CLINICAL CASE STUDY

PATIENT DATABASE

I. Patient Profile

DEMOGRAPHIC AND ADMINISTRATIVE INFORMATION

Name: L. E. Ward: 3 Bed: 27 Age/Sex: 47/M
Civil Status: Single Date of Admission: March 11, 2013 Weight: -
Occupation: Unemployed Case No: 3388433 Height: -
Religion: Roman Catholic Monitoring Period: MSS Classification: D

SUBJECTIVE
Chief Complaint:
Severe Bipedal edema with thigh and scrotal area involvement
Facial edema and decrease urine output

History of Patient Illness:

1 month prior to admission, there was an increase severity of bipedal edema with thigh and scrotal
involvement. The patient also presented facial edema and decrease urine output.

1 week prior to admission, patient experienced persistence of symptoms and occasional difficulty of
breathing which prompted consult to PGH.

Patient Medical History:

 (+) Hypertension for 10 years

 (+) Diabetes Mellitus for 10 years
 Diagnosed with DM Nephropathy last October 2012
 (+) Pulmonary Tuberculosis (2003) – treated for 6 months
 No known allergies
 Maintenance drugs:
o Atorvastatin 40mg tab OD
o Enalapril 10mg tab OD
o Folic Acid 5mg tab OD
o Ferrous Sulfate 325mg tab BID
o Insulin 70/30
 Poorly compliant

Family Medical History:

(+) Hypertension (Father)

(+) Diabetes Mellitus (Father)

Physical Examination;

General Survey: awake, mild dyspnea

Vital Signs: BP – 140/100 CR – 90 RR – 20 Temperature – afebrile
HEENT: Anicteric sclerae, pale palpebral conjunctivae, (-) Neck Vein Engorgement
Chest/Lungs: Equal chest expansion, Clear breathe sounds
CVS: Adynamic precordium, distinct heart sounds, Normal rate regular rhythm
 Abdomen: slightly globular abdomen
Skin/Extremities: FEP, PNB, (+) edema

PSHx:

(+) smoker (30 pack years)

Heavy alcoholic drinker
No use of illicit drugs

Review of Systems:

(-) fever, headache, dizziness vomiting, chest pain, abdominal pain, dysuria, changes in bowel movement,
weight loss
(+) easy fatigability and pallor

OBJECTIVE

Results
HEMATOLOGY
12 Mar 2013
RBW 15.2
RBC 4 – 6 X 1012 / L 3.11
HgB 120 – 180 g / L 89
HCT 0.37 – 0.54% 0.258
MCV 80 – 100 fL 83.2
MCH 27 – 31 pg 28.5
MCHC 320 – 360 g/L 343
WBC 4 – 11 X 109 /L 9.50
NEUT 50 – 70% 66
LYMP% 20 – 44% 27
MONO% 2 – 9% 4
EOSIN% 0 – 4% 3
BASO% 0 – 2% 0
PLT 150 – 450 X109 /L 283

Results
15 Mar 2013
BLOOD CHEMISTRY 12 Mar 13 Mar
(Random
2013 2013
Sample)
GLUCOSE 3.9 – 6.1 mmol/L 23.39
BUN 2.8 – 6.4 mmol/L 3.8
6.25 mmol/24hr
CREATININE 53 – 115 µmol/L 114
(7.1 – 17.7)
7.06 mmol/24hr
TOTAL PROTEIN 64 – 82 g/L
(0.04 – 0.23)
ALBUMIN 34 – 50 g/L 11
86.48
SODIUM 140 – 148 mmol/L 137 139 mmol/24hr
(40 – 220)
POTASSIUM 3.6 – 5.2 mmol/L 1.7 3.9 29.42mmol/24hr
 (25 – 125)
CALCIUM
0.71 mmol/24hr
IONIZED CA++ 2.2 – 2.62 mmol/L 1.75
(2.5 – 7.5)
(1.1 -1.35)
68.15
CHLORIDE 100 – 108 mmol/L 84 97 mmol/24hr
(110 – 250)
MAGNESIUM 0.74 – 1.0 mmol/L 0.55 0.75
HBSAg +/- (-)
HCV +/- (-)
HBA1C (PLASMA) 4.27 -6.07% 3/14/2013: 11.2

Results
ARTERIAL BLOOD GAS
12 Mar 2013
Ph 7.35 – 7.45 7.574
PCO2 35 – 45 mmHg 49.6
PO2 90 – 100mmHg 54.8
HCO3 22 -26 mmol/L 46.3
BE 0 – 2 mEq/L 22.8 mmol/L
%O2 SAT 91.3
FCO2 47.8 mmol/dL

Results
URINALYSIS
12 Mar 2013 13 Mar 2013
COLOR Light yellow Pinkish
TRANSPARENCY Clear Cloudy
SP. GRAVITY 1.016 – 1.022 1.015 1.010
PH 4.6 – 6.5 7.0 6.5
SUGAR (-) +4
ALBUMIN (-) +3 Trace
RBC 0 – 2 hpf +3 Abundant
WBC 0 – 5 hpf +1 Abundant
CASTS (-) 0 (-)
CRYSTALS Acidic/alkaline (-)
EPITH CELLS few 36 (-)
BACTERIA (-) 26 Few
MUCUS THREADS Few Few
KETONES (-) (-) (-)
BILIRUBIN (-) (-)
UROBILINOGEN N N
NITRITE (-) (-)

VITAL SIGNS

Blood Pressure
13 Mar 2013 14 Mar 2013 15 Mar 2013 16 Mar 2013
4 AM - 120/70 120/80 130/80
12 N 120/80 160/100 130/90 110/60
8 PM 120/80 150/80 130/80
 Body Temperature
13 Mar 2013 14 Mar 2013 15 Mar 2013 16 Mar 2013
4 AM - 36.9 36.8 36.5
12 N - 36.6 36.3 36.7
8 PM 36.6 36.8 36.7

Respiratory Rate
13 Mar 2013 14 Mar 2013 15 Mar 2013 16 Mar 2013
4 AM 19 18 21
12 N 20 21 21
8 PM 24 21 20

Pulse
13 Mar 2013 14 Mar 2013 15 Mar 2013 16 Mar 2013
4 AM 85 87 85
12 N 72 82 86 83
8 PM 82 83 82

Date Input Output

3/13 1970 2000
3/14 2120 800
3/15 1530 600

OTHER LABORATORY TESTS:

CXR UTZ
DATE: 3/13/2013 DATE: 3/13/2013
IMPRESSION: PLEURAL EFFUSION IMPRESSION: MINIMAL ASCITES
CYSTITIS WITH SEDIMENTS
NORMAL UTZ OF THE KIDNEYS

ASSESSMENT

 CKD Stage III secondary to DKD vs HTN nephrosclerosis

 T2DM, NO, IR
 HTN Stage II, poor control
 HTN urgency resolved (200/120mmHg)

PLAN

Parenteral:
Human Isophane Insulin 24 units SQ pre-breakfast
GIVEN: 5:30 (15 – 16 MARCH)

Human SR Pre-Supper
GIVEN: 5:30 (14 – 15 MARCH)

CEFTRIAXONE 2G IV OD: (-) ST 2 (BLUE) 3/16

ORAL
13 March 2013 14 March 2013 15 March 2013 16 March 2013
MEDICATIONS
Amlodipine 10 mg
8 8 8 8
tab OD PO
Ferrous sulfate +
8 6 6
FA tab BID PO 8 6 8 6 8
Atorvastatin 40mg
8 8 8
tab @ HS PO 8
Oral Potassium
Chloride 10% 30 cc 8 12 4 8
QID PO 8 12 4 8 12 4
Losartan 50mg tab 8 8
12
@ lunch PO 1 1
Sitagliptin 50mg 2 2 8 8
tab OD
Metformin 500mg
6 8 6
tab 2 tabs BID 8 6
Furosemide 20mg 8 6
tab BID PO Given at 9am
Losartan 100mg
tab @lunch PO 1
2
Treatments
Ketosteril 2 tabs
1 6
TID PO