Group Activity PM401

Leah Marjorie Gaspar 03/21/19

Marianne Nicole Paghubasan
Shannen Kate Tercenio

Subjective :
Chief complaint
- 65 years old
- Occasional headaches and dizziness in the morning
HPI
- States that the patient is dissatisfied with being placed on a low sodium diet
- Chronic cough and shortness of breath while walking
Past Medical History
- Hypertension for 15 years
- Has type 1 DM
- Chronic Obstructive Pulmonary disease, Stage 2 ( Moderate)
- Benign Prostatic Hyperplasia
- Chronic Kidney disease
Past Surgical History
- The patient has no reported past medical surgery
Family History
- The patient father died of acute MI at age 71, while his mother died of lung cancer at the age of
64
- Mother had both HTN and DM
Social History
- Former smoker ( quit 3 years ago)
- Moderate amount of alcohol intake
- Nonadherent to his low sodium diet
- Doesn’t exercise regularly, limited because of his COPD
- Retired and lives alone
Medication History
- The patient intake alot of medication which listed in the medication profile like
Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q AM
Insulin 70/30, 24 units Q AM, 12 units Q PM

Doxazosin 2 mg po Q AM

Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath
Tiotropium DPI 18 mcg 1 capsule INH daily
Salmeterol DPI 1 INH BID

Decolsin 1 capsule Q 12 h PRN cough and cold symptoms
Acetaminophen 500 mg po Q 6 h PRN headache

Review of System
-HEENT: TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema
Neck: Supple without masses or bruits, no thyroid enlargement or lymphadenopathy
Lungs: Lung fields CTA bilaterally. Few basilar crackles, mild expiratory wheezing
Heart :RRR; normal S1 and S2. No S3 or S4
Abd: Soft, NTND; no masses, bruits, or organomegaly. Normal BS.
Genit/Rect: Enlarged prostate; benign
Allergies: PCN - rash

Objectives:

Physical Examination
General:
WDWN male; moderately overweight; in no acute distress
VS
BP 168/92 mm Hg (sitting; repeat 170/90), HR 76 bpm (regular), RR 16 per min, T 37°C; Wt 95 kg, Ht
6'2''
Results of pertinent laboratory tests, Serum Drug concentrations, and Diagnostic Tests

UA
Yellow, clear, SG 1.007, pH 5.5, (+) protein, (–) glucose, (–) ketones, (–) bilirubin, (–) blood, (–) nitrite,
RBC 0/hpf, WBC 1–2/ hpf, neg bacteria, 1–5 epithelial cells

ECG- Normal sinus rhythm

ECHO (6 months ago) - Mild LVH, estimated EF 45%
Explanation:
- The physical examination procedures that are done to the patient are correlated to the symptoms
or complaints that the patient is experiencing primarily occasional headaches, and dizziness, low
sodium intake diet is not accomplished by the patient, in which the medications he used to
alleviate discomfort and bp regulation of the patient affect the results of the diagnostic tests there
are variations in the results of the patient whereas for such in serum blood levels for Na, Mg, Cl
are important in indicating changes in blood pressure. High-risk levels mark a spell of acquiring a
higher chance of chronic medical conditions. Such electrolytes (Na, Mg,K) are helpers to
determine the activity and a high osmolality gives an indication of hydration or renal function. In
fact, in his Fast Lipid Panel, all are somewhat varying since a show of increase in LDL and TG but
Low HDL cholesterol increase the risk of acquiring CVD. In addition, chronic renal disease is
characterized by diminished creatinine clearance (CrCl), typically with elevations in BUN and Cr.

- In the urinalysis, there is a presence of protein which should be negative in normal urine test
moreover, in the ECG and ECHO there is also problematic for such, it is less than (55-70%) in
ranging the LVEF which can cause of increasing the heart disease since the heart’s left ventricle
can’t pump blood which results in uncertainty inside the patients body.
For diabetes mellitus TYPE 1
Primary markers are presented:
Electrolytes
Na 130 mEq/L (normal 136 - 145 mEq/L )
K 5 mEq/L (normal 3.5 - 5.0 mEq/L )
Cl 95 mEq/L (normal 95 - 105 mEq/L )
HCO3 8 mEq/L (normal 22 - 28 mmol/L)
Osmolality 320 mOsm/L (normal 275 - 295 mOsmo/L)
Glucose 500 mg/dL (normal 70 - 110 mg/dL fasting)
Urine ketones 4+
Urine glucose 4+
Blood Gas Findings (Metabolic acidosis with respiratory compensation)
PaO2 110 mm Hg (normal 80 - 100 mm Hg )
PaCO2 23 mm Hg (normal 35 - 45 mm Hg )
HCO3 8 mEq/L (normal 21 - 29 mEq/L)
pH 7.15 (normal 7.35 - 7.45)

Assessment:
Hypertension, uncontrolled
- BP 168/92 mm Hg (sitting; repeat 170/90)

Type 1 diabetes mellitus, controlled on current insulin regimen

- FH: Mother had both HTN & DM
- Glucose 500 mg/dL (normal 70 - 110 mg/dL fasting)

COPD Stage 2, stable on the current regimen (Moderate)

- SH: Former smoker (quit 3 years ago; smoked 1 ppd - 28 years)
- HPI: “usual” chronic cough and shortness of breath, particularly when walking moderate distances.
- ROS: Few basilar crackles sound
- ROS: mild expiratory wheezing (common in COPD)
- often indicates a mild airway obstruction

BPH, symptoms improved on doxazosin

- ROS: Enlarged prostate; benign

Plan:
For…
Uncontrolled Hypertension: lifestyle changes can help control high blood pressure to reduce the risk of
life-threatening complications.
- Advice the patient to lower sodium intake, and if not possible, he should increase the
consumption of water to help flush the sodium.
- The patient, with >4.5 mmol/L, thiazide or thiazide-like diuretics should be given and not
spironolactone to help reduce the amount of sodium in his body.
- Advice to reduce alcohol consumption.
- Advice to have physical activities.
- Control blood pressure with antihypertensive agents such as an ACE inhibitor or ARB; CCB;
Thiazide or Thiazide-like Diuretic.
Type 1 DM:
- Make sure that the patient receives the right amount of insulin.
- Advice the patient to keep blood sugar steady, by matching carbohydrates intake with the
appropriate insulin dose.
COPD Stage 2
- Advice the patient to eat right, exercise and to get rest, and to learn techniques to bring up
mucus.
- The patient should also be advised to take care of his feelings and to manage flare-ups.
- Give bronchodilators to make the breathing easier whenever he suffers because of COPD.
BPH
- The patient should be adviced to continue the intake of Doxazosin because it does not only help
to the BPH but it also has effect/s with hypertension.

The morning headache and dizziness usually encountered by the patient may be benign paroxysmal
positional vertigo (BPPV). BPPV is known to usually cause intense, brief episodes of dizziness or vertigo
associated with moving the head, often when getting up in the morning.
The patient should be advised to:
- Be aware of the possibility of losing balance.
- Sit down when he felt dizzy.
- Use good lighting when he gets up at night