

Health conditions in the family is their core and important in their lives. Since their children are supportive, they prefer to
go on a nearest hospital for check-up. Whenever symptoms occur he used to take medications as prescribed by his
physician. They are not known to use neither herbal medication nor believe in “albularios” and goes to RHU for clinic
consultation.

ACTIVITY AND EXERCISE PATTERN

He is known to e a retired army during his service those times. When he was diagnosed last year he was encouraged by
his private physician to limit heavy and strenuous activities due to his condition. During his hospitalization he was
encouraged to have a bed rest with proper assistance and support by his relatives in doing his ADLs.

SLEEP AND REST PATTERN

Patient often sleeps 3 hours only and sometimes 4 hours at night. According to his daughter being unable to sleep and feel
exhausted at night making him asleep during days and afternoon. During hospitalization he is pretty much comfortable on
sleeping, with a greater rest period at night all day long and wakes up at 6 in the morning to assist him in doing ADLs.

NUTRITION AND METABOLIC PATTERN

PTA, he eats 1cup of rice and eats on a regular meals a day and drinks water less than a liter of it. Prior when he was
diagnosed he is fond of eating fatty and grilled foods and likewise drinking alcohol whenever there are special occasions.
But as of now he was advised by his private physician to cut off those habits. During hospitalization he is on diabetic diet
as ordered and eats his meal on a regular basis and consumes almost a liter of water a day.

ELIMINATION PATTERN
PTA patient urinates 2-3 times a day except when taking diuretics. He is also taking Dulcolacs suppository. As told by his
daughter sometimes due to irregularities on elimination it takes 2-3 days to have his complete gastric emptying. During
hospitalization still he is taking diuretic drug in precaution and dulcolacs suppository to support gastric emptying.

ROLE RELATIONSHIP PATTERN

According to his daughter he is the oldest among the 9 children. A retired army and very supportive father to his children,
moreover he is also a religious person as well.
ENVIRONMENTAL PATTERN AND RELIGIOUS PATTERN
As told by his sister they live at Turod Sur Cordon Isabela on a nearby farmland with many trees grown. Their house is
made up of wood and steel which accommodate their family. Water source came from their private faucet. They have also
a little garden of citrus fruits and vegetables on the backyard. Patient is known Independiente as to religion, a religious
father as told by his sister.