Your SlideShare is downloading. ×
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.

Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply



Published on




This presentation contains real names of persons involve of this particular study. This names should not be copied or rewritten. Used the data of this study as basis only. All rights reserved 2009.

Published in: Education, Health & Medicine
  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 2. CHAPTER ONE INTRODUCTION This is a case study on patient RM, 58 years old, male, Roman Catholic, Filipino, residing at Matabao Tubigon, Bohol and born on October 22, 1948 admitted for the 3rd time in Cebu Velez General Hospital (CVGH) for complaints of right epigastric pain and vomiting. The patient was admitted under the service of Dr. Ceaar Quiza under the Department of Internal Medicine with the case number of 88358. The case was chosen by the researchers on June 28, 2007. Nephrolithiasis (Alternative Names: Renal calculi; Kidney stones; Stones – kidney) DEFINITION The formation of crystal aggregates in the urinary tract results in kidney stones, the clinical condition referred to as nephrolithiasis. Kidney stones may produce no symptoms or may be associated with one or several of the following: flank pain, gross or microscopic hematuria, obstruction of one or both kidneys, and urinary infections. The stones are usually formed by one of four substances: (1) calcium, (2) uric acid, (3) magnesium ammonium phosphates (or struvite), or (4) cystine.1 Occasionally, calcium salts and uric acid will be present in the same stone. CALCIUM STONE DISEASE Calcium stone disease is the most common form of nephrolithiasis and represents about 70% of all stone-forming disease. It occurs most often in the third to fifth decade of life, more often in men than women. SIGNS AND SYMPTOMS Patients often present with episodes of flank pain that radiates to the anterior abdomen or even to the genitalia. The pain is often severe and comes in waves. Often there is microscopic or gross hematuria. Calcium oxalate crystals may be seen with urine microscopy, but this finding is not diagnostic since calcium oxalate crystals may be seen in the urine of non-stone-forming patients. In some patients the renal stones are completely asymptomatic or may produce painless hematuria. DIAGNOSIS Stone analysis is the surest way to diagnose calcium oxalate or calcium phosphate stones. Calcium-containing stones are radiopaque on routine radiography but show up as bright objects on computed helical tomography without contrast. Ultrasonography will detect all types of renal stones if the stone is larger than 3 to 5 mm and the ultrasound is technically satisfactory. Of the conditions associated with calcium stones, only pyelotubular ectasia (medullary sponge kidney) is better demonstrated by intravenous urography. URIC ACID STONE DISEASE Uric acid stone disease is found in about 5% to 10% of stone formers. It is more common in patients with chronic diarrheal disorders and in those with hyperuricosuria. Most uric acid stone formers do not have gout or hyperuricosuria. Uric acid stones may also be partially composed of calcium oxalate, and some patients have both uric acid and calcium oxalate stones. SIGNS AND SYMPTOMS Patients often present with episodes of flank pain that radiates to the anterior abdomen or even to the genitalia, as in calcium stone disease. The pain is often severe and comes in waves. Often there is microscopic or gross hematuria. DIAGNOSIS Uric acid stone disease should be suspected in any patient with typical symptoms of renal colic in whom the plain radiographs do not show a calcified stone. Urate crystals may be present in the urine, but occur in patients without stones as well. The urine pH will usually be less than 5.5. Stone analysis will provide sure diagnosis.
  • 3. STRUVITE STONE DISEASE Infection stones, also known as struvite or magnesium ammonium phosphate stones, occur in about 10% to 12% of patients, more often in women. They occur more often also in patients with spinal cord injury, neurogenic bladder, vesicoureteral reflux, chronic indwelling Foley catheters, and recurrent urinary infections, and in those with chronic obstruction of the upper urinary tracts. SIGNS AND SYMPTOMS These stones may cause the typical symptoms of renal colic, but often they are discovered in the course of investigating a patient with recurrent urinary infections or in a patient with asymptomatic bacteriuria. Since these stones can grow to significant size, they are often found in the renal pelvis and infundibula of the kidneys. DIAGNOSIS The diagnosis of struvite stones is suspected by finding large or branched stones in the kidneys of a patient with persistently infected urine. Stone analysis will confirm the diagnosis. CYSTINE STONE DISEASE PREVALENCE Cystine stone disease occurs in less than 1% of all adult stone formers and in about 6% to 8% of children with nephrolithiasis. SIGNS AND SYMPTOMS The patient presents with symptoms of nephrolithiasis, often at a younger age than a person with calcium stone disease. The stones are radiopaque (ground-glass appearance) and amber. Family history is often helpful (ie, siblings may have the disorder). DIAGNOSIS Normal urine contains less than 20-30 mg/d (<100mg/gm creatinine) of cystine. Urinary cystine excretion of greater than 250 mg/g creatinine in adults is clearly abnormal and is the usual amount found in patients with cystinuria. The examination of a concentrated, acidic urine specimen will often reveal the presence of the cystine crystals, which are transparent and hexagonal. Cystine can be detected qualitatively by adding sodium nitroprusside to the urine and observing a purple-red color. Stone analysis is diagnostic. Foods and Drinks Containing Oxalate People prone to forming calcium oxalate stones may be asked by their doctor to cut back on certain foods if their urine contains an excess of oxalate: • beets • chocolate • coffee • cola • nuts • rhubarb • spinach • strawberries • tea • wheat bran People should not give up or avoid eating these foods without talking to their doctor first. In most cases, these foods can be eaten in limited amounts. CAUSES, INCIDENCE AND RISK FACTORS: Kidney stone formation may result when the urine becomes overly concentrated with certain substances. These substances in the urine may complex to form small crystals and subsequently stones. Stones may not produce symptoms until they begin to move down the ureter, causing pain. The pain is severe and often starts in the flank region and moves down to the groin. Kidney stones are common. About 5% of women and 10% of men will have at least one episode by age 70. Kidney stones affect about 2 out of every 1,000 people. Recurrence is common, and the risk of recurrence is
  • 4. greater if two or more episodes of kidney stones occur. Kidney stones are common in premature infants. A personal or family history of stones is associated with increased risk of stone formation. Other risk factors include renal tubular acidosis and resultant nephrocalcinosis. SYMPTOMS: • Flank pain or back pain on one or both sides progressive, severe, colicky (spasm-like) may radiate or move to lower in flank, pelvis, groin, genitals • Nausea, vomiting • Urinary frequency/urgency, increased (persistent urge to urinate) • Blood in the urine • Abdominal pain • Painful urination • Excessive urination at night • Urinary hesitancy • Testicle pain • Groin pain • Fever • Chills • Abnormal urine color SIGNS AND TESTS • Pain may be severe enough to require narcotics. There may be tenderness when the abdomen or back is touched. If stones are severe, persistent, or come back again and again, there may be signs of kidney failure. • Straining the urine may capture urinary tract stones when they are excreted. • Analysis of the stone shows the type of stone. • Urinalysis may show crystals and red blood cells in urine. • Uric acid elevated Stones or obstruction of the ureter may be seen on: • Kidney ultrasound • IVP (intravenous pyelogram ) • Abdominal x-rays • Retrograde pyelogram • Abdominal CT scan • Abdominal/kidney MRI MEDICAL THERAPY The doctor may prescribe certain medications to prevent calcium and uric acid stones. These drugs control the amount of acid or alkali in the urine, key factors in crystal formation. The drug like: 1.) allopurinol - These drugs decrease the amount of calcium released by the kidneys into the urine by favoring calcium retention in bone. They work best when sodium intake is low.
  • 5. 2.) Thiola and Cuprimine – these help reduce the amount of cystine in the urine. 3.) acetohydroxamic acid (AHA) - AHA is used with long-term antibiotic drugs to prevent the infection that leads to stone growth SURGICAL TREATMENT Surgery should be reserved as an option for cases where other approaches have failed. Surgery may be needed to remove a kidney stone if it does not pass after a reasonable period of time and causes constant pain is too large to pass on its own or is caught in a difficult place blocks the flow of urine causes ongoing urinary tract infection damages kidney tissue or causes constant bleeding has grown larger. 1.) Extracorporeal shockwave lithotripsy (ESWL) is the most frequently used procedure for the treatment of kidney stones. In ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into sand-like particles and are easily passed through the urinary tract in the urine. Complications may occur with ESWL. Most patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves are also common. To reduce the risk of complications, doctors usually tell patients to avoid taking aspirin and other drugs that affect blood clotting for several weeks before treatment. 2.) Percutaneous nephrostolithotomy allows fragmentation and removal of large calculi from the kidney and ureter and is often used for the many ESWL failures. A needle, and then a wire, over which is passed a hollow sheath, are inserted directly in the kidney through the skin of the flank. 3.) Lithotripsy may be an alternative to surgery. COMPLICATIONS • Recurrence of stones • Urinary tract infection • Obstruction of the ureter, acute unilateral obstructive uropathy • Kidney damage, scarring • Decrease or loss of function of the affected kidney PREVENTION If there is a history of stones, fluids should be encouraged to produce adequate amounts of dilute urine (usually 6 to 8 glasses of water per day). Depending on the type of stone, medications or other measures may be recommended to prevent recurrence. HYPERTENSION (HPN)  High blood pressure (140/90 mmHg or greater)  Condition when the pressure inside of your large arteries is too high. Three stages of HPN: Sytolic (mmHg) Diastolic (mmHg) Stage I 140-159 or 90-99 Stage II 160-179 or 100-109
  • 6. Stage III >=180 or >=110 Types of HPN:  ESSENTIAL - diagnosed when there is no identifiable cause for the occurrence of hypertension. - condition that is most commonly seen.  SECONDARY - an increase in the blood pressure as a result of another disease condition. - Common disease entities that may cause HPN include renal artery stenosis, renal failure, phenochromocytoma, & adrenal insufficiency. Incidence Report:  The latest local data (1998) shows a 21% prevalence among Filipinos.  With a projected population of 78.4 million by year 2000, roughly 8.6 million Filipinos are hypertensive  About 59% have target organ damage – heart attacks (myocardial infarction) in 3.4%, stroke in 11.5% and kidney damage in 53%  Since hypertension causes minimal or no symptoms at all, only 13.6% of hypertensives are aware of their condition. Causes  Genes  Lifestyle and environment- ex. smoking & alcohol intake  Diet  Certain medications  Disorders of the kidneys or endocrine glands. Signs and Symptoms  High BP (pls. refer to the first page for values)  Individuals with high BP rarely have symptoms  Few complain of headache, nape pains or dizziness, which are usually mild and tolerable.  Thus, hypertension is treated not only to relieve symptoms, but to prevent the development of target organ damage, which occur in those with chronic untreated, elevated blood pressure. Complications  Target organ damage is a general term used for the complications occurring as a result of uncontrolled hypertension. They include the brain, the eyes, the kidneys, and the heart.  Stroke results when arteries in the brain burst (bleeding) or become blocked (thrombosis). Part of the brain dies and the patient becomes paralyzed
  • 7.  Heart Attack occurs when coronary arteries in the heart are blocked. The heart muscle dies, and may stop beating. Patient dies as a consequence.  Heart Failure results when the heart pumps too hard for too long, trying to keep blood flowing through the body. Eventually, the heart weakens. The patient now tires easily and is always out-of-breath  Kidney Failure happens when tiny vessels in the kidneys are blocked. The kidneys malfunction are unable to clean the body of wastes. Patient is slowly poisoned, becomes weak and bloated. Unless “dialyzed”, the patient will die of poisoning from his own body wastes  Blindness or Impaired Vision occurs when tiny blood vessels in the eye rupture or become blocked, damaging the surrounding eye tissues BRAIN Prolonged hypertension predisposes and individual to the occurrence of strokes whether by occlusion (ischemic infarct) or by bleed (hemorrhagic infarct) HEART Hypertension increases the work needed to be done by the heart to meet the demands of the body. This prolonged increase in the workload of the heart eventually results to enlargement of the heart and predisposes to the occurrence of heart failure and heart attack. KIDNEYS Prolonged hypertension can eventually result to kidney failure, which in the end-stage may necessitate dialysis treatment. EYES Hypertension predisposes to development of hypertensive retinopathy with subsequent development of visual problems for the patient. Risk factors  Blood lipid levels, diabetes, obesity, family history, fibrinogen and other clotting factors, homocysteine and cardiac disorders. Medical Management  Diuretics, which initially increase urination to reduce salt and water retention and lower blood volume.  Beta-blockers (BB’s), which slow the heart rate and lower the output of the heart.  Angiotensin converting enzyme (ACE) inhibitors, which block production of a specialized hormone called angiotensin II. Angiotensin II causes the arteries to constrict and also stimulates the release of another hormone that causes the kidneys to retain salt.  Angiotensin II receptor blockers (ARBs or A II A’s), which relax blood vessels by blocking the action of angiotensin II.  Calcium channel blockers (CCB’s) of which there are two types: Dihydropyridines (DHPs), and heart rate slowing calcium channel blockers. Both types relax blood vessels by slowing the entry of calcium into cells. The DHPs increase the heart rate a little while the others slow it a little.  Alpha-1 blockers work on the blood vessels to block the effect of constricting hormones such as norepinephrine. These are also commonly used to treat prostate problems.  Alpha-2 agonists, which work in the brain to decrease the action of the nervous system to constrict blood vessels.  Direct vasodilators, which relax the artery walls.  Sympathetic nerve blockers, which prevent those nerves from constricting blood vessels.
  • 8. Diabetes Mellitus Type 2 Mortality rate has increased by 92% over a ten year period from 1986 to 1995 and it is estimated that there are currently 3 million Filipinos who are diabetic. The World Health Organization projected that by 2030, the number of cases of diabetes worldwide is estimated at 334 million. Based on the WHO study, the Philippines is projected to have an estimated number of 7.8 million cases by 2030 and eventually may rank ninth in th elist of countries with the highest estimated cases worldwide. Given these figures, it is crucial to know and understand the facts about this disease. Many patients with type 2 diabetes are asymptomatic, and their disease is undiagnosed for many years. Studies suggest that the typical patient with new-onset type 2 diabetes has had diabetes for at least 4-7 years before it is diagnosed. Among patients with type 2 diabetes, 25% are believed to have retinopathy; 9%, neuropathy; and 8%, nephropathy at the time of diagnosis. Prediabetes often precedes overt type 2 diabetes. Prediabetes is defined by a fasting blood glucose level of 100-125 mg/dL. Patients who have prediabetes have an increased risk for macrovascular disease, as well as diabetes. Risk Factors • Age - Older than 45 years (though, as noted above, type 2 diabetes is occurring with increasing frequency in young individuals) • Obesity - Weight >120% of desirable body weight (true for approximately 90% of patients with type 2 diabetes) • Family history of type 2 diabetes in a first-degree relative (eg, parent or sibling) • Hispanic, Native American, African American, Asian American, or Pacific Islander descent • History of previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) • Hypertension (>140/90 mm Hg) or dyslipidemia (high-density lipoprotein [HDL] cholesterol level <40 mg/dL or triglyceride level >150 mg/dL) • History of GDM or of delivering a baby with a birth weight of > 9 lbs • Polycystic ovarian syndrome (which results in insulin resistance) Signs and Symptoms These may include frequent urination, unexplained weight loss, unusual or excessive thirst, extreme hunger, sudden changes in vision, tingling or numbness in hands or feet, presence of sores that are slow to heal and feeling tired most of the time. According to the American Diabetes Association, either the Fasting Plasma Glucose (FPG or FBS) or an Oral Glucose Tolerance Test (OGTT) can be used to diagnose the condition. The FPG or FBS is frequently used because it is less expensive and easier to perform. Fasting blood sugar level between 100 to 125 mg/dl signals pre-diabetes. Pre-diabetes is a term which distinguishes individuals who are at a risk of developing diabetes which may be due to impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). If the fasting blood sugar is 126 mg/dl or higher, this may indicate that the person has diabetes. Diagnostic Tests 1. Physical Examination 2. C-peptide blood test 3. Insulin level blood test 4. Urine Sugar Test
  • 9. 5. Urine Ketone Test 6. Oral Glucose Tolerance Test (OGTT) 7. Blood Glucose Tests: a. Fasting Plasma Glucose (FPG) b. Random Plasma Glucose Complications • Complications include hypoglycemia and hyperglycemia, increased risk of infections, microvascular complications (eg, retinopathy, nephropathy), neuropathic complications, and macrovascular disease. • Diabetes is the major cause of blindness in adults aged 20-74 years, as well as the leading cause of nontraumatic lower-extremity amputation and end-stage renal disease (ESRD). Treatment Options Individuals who suspect they have diabetes must visit their doctor for diagnosis. Healthy eating, maintaining an ideal body weight, regular physical activity and regular blood glucose testing are the basic recommendations given. Many individuals with type 2 diabetes may require oral medicaiton, insulin or both to control their blood sugar levels depending on the case. Persons with type 2 diabetes can still live long and healthy lives as long as proper treatment and management is given. They must consult an endocrinologist, a medical specialist who is an expert in the management of diabetes and an opthalmologist for eye examinations. Based on several studies, regular physical activity or exercise can significantly reduce the risk of developing type 2 diabetes. Regular exercise of at least 3 times a week fro at least 30 minutes per session improves cardiovascular fitness, helps insulin to function well in maintaining blood sugar levels, controls body weight and helps lower blood pressure and cholesterol levels. Individuals must first consult their physician before engaging in a regular exercise program. Other preventive measures include having a healthy diet and attaining an ideal body weight. ACUTE CHRONIC INFECTIONS Severe glyperglycemia Hyperosmolar Coma Ketoacidosis Lactic Acidosis Hypogycemia Microvascular (small blood vessels for the eyes, kidneys, and nerves) Macrovascular (large blood vessels for the brain, heart, and limbs) Neuropathy Cataracts, glaucoma Infections of the skin, eyes, ears, nose, throat, lungs, gallbladder, kidneys, and genitor-urinary tract HYDRONEPHROSIS Hydronephrosis is the distention of the pelvis and calices of the kidney with urine, as a result of obstruction of the ureter, with accompanying atrophy of the parenchyma of the organ. The signs and symptoms of hydronephrosis depends upon whether the obstruction is acute or chronic. Unilateral hydronephrosis may even occur without symptoms. Blood tests can show raised creatinine and electrolyte imbalance. Urinalysis may show an elevated pH due to the secondary destruction of nephrons within the affected kidney.
  • 10. Symptoms that occur regardless of where the obstruction lies include loin or flank pain. An enlarged kidney may be palpable on examination. Where the obstruction occurs in the lower urinary tract, suprapubic tenderness (with or without a history of bladder outflow obstruction) along with a palpable bladder are strongly suggestive of acute urinary retention, which left untreated is highly likely to cause hydronephrosis. Upper urinary tract obstruction is characterised by pain in the flank, often radiating to either the abdomen or the groin. Where the obstruction is chronic, renal failure may also be present. If the obstruction is complete, an enlarged kidney is often palpable on examination. Etiology The obstruction may be either partial or complete and can occur anywhere from the urethral meatus to the calyces of the renal pelvis. The obstruction may arise from either inside or outside the urinary tract or may come from the wall of the urinary tract itself. Intrinsic obstructions (those that occur within the tract) include blood clots, stones, sloughed papilla along with tumours of the kidney, ureter and bladder. Extrinsic obstructions (those that are caused by factors outside of the urinary tract) include pelvic or abdominal tumours or masses, retroperitoneal fibrosis or neurological deficits. Strictures of the ureters (congenital or acquired), neuromuscular dysfunctions or schistosomiasis are other causes which originate from the wall of the urinary tract. Tests Blood (U&E, creatinine) and urine (MSU, pH) tests should be taken. Ultrasounds, CTs and MRIs are also important tests. Ultrasound allows for visualisation of the ureters and kidneys and can be used to assess the presence of hydronephrosis and/or hydroureter. An IVU is useful for assessing the position of the obstruction. Antegrade or retrograde pyelography will show similar findings to an IVU but offer a therapeutic option as well. The choice of imaging depends on the clinical presentation (history, symptoms and examination findings). In the case of renal colic (one sided loin pain usually accompanied by a trace of blood in the urine) the initial investigation is usually an intravenous urogram. This has the advantage of showing whether there is any obstruction of flow of urine causing hydronephrosis as well as demonstrating the function of the other kidney. Many stones are not visible on plain xray or IVU but 99% of stones are visible on CT and therefore CT is becoming a common choice of initial investigation. Complications Complications for untreated hydronephrosis may include: 1. pyelonephritis 2. kidney damage 3. kidney failure Treatment Treatment of hydronephrosis focuses upon the removal of the obstruction and drainage of the urine that has accumulated behind the obstruction. Therefore, the specific treatment depends upon where the obstruction lies, and whether it is acute or chronic. Acute obstruction of the upper urinary tract is usually treated by the insertion of a nephrostomy tube. Chronic upper urinary tract obstruction is treated by the insertion of a ureteric stent or a pyeloplasty. Lower urinary tract obstruction (such as that caused by bladder outflow obstruction secondary to prostatic hypertrophy) is usually treated by insertion of a urinary catheter or a suprapubic catheter.
  • 11. RHEUMATOID ARTHRITIS Rheumatoid arthritis is a systemic autoimmune disease that causes chronic inflammation of the joints. RA can also cause inflammation of the tissue around the joints, as well as other organs in the body. Autoimmune diseases are illnesses that occur when body tissues are mistakenly attacked by its own immune system. The immune system is a complex organization of cells and antibodies designed normally to “seek and destroy” invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues where they can be associated with inflammation. The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none have been proven as the cause. Some scientist believed that the tendency to develop rheumatoid arthritis may be genetically inherited. Environmental factors also seem to play some role in causing rheumatoid arthritis. Rheumatoid Factor (an autoantibody directed against immunoglobulin G), antibodies against collagen, Epstein-Barr virus, encoded nuclear antigen, and certain other antigens have been identified in clients with RA. The role of antibodies in RA is still unclear, but research has focused attention on pre-illness immunologic status in the pathogenesis of RA. Anti-keratin antibody (AKA) and anti-perinuclear factor (APF) apper to be markers that predict the development of RA in RF-positive clients. RA may be mild and relapsing, involving a few joints for a brief period, or markedly progressive, with the development of deformities and severe systemic disease. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but most often starts after age forty and before sixty. In some families, multiple members can be affected, suggesting a genetic basis for the disorder. Signs and symptoms include fatigue, lack of appetite, low grade fever, muscle and joint aches, stiffness, hoarseness of voice, pleuritis, and anemia. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint becomes inflamed, resulting in the production of excessive joint fluid. Optimal treatment for the disease involves a combination of medications, rest, joint strengthening exercises, patient (and family) education, joint protection to achieve the primary goals of providing pain reduction, protecting articular surfaces to prevent bone and cartilage destruction, maintaining or restoring joint function, and controlling systemic involvement. Treatment is most successful when there is close cooperation between the doctor, nurse, patient, and family member. Two classes of medications are used in treating rheumatoid arthritis: fast-acting “first-line drugs” and slow-acting “second-line drugs” (also referred to as Disease- Modifying Anti-rheumatoid drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate and hydroxychloroquine (plaquenil) promote disease remission and prevent progressive joint destruction, but they are not anti- inflammatory agents SURGICAL MANAGEMENT Surgery may be used to reduce pain, improve function, and correct deformities.  TENDON TRANSFER-can prevent progressive deformity. Nodules or benign bony tumors may be surgically removed and flexion contractures surgically relieved.
  • 12.  OSTEOTOMY- may improve the function of deformed joints or limbs. For example, a femoral head osteotomy may give symptomatic relief by changing the position of the head of the femur when it is being subjected to the stress of impact against the acetabulum.  SYNOVECTOMY- removal of synovia, as in the elbows, wrist, fingers, or knees. Help maintain joint function  ARTHRODESIS- is a surgical procedure to produce bony fusion of a joint and is used for clients with bone loss after joint infection, tumors, musculoskeletal trauma, and paralysis.  JOINT REPLACEMENT- is the surgical replacement of natural diseased joint or joint components with artificial joints or joint components.  SHOULDER ARTHROPLASTY- is the replacement of humeral head and glenoid articulating surface with a metal and polyethylene prosthesis.  ELBOW ARTHROPLASTY- uses hinge joints made from metal and polyethylene. This metal and plastic joints allows for some medial to lateral and rotational movements.  HAND ARTHROPLASTY- surgery includes tendon transfers to improve pinch grasp and arthrodesis for strength and position of the thumb for opposition. Cholelithiasis Definition Cholelithiasis is another name for gallstones. Gallstones are hard, solid lumps that form from bile in the gallbladder. Bile is a special liquid chemical made by the liver that helps the body break down and digest fats. The gallbladder is a storage sack for bile. One may have just one or many gallstones that can be as small as a piece of sand or as large as golf balls. There are different kinds of gallstones. The most common stone is made of cholesterol (a fat-like material). A pigment stone is made up from bilirubin, which is a part of old, dead blood cells. Other kinds of stones may be a mixture of cholesterol and bilirubin. Gallstones in the gallbladder or in the bile ducts can cause problems. Stones can block bile ducts (flexible tubes). Bile ducts go from the liver to the gallbladder or from the gallbladder to the small intestine. Gallstones are more common in woman than in men between 20 and 50 years of age. But, as one gets older, anyone can get gallstones. Symptoms Symptoms usually manifest after a stone of sufficient size (larger than 8mm) blocks the cystic duct or the common bile duct. The cystic duct drains the gallbladder, and the common bile duct is the main duct draining into the duodenum. Collectively, these ducts form part of the biliary system. A stone blocking the opening from the gallbladder or cystic duct usually produces symptoms of biliary colic, which is right upper quadrant abdominal pain that feels like cramping. If the stone does not pass into the duodenum and still continues to block the cystic duct, acute cholecystitis, an inflammation of the gallbladder, results. If the common bile duct is blocked for a substantial period of time, certain bacteria may find their way up behind the stone and grow in the stagnant bile, producing symptoms of cholangiti, an inflammation to the bile ductss. This is a serious condition and usually requires hospitalization. Continued blockage of normal bile flow may produce jaundice. Stones blocking the lower end of the common bile duct where it enters the duodenum may obstruct secretion from the pancreas, producing pancreatitis, an inflammation of the pancreas. This condition can also be serious and may require hospitalization. In general, following symptoms must be observed closely:
  • 13. • Abdominal pain in the right upper quadrant or in the middle of the upper abdomen, which may be: o recurrent o sharp, cramping, or dull o radiate to the back or below the right shoulder blade o made worse by fatty or greasy foods o Occurs within minutes of a meal • Jaundice • Fever Often there are no symptoms. Additional symptoms that may be associated with this disease include : • Clay-colored stools • Nausea and vomiting • Heartburn • Gas or excessive flatus • Abdominal indigestion • Abdominal fullness, gaseous As for our patient, he currently manifested slight yellowish coloration of his skin or more commonly known as jaundice. Causes Cholelithiasis is usually incidentally discovered by routine x-ray study, surgery, or autopsy. Virtually all gallstones are formed within the gallbladder, an organ that normally functions to store bile excreted from the liver. Bile is a solution composed of water, bile salts, lecithin, cholesterol and some other small solutes. Changes in the relative concentration of these components may cause precipitation from solution and formation of a nidus, or nest, around which gallstones are formed. The cystic duct drains bile from the gallbladder. The hepatic duct drains bile from the liver. The hepatic duct and cystic duct join to form the common bile duct which carries bile to the small intestine. When gallstones block these ducts, they may lead to the following more serious conditions These stones may be as small as a grain of sand, or they may become as large as an inch in diameter, depending on how much time has elapsed from their initial formation. Depending on the main substance that initiated their formation (for instance, cholesterol), they may be yellow or otherwise pigmented in color. Risk Factors • Gender - Women tend to get gallstones more frequently than men due to their higher estrogen levels. • Oral Estrogen Use - In addition, women who take oral contraceptives or postmenopausal hormone replacement therapy seem to have a higher risk of gallstones due to the estrogen these
  • 14. therapies contain. • Pregnancy - Pregnancy also increases estrogen levels, thereby increasing risk of gallstones. • Increasing Age - As you get older, usually 40 and over, your risk of gallstones increases. • Obesity and Diet - Having mainly abdominal fat appears to raise your risk of getting gallstones. Being even moderately overweight increases cholesterol in your bile, which may easily form gallstones. In addition, rapid weight loss or fluctuating weight can also increase your risk because low-calorie diets cause the gallbladder to contract less. People who have had gastric-bypass surgery to lose weight quickly also have an increased risk for gallstones. • Lack of Physical Activity - Lack of exercise is associated with a higher risk of developing gallstones, perhaps because the gallbladder is contracting less. • Family History of Gallstones - Like many other conditions, gallstones tend to run in families. • Native American Ethnicity - Native Americans develop gallstones more frequently than any other ethnicity in the United States. • Diseases of the Small Intestines - Having a disease of the small or large intestine such as Crohn’s disease is associated with a higher risk of gallstones. • Need for Long-term Intravenous Nutrition (Total Parenteral Nutrition) - When it is necessary to provide nutrition through the veins, therefore bypassing the intestines, the gallbladder is less stimulated since there is no food going through the intestines. This increases your risk of gallstones. Diagnostic Tests: o Blood Tests. o ERCP is also called endoscopic retrograde cholangiopancreatography, a test done during an endoscopy to find stones, tumors, or other reasons for the problem. Dye is put into the endoscopy tube. The dye then goes into your pancreas and bile ducts to help them show up better on x-rays. If one has stones, they can sometimes be removed during ERCP. People who are allergic to shellfish (lobster, crab, or shrimp) may be allergic to this dye, thus assessment for allergies are important. o HIDA scan is a nuclear medicine test. Radioactive material is given in IV fluids. Then x-rays are taken to help caregivers find blockages. o Oral cholecystography is a test where one is given a shot or take pills with a special dye in them. X-rays are then taken over time. The test shows the gallbladder and any stones that might be blocking the ducts. Some people are also allergic to this kind of dye. Assess for allergies to shellfish (lobster, crab, or shrimp). o Ultrasound. Our patient underwent ultrasound of his abdomen and revealed an 8.00mm stone within gallbladder with no evidence of cholecystitis. Medical Management o Changes in the diet such as eating foods that have less fat. o Medicines for pain and nausea. o ESWL is also called extracorporeal shockwave lithotripsy. Shock waves from a special machine are used to break up stones. The tiny pieces then pass through the bile ducts without getting stuck.
  • 15. Surgical Management o Focused on removing the stones. The most common surgery is called a laparoscopic cholecystectomy. - The surgical removal of the gallbladder, a muscular, pear-shaped organ that lies underneath the liver. RATIONALE OF STUDY In choosing this case study for the presentation, we first weighed the significance of the case. Though it was quite complex making this choice, but we had to make a stand firm. Upon making our history and assessment of our patient, we learned that he is currently faced with 5 problems, which added more interest to the case. 1st is Diabetes Mellitus, diagnosed 16 years ago. He has DM type 2, considered the most common form. It appears most often in middle-aged adults. It develops when the body doesn’t make enough insulin and doesn’t efficiently use the insulin it makes (insulin resistance), thus is also known as non insulin-dependent diabetes mellitus. 2nd is his Hypertension stage 2 diagnosed 6 years ago, a medical condition in which constricted arterial blood vessels increase the resistance to blood flow, causing an increase in blood pressure against vessel walls. The heart then must work harder to pump blood through the narrowed arteries. This stage 2 hypertension is the type wherein blood pressure readings reach 160/100
  • 16. mm Hg or higher. 3rd is Cholelithiasis diagnosed last June 27, 2007, a condition wherein gallstones are formed within the gallbladder by accretion or concretion of normal or abnormal bile components. 4th is Nephrolitiasis diagnosed just recently on June 29, 2007. This is the formation of a stone within the urinary tract. Most of these stones are too large to pass through the narrow conduits of the collecting system, thus obstruct the flow of urine and often cause severe pain. 5th is his Rheumatoid Arthritis, diagnosed last 2000, which is an autoimmune disease that causes chronic inflammation of the joints. This can also cause inflammation to the tissue around the joints, as well as other organs in the body. With his present condition, this caught our attention and concern as good citizens of the society and as nursing students. In making this case study presentation of R.M., we seek to discover more about these various conditions, how such conditions could complicate to other disease processes, and ways of preventive measures and management in dealing with his illnesses. This study is guided by a theory. We opted to use Betty Neuman’s System Model, since it reflects the morals of our practice by focusing on the person as a complete system, and provide a wholistic overview of the physiological, psychological, sociocultural, and developmental aspects of human beings. The use of nursing theories helps to serve as a framework for the development of nursing knowledge REVIEW OF RELATED LITERATURE Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, which result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with “sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine. Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime. Proper nutrition is essential for anyone living with diabetes. Control of blood glucose levels is only one goal of a healthy eating plan for people with diabetes. A diet for those with diabetes should also help achieve and maintain a normal body weight as well as prevent heart and vascular disease, which are frequent complications of diabetes. There is no prescribed diet plan for those with diabetes. Rather, eating plans are tailored to fit an individual’s needs, schedules, and eating habits. A diabetes diet plan must also be balanced with the intake of insulin and oral diabetes medications. In general, the principles of a healthy diabetes diet are the same for everyone. Consumption of a variety of foods including whole grains, fruits, non-fat dairy products, beans, and lean meats or vegetarian substitutes, poultry and fish is recommended to achieve a healthy diet. Many experts, including the American Diabetes Association, recommend that 50 to 60 percent of daily calories come from carbohydrates, 12 to 20 percent from protein, and no more than 30 percent from fat. People with diabetes may also benefit from eating small meals throughout the day instead of eating one or two heavy meals. No foods are absolutely forbidden for people with diabetes, and attention to portion control and advance meal planning can help people with diabetes enjoy the same meals as others in the family. Some people with diabetes will benefit from using specific methods to help follow a diabetes meal plan. None of these diet plans is required for people with diabetes, but many people will find one them useful. Some of these ways include:
  • 17. Rating your plate is a meal planning system based upon portion size. Imaginary lines are used to divide a meal plate into two halves, and one half is further divided into fourths. One-fourth of the plate should contain grains/starches, one-fourth should contain protein, and the remaining half should contain non-starchy vegetables. Exchange lists help in the planning of balanced meals by grouping together foods that have similar carbohydrate, protein, fat, and calorie content. Meal planning exchange lists have been published by The American Dietetic Association and the American Diabetes Association. Carbohydrate counting is based upon the total carbohydrate intake (measured in grams) of foods. Glycemic Index ranks carbohydrates according to the effects they have on blood sugar levels. [] Nephrolithiasis: The process of forming a kidney stone, a stone in the kidney (or lower down in the urinary tract). Kidney stones are a common cause of blood in the urine and pain in the abdomen, flank, or groin. Kidney stones occur in 1 in 20 people at some time in their life. The development of the stones is related to decreased urine volume or increased excretion of stone-forming components such as calcium, oxalate, urate, cystine, xanthine, and phosphate. The stones form in the urine collecting area (the pelvis) of the kidney and may range in size from tiny to staghorn stones the size of the renal pelvis itself. [] Calcium oxalate kidney stone formers are invariably advised to increase their fluid intake. In addition, magnesium therapy is often administered. Recently, a prospective study showed that a high dietary intake of calcium reduces the risk of symptomatic kidney stones. The present study was performed to test whether simultaneous delivery of these factors--high fluid intake, magnesium ingestion and increased dietary calcium--could reduce the risk of calcium oxalate kidney stone formation. A French mineral water, containing calcium and magnesium (202 and 36 ppm, respectively) was selected as the dietary vehicle. Twenty calcium oxalate stone- forming patients of each sex as well as 20 healthy volunteers of each sex participated in the study. Each subject provided a 24-hour urine collection after ingestion of mineral water over a period of 3 days; after a suitable rest period the protocol was repeated using local tap water (Ca: 13 ppm, Mg: 1 ppm). In addition, 24-hour urines were collected by each subject on their free diets. The entire cycle was repeated at least twice by each subject. Several risk factors (excretion of oxalate; relative supersaturations of calcium oxalate, brushite and uric acid; calcium oxalate metastable limit; oxalate:magnesium ratio and oxalate:metastable limit ratio) were favourably altered by the mineral water and tap water regimens but the former was more effective. In addition, the mineral water protocol produced favourable but unique changes in the excretion of citrate and magnesium as well as in the relative supersaturation of brushite which were not achieved by the tap water regimen. To the contrary, tap water produced an unfavourable change in the magnesium excretion. The group which benefitted most were male stone formers in whom 9 risk factors were favourably altered by the mineral water protocol. It is concluded that mineral water containing calcium and magnesium, such as that used in this study, deserves to be considered as a possible therapeutic or prophylactic agent in calcium oxalate kidney stone disease. [] One in every 20 people develop a kidney stone at some point in their life. A kidney stone is a hard mineral and crystalline material formed within the kidney or urinary tract. Kidney stones are a common cause of blood in the urine and pain in the abdomen, flank, or groin. Kidney stones are sometimes called renal calculi. New research shows that lemonade is an effective -- and delicious -- way for kidney-stone-prone people to slow the development of new stones. "When treating patients in our kidney stone center, we put everyone on lemonade therapy," says Steven Y. Nakada, chair and professor of urology at the University of Wisconsin, Madison. If you've ever passed a kidney stone, you won't forget the sudden, intense pain in your flank. Some patients compare the pain with that of childbirth. Kidney stones form when urine in the kidney becomes supersaturated with stone-forming salts -- and when the urine doesn't contain enough stone-preventing substances. One of these substances is citrate. For people prone to stones, doctors usually prescribe potassium citrate. It can be taken as a pill or in liquid form. But lemon juice is full of natural citrate. When made into low-sugar or sugar-free lemonade, Nakada and colleagues found, lemon juice increases the amount of citrate in the urine to levels known to inhibit kidney stones. It doesn't work quite as well as potassium citrate. But for patients who'd rather avoid yet another medication, lemonade is an attractive alternative. "The trend is going to be, if you can make a change in your diet and avoid medications, you are going to try to do that," Nakada said. "We see lemonade therapy as playing a role." David Kang, a medical student and researcher at the Duke University Comprehensive Kidney Stone Center, found that this role can play for a long time. Kang and colleagues followed 12 kidney-stone patients who had been on lemonade therapy for up to four years. Over the time they drank lemonade they had a lower burden of kidney stones and appeared to form kidney stones at a slower rate than they did before starting lemonade therapy. Kang says a large-scale clinical trial will be
  • 18. needed to confirm these findings. "None of the patients needed medical intervention over a mean treatment period of four years," Kang said. But lemonade alone isn't the answer to kidney stones. It's only part of a stone-preventing diet. "First, you should reduce the amount of salt in the diet," Stoller says. "Get rid of the salt shaker at the table. Use a potassium-based salt substitute. If you have a choice of two products, go to the one with less salt. Eat out less -- restaurant food is salty -- and never salt your food before tasting it." Second on Stoller's stone-prevention diet is eating smaller portions of meat and fish at each meal. "We are not saying to eat less meat, just eat less at individual meals," he says. Third, increase fluid intake to where one is passing 1.5 to 2 liters of urine each day. " In the quest for the causes of and potential treatments for rheumatoid arthritis, Japanese researchers have identified a protein that could be a target for future therapy. Rheumatoid arthritis (RA) is a chronic and disabling autoimmune disease that first attacks the fluid that surrounds the joints, causing it to thicken and grow abnormally, damaging the joints and surrounding cartilage rather than protecting them. More than 2 million Americans suffer from the illness, according to the Arthritis Foundation. By identifying a protein that appears to be one of the culprits in the unhealthy buildup of this fluid, which is called synovial fluid, Dr. Yasushi Miura and her colleagues at Kobe University School of Medicine hope that a new, targeted medication can be developed to treat the disease. "The protein Decoy receptor 3 (DcR3) is one of the pathological factors of RA and can be a new therapeutic target for treatment," said Miura, an associate professor in the division of orthopedic sciences at the medical school. DcR3 is a member of the large tumor necrosis factor receptor (TNFR) "super family," which has been identified in the last decade as important in the regulation of cell growth and cell death, fundamental processes in biology, said Dr. Robert Hoffman, director of the division of rheumatology and immunology at the University of Miami Miller School of Medicine in Florida. "We have known of the importance of cell growth and cell death in studying cancer but more recently have found that it is also important in autoimmune diseases like RA and lupus," he said. It was the similarity between the growth of malignant tumors and the abnormal growth of synovial tissue, called hyperplasia, that sparked Miura's research into DcR3 and rheumatoid arthritis. DcR3 is known to be produced in tumor cells, including lung and colon cancers. What Miura and her colleagues found was that DcR3 works with another member of the TNFR family to slow the normal cell death of synovial fluid cells, resulting in the hyperplasia that causes some of the inflammation characteristic of rheumatoid arthritis. Hoffman said: "This is a novel application of the connection between this specific member of the TNFR super family and RA, and studies like this are how we advance science. But it is currently a giant leap to suggest that this could be a therapy for RA." For their study, Miura and her colleagues isolated and cultured synovial fluid from19 patients with rheumatoid arthritis, obtained during total knee replacement surgery. For comparison, they also extracted synovial fluid in the same manner from 14 patients with osteoarthritis. The researchers then exposed the synovial fluid to another TNFR protein called Fas, which induces cell death, called apoptosis. Finally, the fluid was incubated with a pro-inflammatory member of the TNFR family, called TNFa. The TNFR family includes proteins that both induce and retard cell death, Miura explained. While DcR3 was present in the same amounts in the fluids of both the rheumatoid arthritis and osteoarthritis patients, when the TNFa was introduced, DcR3 production increased in the fluid of the RA patients, slowing down the Fas-induced cell death. The rate of cell death did not change in the fluid of the osteoarthritis patients, perhaps, Miura suggested, because the TNFa levels were higher in the fluid of RA patients to begin with. Miura said the results show that DcR3 acts in conjunction with TNFa to suppress the cell death necessary to keep synovial fluid healthy, and research aimed at reducing the amount of DcR3 in the synovial fluid in rheumatoid arthritis patients could be productive. Dr. Stephen Lindsey, head of rheumatology at the Ochsner
  • 19. Clinic Foundation., said, "We are always looking for better and more specific targets to control immune response, and this study is very intriguing." Lindsey said there are drugs available that inhibit those proteins that suppress cell death, but because they are "global," rather than targeted to particular proteins, there are many side affects, including infection. [] Gallstones are stones that form in the gall (bile). Bile is a watery liquid made by the cells of the liver that is important for digesting food in the intestine, particularly fat. Liver cells secrete the bile they make into small canals within the liver. The bile flows through the canals and into larger collecting ducts within the liver (the intrahepatic bile ducts). The bile then flows within the intrahepatic bile ducts out of the liver and into the extrahepatic bile ducts-first into the hepatic bile ducts, then into the common hepatic duct, and finally into the common bile duct. From the common bile duct, there are two different directions that bile can flow. The first direction is on down the common bile duct and into the intestine where the bile mixes with food and promotes digestion of food. The second direction is into the cystic duct, and from there into the gallbladder (often misspelled as gall bladder). Once in the gallbladder, bile is concentrated by the removal (absorption) of water. During a meal, the muscle that makes up the wall of the gallbladder contracts and squeezes the concentrated bile in the gallbladder back through the cystic duct into the common duct and then into the intestine. (Concentrated bile is much more effective for digestion than the un-concentrated bile that goes from the liver straight into the intestine.) The timing of gallbladder contraction-during a meal-allows the concentrated bile from the gallbladder to mix with food. Yo-yo dieting may have another unhealthy and particularly painful side effect for men: gallstones. A new study shows men who repeatedly lose, then regain 20 or more pounds through dieting are up to 76% more likely to develop gallstones later in life than men who maintain a constant weight. Gallstones occur when a solid mass of cholesterol, bile, and calcium salts form in the gallbladder, often causing severe pain in the stomach area and requiring surgical treatment. Obesity and rapid weight loss associated with dieting are known to increase the risk of developing gallstone disease, but researchers say the long-term effects of frequent weight fluctuation on gallstone risk in men hasn't been clear. In the study, published in the Archives of Internal Medicine, researchers analyzed data on nearly 25,000 men who participated in the Health Professionals Follow-up Study. The men provided information on weight fluctuations from 1988 to 1992 and were followed from 1992 to 2002 for gallstones. The results showed gallstones were more likely in men whose weight fluctuated more than 5 pounds than those who maintained a constant weight, and the risk of gallstones increased with the degree of weight fluctuation. Percentages take into account other factors, such as age, physical activity, alcohol intake, smoking, dietary factors, and use of certain medications. The risk of gallstones also increased with the number of yo-yo dieting attempts. Men who lost and regained weight more than once had nearly double the risk of gallstones when compared with men who maintained their weight. Researcher Chung-Jyi Tsai, MD, ScD of the University of Kentucky Medical Center, Lexington, and colleagues say many factors associated with yo-yo dieting may work to raise the risk of gallstones, such as an increased concentration of cholesterol in the bile associated with rapid weight loss. High blood pressure or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase
  • 20. blood pressure. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "pre–hypertension", and a blood pressure of 140/90 or above is considered high. It seems that the association between body mass index (BMI) and high blood pressure or hypertension has decreased since 1989, researchers say. The finding suggests that obesity may not have as much of an impact on heart-related disease as previously thought. "High blood pressure is a leading cause of the global burden of disease," Dr. Pascal Bovet, of the University of Lausanne, Switzerland, and colleagues write in the medical journal Epidemiology. "The prevalence of hypertension, and of several other conditions (including diabetes), is considered to be linked to the worldwide epidemic of obesity." The researchers examined trends in blood pressure and BMI over a 15-year interval in the Seychelles. Their analysis was based on two independent surveys conducted in 1989 and 2004 using representative samples of the population between the ages of 25 and 64 years. There was a slight decrease in average blood pressure between 1989 and 2004 in both men and women. The prevalence of high blood pressure changed little during this time -- from 45 to 44 percent in men and from 34 to 36 percent in women. The percentage of people who were overweight, defined as a BMI of 25 or more, increased from 39 percent to 60 percent between 1989 and 2004. However, the association between BMI and BP decreased "substantially and consistently" between 1989 and 2004, irrespective of sex, Bovet's team writes. "If confirmed, a decreasing association between BMI and blood pressure over time could imply that the impact of the overweight epidemic on cardiovascular disease might be less important than predicted," the investigators conclude. "This decreased relationship could also help to explain the current favorable trends in cardiovascular disease (declining incidence) observed in many countries despite the increasing prevalence of obesity," they point out. [] Chocolate treat may be better than green or black tea at keeping high blood pressure in check. A new study suggests that dark chocolate and other cocoa-rich products may be better at lowering blood pressure than tea. Researchers compared the blood pressure-lowering effects of cocoa and tea in previously published studies and found eating cocoa-rich foods was associated with an average 4.7-point lower systolic blood pressure (the top number in a blood pressure reading) and 2.8-point lower diastolic blood pressure (the bottom number). But no such effect was found among any of the studies on black or green tea. Cocoa and tea are both rich in a class of antioxidants known as polyphenols. But researchers say they contain different types of polyphenols, and those in cocoa may be more effective at lowering blood pressure. ANATOMY OF THE LIVER - the largest organ in the body located under the diaphragm more on the right side of the body specifically at the upper right quadrant of the body. The dark, reddish brown colored liver usually weighs 1.4 kg or about 3 lbs. It is enclosed by a fibrous connective tissue known as capsule. It has four lobes and is suspended from the diaphragm and abdominal wall by a delicate mesentery cord, the falciform ligament. It has many metabolic and regulatory roles; however, its digestive function is to produce bile. Bile leaves the liver through the common hepatic duct and enters the duodenum through the bile duct. The functional unit of liver is lobule and hepatocyte is the major cell. Bile is a yellow-to-green, watery solution containing bile salts, bile pigments(chiefly bilirubin, a breakdown product of hemoglobin), cholesterol, phospholipids, and a variety of electrolytes. Of these components, only the bile salts (derived from
  • 21. cholesterol) and phospholipids aid the digestive process. Bile does not contain enzymes, but its bile salts emulsify fats by physically breaking large fat globules into smaller ones, thus providing more surface area for the fat-digesting enzymes to work on. From the liver, bile drips into the hepatic duct, which soon meets the cystic duct arriving from the gallbladder. Converging, they form one duct, the common bile duct, which meets the pancreatic duct, carrying enzymatic fluid from the pancreas. Like a smaller river meeting a larger one, the pancreatic duct loses its own name at this confluence and becomes part of the common bile duct, which empties on demand into the duodenum. When the sphincter of the bile duct is closed, bile from the liver is forced to back up into the cystic duct, and eventually into the gallbladder. There it is stored and concentrated until needed, when it flows back down the cystic duct. Lobes of liver: - right and left lobes * liver receives blood from 2 sources:  Hepatic artery-will supply oxygen blood to the liver cells  Hepatic portal vein- will bring deoxygenated Functions of liver: 1. Detoxify poisonous and harmful chemicals like drugs and alcohol 2. maintaining blood glucose levels within normal range(70mg-110mg/dL or 80mg-120mg/dL)  Glycogenesis- glucose converted to glycogen and stored in the liver.  Glycogenolysis- stored glycogen converted to glucose  Gluconeogenesis- glucose formation from no-carbohydrate substances such as fats and proteins. Also known as “formation of new sugar” 3. cholesterol metabolism and transport  LDL’s- transports cholesterol and other lipids to body cells -large amounts will be deposited on the arterial walls causing atherosclerosis -tagged as bad lipoproteins  HDL’s- good cholesterol because this is destined to be broken down and be eliminated from the body Functions of bile: - emulsifies fats - absorption of fat-soluble vitamins(K,D, and A) ANATOMY OF THE GALLBLADDER - is a small, thin-walled green sac that snuggles in a shallow fossa in the inferior surface of the liver. When food digestion is not occurring, bile backs up the cystic duct and enters the gallbladder to be stored. While being stored in the gallbladder, bile is concentrated by the removal of water. Later, when fatty food enters the duodenum, a hormonal stimulus prompts the gallbladder to contract and spurt out stored bile, making it available to the duodenum Functions of gallbladder: - Act as storage of to-be-used bile Remember:
  • 22. If bile is stored in the gallbladder for too long or too much water is removed, the cholesterol it contains may crystallize, forming gallstones. Since gallstones tend to be quiet sharp blockage of the common hepatic duct or bile ducts prevents bile from entering the small intestine, and it begins to accumulate and eventually backs up into the liver exerting pressure into the liver cells. Then, bile salts and bile pigments begin to enter the bloodstream. As it circulates through the body, the tissues become yellow, or jaundiced. Jaundice caused by blockage of ducts more often results from actual liver problems such as hepatitis(liver inflammation) or cirrhosis, a chronic inflammatory condition in which the liver is severely damaged and becomes hard and fibrous. ANATOMY OF THE PANCREAS It is an elongated, soft lobulated organ that stretches obliquely across the posterior abdominal wall in the epigastric region. It is situated behind the stomach and extends from the duodenum to the spleen. The pancreas lies across the transpyloric plane. The pancreas is divided into a head, neck, body and tail. The head of the pancreas is disc shaped and lies within the concavity of the deudenum. A part of the head extends to the left behind the superior mesenteric vessels. The neck is the constricted portion of the pancreas and connects the head to the body. It lies in front of the beginning of the portal vein and the origin of the superior mesenteric artery from the aorta. The body runs upward and to the left across the midline. It is somewhat triangular in cross section. The tail passes forward in the splenicorenal ligament in contact with the hilum of the spleen. The pancreas is composed of two major type of cell, the acini and the islet of Langerhans. The acini secretes digestive juices into the deudenum and the islet of Langerhans secrete insulin and glucagons directly into the blood. The secretion of the exocrine portion of the pancreas is collected in the pancreatic duct, which joins the common bile duct and enters the deudenum at the ampulla of Vater. Surrounding the ampulla is the sphincter of Oddi, which partially controls the rate at which secretions from the pancreas and gallbladder enter the deudenum. The secretions of the exocrine pancreas are digestive enzyme high in protein content and an electrolyte-rich fluid. The secretions, which are very alkaline because of their high concentration of sodium bicarbonate, are capable of neutralizing the high gastric juice that enters the duodenum. The enzyme secretions are amylase, trypsin and lipase. The enzyme amylase aids in the digestion of carbohydrate, the trypsin aids the digestion of proteins and the lipase aids the digestion of fats. Other enzyme that promote the breakdown of more complex foodstuffs are also secreted. Hormones originating in the gastrointestinal tract stimulate the secretion of these exocrine pancreatic juices. The hormone secretin is the major stimulus for increased bicarbonate secretion from the pancreas. The vagus nerve also influences exocrine pancreatic secretion. The islet of Langerhans is the endocrine part of the pancreas. It is a collection of cells embedded in the pancreatic tissue. The islet of Langerhans contain three major type of cells, the alpha, beta and delta cells. The alpha cells secrete glucagons, the beta cells secrete insulin and the delta cells secrete somatostatin. Relations: Anteriorly: from right to left, the transverse colon and the attatchment of the transverse mesocolon, the lesser sac, and the stomach. Posteriorly: from right to left, the bile duct, the portal and spleenic veins, the inferior vena cava, the aorta, the origin of the superior mesenteric artery, the left psoas muscle, the left suprarenal gland, the left kidney, and the hilum of the spleen. Pancreatic Ducts: The main duct of the pancreas begins in the tail and runs the length of the gland, receiving numerous tributaries on the way. It opens in the second part of the deudenum at about its middle with the bile duct drains separately into the deudenum. The accessory duct of the pancreas, drains the upper part of the head and then opens into the deudenum short distance above the main duct. The accessory duct frequently communicates with the main duct. Blood Supply: Arteries: The spleenic and the superior and inferior pancreaticoduodenal arteries supply the panceas. Veins: The corresponding vein drain into the portal systm.
  • 23. Lymph drainage: Lymph nodes situated along the arteries supply the gland. The efferent vessels ultimately drain into the celiac and superior mesenteric lymph nodes. Nerve Supply: Sympathetic and parasympathetic (vagal) nerve fibers supply the area. Function of pancreas: Exocrine- release of pancreatic enzymes  Pancreatic lipases- responsible for final digestion of fats  Pancreatic amylase- completes starch digestion  Trypsin- splits proteins into shorter amino acids chains known as peptides  Chymotrypsin, carboxypeptidase- carries about half of protein digestion Endocrine- release of insulin and glucagons by the islets of langerhans  Insulin- high blood glucose levels stimulates its release from the beta cells  Glucagons- low blood glucose levels stimulates its release from the alpha cells • without insulin, blood glucose levels rise to higher levels leading known as hyperglycemia. In such cases, glucose begins to spill into the urine because tubule cells of kidney cannot reabsorb it fast enough. As glucose flushes into the body, water follows leading to dehydration. The clinical name for this condition is called diabetes mellitus. For cells cannot use glucose, fats and even protein are broken down and used to meet body requirements. As a result, body weight begins to decline. Loss of body proteins leads to decreased ability to fight infections, so diabetic must be very careful in hygiene and caring for even small cuts and bruises. When large amounts of fats(instead of sugars) are used for energy, blood becomes very acidic(acidosis)as ketones appear in the blood. • Three cardinal signs are: 1. polyuria- increased urination 2. polydipsia- excessive thirst 3. polyphagia- hunger due to inability to use sugars and loss of fats and proteins Pancreatic juice contains:  Bicarbonates- responsible for its basicity (pH 8) Hormones:  Secretin- causes the liver to increase its output of bile  Cholecystokinin(CCK)- causes gallbladder to contract and release stored bile into the bile duct so that bile and pancreatic juice enter the small intestine together ANATOMY OF THE KIDNEYS The kidneys balance the urinary excretion of substances against the accumulation within the body through ingestion and production. They are a major controller of fluid and electrolyte balance. The kidneys also have several nonexcretory metabolic and endocrine functions, including blood pressure regulation, erythropoietin production, insulin degradation, prostaglandin synthesis, calcium and phosphorus regulation and vitamin D metabolism. The kidneys are two reddish brown bean-shaped organs situated retroperitoneally on the posterior abdominal wall, one on each side of the vertebral column. They lie between the 12th thoracic and the 3rd lumbar vertebrae. The right kidney lies at a slightly lower level than the left kidney (because of the bulk of the right lobe of the liver). The left kidney gives rise to a ureter that runs vertically downward the psoas muscle.
  • 24. Both kidneys move downward in a vertical direction by as much as 1 inch with the contraction of the diaphragm. Adult kidneys average approximately 11cm in length, 5 to 7.5 cm in width, and 2.5 cm in thickness and approximately weigh 113 to 170g. Behind the parietal peritoneum is a mass of perirenal fat or the adipose capsule covers the fibrous capsule which forms the external covering of the kidney and is closely applied to its outer surface. The condensation of connective tissue called Gerota’s fascia which lies outside the perirenal fat encloses the kidneys and suprarenal glands. It is contiuous laterally with the fascia transversalis. Lies external to the renal fascia and often in large quantity is the pararenal fat which forms part of the retroperitoneal fat. The perirenal fat, renal facia and pararenal fat support the kidneys and hold them in position on the posterior abdominal wall. The kidney is further protected externally by layers of muscle of the back, flank, and abdomen as well as by layers of fat, subcutaneous tissue, and skin. The kidney has a curved shape with a convex distal edge and a concave medial boundary. The medial concave border of each kidney is a vertical slit that is enclosed by thick lips of renal substance which is called the hilus. On The hilum extends into a large cavity called the renal sinus. The hilum transmits, the renal vein, two branches of the renal artery, the renal pelvis which is the upper extension of the ureter and the third branch of the renal artery. Lymph vessels and sympathetic fibers also pass through the hilum. Each kidney has a dark brown outer cortex and a light brown inner medulla. The cortex of the kidney lies just under the fibrous capsule and portions of it extend down into the medullary layer to form the renal columns which is called the columns of Bertin. It is a cortical tissue that separates the renal pyramids. The medulla is divided into 8 to 18 cone-shaped masses of collecting ducts called the renal pyramids. Each renal pyramid has its base oriented toward the cortex. Their apices extend toward the renal pelvis forming the renal papilla which projects medially. The papillae have 10 to 25 openings each on the surface through which the urine empties into the renal pelvis. Eight or more groups of papillae are present in each pyramid. Each pyramid empties into a minor calyx and several minor calices join to form a major calyx. The two to three major calices channels the urine from the pyramids to the renal pelvis. The renal pelvis is a cavity lined with transitional epithelium. The combined volume of the pelvis and calices is approximately 8 ml. Volume in excess of this amount damage the renal parechymal tissue. The renal pelvis narrows as it reaches the hilus and becomes the proximal end of the ureter. Within the cortex lies the nephron, the functional unit of the kidney. Each kidney in the human is made up of about 1 million nephrons each capable of forming urine. Each nephron consists of both vascular and tubular elements. The vascular element is the glomerulus through which large amounts of fluid are filtered form the blood and the long tubular element in which the filtered fluid is converted into urine on its way to the pelvis. The glomerulus is composed of a network of branching and anastomosing glomelular capilliaries that have a high hydrostatic pressure (about 60mmHg). The glomelular capilliaries are covered by epithelial cells. Filtration begins at the renal glomerulus. The glomelura tuft or the glomerulus which is composed of a network of branching and anastomosing capiliaries and the beginning of the tubule system which is the Bowman’s capsule. Filtrate from the glomerulus enters the Bowman’s capsule and then passes through a series of tubule segments which is the proximal tubule that modify the filtrate as it passes through the renal cortex. From the proximal tubule, fluid flows into the loop of henle that dips into the renal medulla. Each loop consist of a descending and an ascending limb. The walls of the descending limb and the lower end of the ascending limb are very thin thus are called the thin segment of the loop of Henle. After the ascending limb of the loop has returned part back to the cortex, its wall becomes thick like the other portions of the tubular system. At the end of the thick ascending limb is a short segment known as macula densa. Beyond the macula densa, fluid enters the distal tubule which lies also in the renal cortex. This is followed by the connecting tubule and the cortical collecting tubule, which lead to the cortical collecting duct. The collecting ducts merge to form progressively larger ducts that eventually empty into the renal pelvis through the tips of renal papillae. A secondary capillary bed which is the peritubular capillaries carries the reabsorbed water and solutes back toward the vena cava. Anterior organs of the right kidney are the suprarenal gland, the liver, the second part of the deudenum, and the right colic flexure. Posterior of it are the diaphragm, the twelfth rib, and the psoas and transverses muscle. While in anterior to the left kidney is the suprarenal gland, the spleen, the stomach, the pancreas, the left colic flexure, and coils of jejunum. Posteriorly are the diaphragm, the eleventh and twelfth ribs and the psoas. ANATOMY OF CARDIOVASCULAR SYSTEM
  • 25. Heart Location & Size: Approximately the size of a person’s fist, the hollow, cone-shaped heart weighs less than a pound. The heart is located within the bony thorax and is flanked on each side by the lungs. Its more pointed apex is directed toward the left hip and rests on the diaphragm, approximately at the level of the fifth intercostal space. Its broader posterosuperior aspect, or base, from which the great vessels of the body emerge, points toward the right shoulder & lies beneath the second rib. Covering & Wall: The heart is enclosed by a double sac of serous membrane, the pericardium. The thin visceral pericardium, or epicardium tightly hugs the external surface of the heart and is actually part of the heart wall. It is continuous with the heart base with the loosely applied parietal pericardium, which is reinforced on its superficial face by dense connective tissue. This fibrous layer helps protect the heart and anchors it to surrounding structures, such as the diaphragm and the sternum. The heart walls are composed of three layer. The outer epicardium (the visceral pericardium described above), the myocardium, and the innermost endocardium. The myocardium consists of thick bundles of cardiac muscle twisted in ringlike arrangements. It is the layer that actually contracts. The myocardium is reinforced internally by a dense, fibrous connective tissue network called the “skeleton of the heart.” The endocardium is a thin, glistening sheet of endothelium that lines the heart chambers. Chambers & Associated Great Vessels: The heart has four hollow chambers of cavities—two atria and two ventricles. The superior atria are primarily receiving chambers. As a rule, they are not important in the pumping activity of the heart. Blood flows into the atria under low pressure from the veins of the body and then continues on to fill the ventricles. The inferior thick-walled ventricles are the discharging chambers or actual pumps of the heart. When they contract, blood is propelled out of the heart and into the circulation. The septum that divides the heart longitudinally is referred to as the interventricular or interatrial septum, depending on which chamber it divides and separates. Although it is a single organ, the heart functions as a double pump. The right side works as the pulmonary circuit pump (pulmonary circulation) and the left side is responsible for the systemic circulation. Valves: The heart is equipped with four valves, which allow blood to flow in only one direction through the heart chambers. The atrioventricular, or AV, valves are located between the atrial and ventricular chambers on each side. The AV valves prevent backflow into the atria when the ventricles contract. The left AV valve—the bicuspid or mitral valve consists of two cusps, or flaps, of endocardium. The right AV valve, the tricuspid valve, has three cusps. Tiny white cords, the chordae tendianeae—literally “heart strings”, anchor the cusps to the walls of the ventricles. The second set of valves, the semilunar valves, guards the bases of the two large arteries leaving the ventricular chambers. Thus, they are known as pulmonary and aortic semilunar valves. Each semilunar valve has three cusps. Each set of valves operates at a different time. The AV valves are open during heart relaxation and closed when the ventricles are contracting. The semilunar valves are closed during hear relaxation and are forced open when the ventricles contract. Cardiac Circulation: Although the heart chambers are bathed with blood almost continuously, the blood contained in the heart does not nourish the myocardium. The blood supply that oxygenates and nourishes the heart is provided by the right and left coronary arteries. The coronary arteries branch from the base of the aorta and encircle the heart in the atrioventricular groove at the junction of the atria and ventricles. The coronary arteries and their major branches (the anterior interventricular and circumflex arteries on the left, and the posterior interventricular and marginal arteries on the right) are compressed when the ventricles are contracting and fill when the heart is relaxed. The myocardium is drained by the cardiac veins, which empty into a large vessel on the backside of the heart called the coronary sinus. The coronary sinus, in turn, empties into the right atrium. Conduction System of the Heart:
  • 26. Two types of controlling systems act to regulate heart activity. One of these involves the nerves of the autonomic nervous system that act like “brakes” and “accelerators” to decrease and increase the heart rate depending on which division is activated. The second system is the intrinsic conduction system, or nodal system, that is built into the heart tissue. The intrinsic conduction system is composed of special tissue found nowhere else in the body. This system cause heart muscle depolarization in only one direction—from the atria to the ventricles. In addition, it enforces a contraction rate of approximately 75 beats per minute on the heart; thus, the heart beats as a coordinated unit. One of the most important parts of the intrinsic conduction system is a crescent-shaped node of tissue called the sinoatrial (SA) node, located in the right atrium. Other components include the atrioventricular (AV) node at the junction the atria and ventricles, the atrioventricular (AV) bundle (bundle of His), and the right and left bundle branches located in the interventricular septum, and finally the Purkinje fibers, which spread within the muscle of the ventricle walls. Because the SA node has the highest rate of depolarization in the whole system, it starts each heart beat and sets the pace for the whole heart. Consequently, it is often called the pacemaker. SYSTEMIC CIRCULATION Left Atrium ↓ Mitral valve ↓ Left Ventricle ↓ Aortic Semilunar Valve ↓ Aorta ↓ All parts of the body Regulating Blood Pressure: The Renin-Angiotensin-Aldosterone System
  • 27. 1.
  • 28. STATEMENT OF THE PROBLEM This case study aims to determine “How the patient acquired one illness to the development of another, and the process by which the body responds to the situation”. This also specifically attempts to answer the following questions: • What are Diabetes Mellitus, Hypertension, Cholelithiasis, Nephrolithiasis and Rheumatoid Arthritis? • What system, organs or parts of the body are affected by the disease process? • Where and how the illness was obtained, how it progressed and affected the body? • What were the predisposing factors that lead the patient to acquire the diseases? • Why dialysis is needed to be performed to the patient? • What interventions are needed to manage such condition? Were the interventions effective in helping the patient recover?
  • 29. THEORETICAL BACKGROUND The function of a theoretical framwework is to guide the research process. Nursing has passed the point where it operates within the framework of functionalism- only relating one variable to another. The theory must be both understandable and applicable to the real world of nursing. The Betty Neuman Health Care Systems Model This health care systems model is called the “Total Person Approach to Patient Problems.” The conceptual framework encompassing this model vies people as unique individuals with a composite of characteristics within a normal given range of response. Each person in a state of wellness or illness is a dynamic composite of the interrelationship of physiological, psychological, sociocultural, and developmental variables. Although Neuman uses the term composite, the conceptual framework encompasses the Gestalt theory, which holds that each of us is surrounded by a perceptual field that is in a dynamic equilibrium. A field theory approach such as this maintains that all parts are intimately related and interdependent. The total organization of the field and its impact upon the functional behavior of the individual is the primary focus. In this total person model, the organization of the field considers: 1. the effect of the stressors 2. The reaction of the organism to the stressors 3. The organism itself, while taking into consideration the simultaneous interaction of the physiological, psychological, sociocultural, and development variables.
  • 30. This total person framework, then, is an open system model with two major components, stress and the reaction to stress. In the Gestalt theory each stressor would affect the individual’s reaction to any other stressor. The individual’s behavior then would be a function of the dynamic interaction between stressors and the defenses against stressors supplied by the individual as well as the supporting environment. Commonplaces Commonplaces are topics commonly addressed by most theorists. These topics are usually vague, indicating locations rather than specific entities. The commonplaces in a theory may be used to organize a theory or as structures with which to evaluate and understand a theory. Definitions of the commonplaces utilized in the Neuman Systems Model are made by identifying the elements and relationships that have significance for Neuman. Person The conceptual framework encompassing this model views people as unique individuals who are a composite of characteristics within a normal given range of response. Each person in a state of wellness or illness is a dynamic composite of the interrelationship of physiological, psychological, sociocultural, and developmental variables. Person is an open system with interaction with the environment. Nursing Nursing is viewed as a unique profession in that it is concerned with all the variables affecting an individual’s response to stressors. The nurse has an obligation to seek the highest potential level of stability for each individual. Health Wellness is considered the ability of an individual’s flexible line of defense against any stressor to maintain equilibrium. Any variances of wellness occur when stressors are able to penetrate the flexible line of defense. Neuman views health on a continuum with levels of wellness and variances of wellness. If a person’s total needs are met, he or she is in an optimal level of wellness. Hence, a reduced state of wellness is the result of needs not being met. Person to Nurse The nurse assesses and validates the individual’s response to stressors. Response to some stressors are known whereas others are manifested depending on the meaning of the experience to the individual. The nurse has a knowledge of the relation of the environment and the person’s reaction to stress and reconstitution. Person to Health People retain harmony and balance with the environment by a process of interaction and adjustment. Persons are views as a total person composed of physiological, psychological, sociocultural, and developmental variables. The interrelationship of these variables determines the degree of reaction and individual has to any
  • 31. stressor. Each individual is seen as unique, but containing a blend of common attributes within a normal range of response. This normal range of response is known as a normal line of defense- that which is necessary to maintain an individual’s equilibrium. Nursing to Health The nurse assists individuals, families, and groups to attain or maintain a maximum level of wellness by appropriate interventions. Nursing actions are interventions at the primary, secondary, and tertiary prevention levels that will reduce stress factors, strengthen the line of defense, and maintain a reasonable degree of adaptation. Environment The environment consists of internal and external factors. Internal is the flexible line of defense against stressors, such as the body’s immune response pattern or the mobilization of white blood cells. External consists of an individual’s coping ability, lifestyle, developmental stage, and so forth, and is known as the normal line of defense. Stressors Stressors may vary as to impact or reaction. There are three types of stressors: 1. Intrapersonal forces occurring within the individual. 2. Interpersonal forces occurring between one or more individuals. 3. Extrapersonal forces occurring outside the individual. A stressor attempts to penetrate an individual’s normal line of defense to cause disequilibrium
  • 32. CHAPTER TWO Data Collection, Analysis and Interpretation OPT Model CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION R.M, 58 years old, male, Roman Catholic, Filipino, residing at Matabao, Tubigon Bohol, Birthdate October 22, 1948 , was admitted for the 3rd time in Cebu Velez General Hospital (CVGH) for complaints of vomiting and right epigastric pain. Patient was admitted under the services of Dr.Cesar Quiza under the Department of Internal Medicine with the case number of 88358. History of Present Illness 1 month PTA, pt complained of vomiting of previously ingested food with an estimate of 1/8 cup per episode, every after meal with 2-3 episodes per day for duration of 1 week. He lost 10 kg in a month and sought no consult nor self-medicated. 3 wks PTA, pt sought consult @ Ramiro Hospital in Bohol where he was confined for a day and was ordered for UGI endoscopies, UTZ, CBC,U.A,. The UTZ ER Blotter Accompanied by wife, patient arrived at CVGH-ER at 8:50am on June 27, 2007 per taxi, awake, conscious, responsive, coherent, afebrile, with the following vital signs: BP:120/80mmHg PR: 70 bpm RR: 30 cpm T: 36.0 C/axilla. At around 9:50 am, she was admitted to the Medical-Surgical department under the services of Dr. Cesar Quiza with case # 88358 and was transported around 10:00 am to PPW 4th floor per wheelchair. DATE OF ASSESSMENT: June 28, 2007 Ht: 175cm Wt: 85 kg IBW: 68 kg Physiologic Measurements T°: 36.5°C/axilla RR: 23 cpm PR:84 bpm BP: 110/80 mmHg June 28, 2007 GENERAL APPEARANCE
  • 33. was taken and revealed renal and gall bladder stones and his UGI endoscopies showed gastric erosions. No management was done. He was discharged improved but upon arriving home complained of left flank, intermittent pain, which was associated with urgency and frequency of urination, but no pain and change in urine color, was noted. 5 days PTA, pt sought consult with an AP who advised for admission for further treatment and monitoring. The night after consult they went back to Bohol to settle things at home before admission. Pt was admitted @ CVGH 2 days after consult last 6/27/2007(Wednesday). PAST HISTORY Health History 1.) 16 yrs PTA diagnosed with DM type 2 with poor compliance to meds. CBG monitoring was not practiced. His maintenance meds include glipizide (Minidiab) 5mg/tab 1 tab OD and metformin (Glucophage) 500mg/tab, 1 tab BID. He had occasional complaints of tingling sensation in the hands but not in the feet and with increased urgency and frequency of urination especially at night, voiding up to 4 times per night. 2.) 16 yrs PTA, he experienced one episode of painless passing out of urinary stone. He had reports of left 4pm >seen on bed, awake, conscious, responsive, coherent, with IVF 1 PNSS 1 liter @ 10 gtts per minute infusing well on left hand, with the following vital signs: PR: 84 bpm RR: 23 cpm BP:110/80 mmHg T: 36.5°C/axilla Skin and appendages: Presence of IV line on left arm, Presence of jaundice on skin and soles of feet and palms with good skin turgor, no edema, no lesions, long fingernails and toenails with pale nail beds, with presence of nail clubbing, with CRT >2 secs, no cyanosis. Head: normocephalic, (+) ROM, Hair is fine, wavy, black, presence of dandruff but no lice infestations Eyes : symmetrical, anicteric sclerae, smooth, moist and pale palpebral conjunctivae and clear bulbar conjuctivae, (-)discharges, equal distribution of eyebrows and eyelashes, (+) Pupils Equally Round and Reactive to Light and Accomodation, wears reading glasses with unrecalled grade Ears : symmetrical, no lesions, pinna is in line with the outer canthus of the eye, no swelling, pinna is nontender, no discharges noted on auditory meatus. Nose: symmetrical, no masses, no discharges, nasal septum at midline Mouth and throat: lips are symmetrical but pale, no ulcerations and no lesions, pinkish gums with no ulcerations, tongue located at midline, uvula at midline, with presence of tooth decays, no lesions, equal chest expansion, presence of 2 molars,2 pre molars,2 canines and 2 incisors on lower teeth Lungs: Equal lung expansion, upon auscultation, clear breath sounds, no rales and crackles heard upon auscultation Heart: distinct s1 and s2 heart sounds upon ausculation, no murmurs heard, heart rate of 84 bpm with regular rhythm.
  • 34. flank, intermittent, non-radiating pain. It was not relieved with position changes. The symptoms recurred 7 yrs PTA and no consultation and meds were done 3.) 6yrs PTA was diagnosed with Secondary HPN by Dr. Lara, their family doctor with maintenance meds of captopril (Capoten) 25mg OD taken with good compliance. 5 days PTA med was shifted to valsartan (Diovan) 80mg/tab 1 tab OD. His wife monitors his BP regularly with the usual readings of 110-140/80mmHg and with the highest reading of 160/90mmHg. 4.) 7yrs PTA diagnosed with Rheumatoid arthritis by Dr. Quiza @ CVGH. His symptoms include weakness and pain in both Calves on legs upon eating internal organs. He was given Celebrex 200mg 1 tab PRN as pain reliever. Previous Hospitalizations: Previous hospitalizations include one in the 1960’s when R.M was still in his 20’S far inguinal Hernia @ CVGH by Dr. Tambuyong. He went under Hernioraphy. He suspected that the cause of his hernia was because of not wearing a supporter when playing basketball. He claimed to feel pain and felt his testes becoming heavy everytime he stands. He was given unrecalled meds and was discharged 3 days after with condition improved. Abdomen: protuberant, no masses, no tenderness, presence of bowel sounds at 8 gurgling sounds/minute auscultated at right lower quadrant, (+) liver hook test, (-)kidney punch, (-) Murphey’s sign GUT-Reproductive: grossly male, no swelling, no abnormal discharges, no lesions, no rashes. Anus: no lesions, no hemorrhoids, no rashes. Extremities: symmetrical, (+) ROM for all extremities, no lesions, presence of bent little finger at right hand Musculoskeletal: good muscle tone. NEUROLOGIC ASSESSMENT Mental Status/Cerebral Functioning Awake, alert, conscious, responsive, coherent. Motor/Cerebellar Functioning Able to grasp student nurse’s wrist tightly. Extremities symmetrically folded inward with good muscle tone. Reflexes (+) triceps reflex (+) biceps reflex (+) Achilles reflex (+) patellar reflex Sensory Functioning Responsive to light touch (hanky) and pain (slight pinch) at both upper and lower extremities and both sides of the face. Cranial Nerve Testing CN 1 (Olfactory) – distinguished the smell of lotion from alcohol CN 2 (Optic) – (+) PERRLA,(+) Blinking reflex CN 3 (Oculomotor) – (+) PERRLA CN 4 (Trochlear) – (+) PERRLA (+)Cardinal Gaze CN 5 (Trigeminal) – (+) blink reflex, can open and close mouth, can feel the touch of student nurse’s hand on face CN 6 (Abducens) – (+) PERRLA (+)Cardinal Gaze CN 7 (Facial) – able to close eyes, can smile, wrinkle forehead, can clench jaw from side to side CN 8 (Auditory) – (+) whisper test, can hear the tick of the
  • 35. His second hospitalization was in the 1980’s @ Ramiro hospital in Bohol for pneumonia. His occasional complaints were chest pains. He was given unrecalled meds and was confined for five days. After discharge, he transferred to CVGH by his request for 2nd opinion and further treatment and monitoring. He was confined @ CVGH for 3 days with condition improved. His third hospitalization was in 1991 for MVA @ CVGH. Pt claimed to have dislocated his right arm because he was using it to hold his body up from falling from the accident. Pt recalled being chased by dogs from behind his motorcycle and was forced into a post at the corner of the road. His x-ray revealed no fractures. He was given unrecalled meds and was on cast for 3 mos. Where it was removed by Dr. Mediano @ CVGH. He was confined for 3 days with condition improved. His fourth hospitalization was last Oct.23,2006 @ Ramiro hospital in Bohol for complications from MVA 6 months PTA. He recalled being chased again by dogs from behind his motorcycle and he was crashed to a nearby tree. Before hospitalization R.M noticed swelling of his feet. The next month, he went to Dr. Lim’s clinic @ Ramiro hospital and was advised for an x-ray of both femurs and it revealed no fractures. He was advised to use crutches from the swelling of his feet. He went back to Dr. lim’s clinic 6 month’s PTA for wrist watch at 1 foot away CN 9 (Glossopharyngeal) – (+) gag reflex, able to swallow, able, can taste sugar at the anterior part of the tongue CN 10 (Vagus)- (+) gag reflex , able to swallow, can taste salty food at the posterior part of the tongue CN 11 (Accessory) – able to shrug shoulder against resistance CN 12 (Hypoglossal) – mouth opens when nose is pinched, tongue midline at protrusion DATE OF ASSESSMENT: June 29, 2007 General Appearance: 4pm> Seen lying on bed, awake, conscious, responsive, coherent, afebrile, with IVF of 1 PNSS 1 liter @ 10 gtts / min, infusing well at left hand, with the following vital signs: Temperature: 36.3ºC/axilla Pulse Rate: 85 bpm Respiratory rate: 23 cpm BP: 120/80mmHg Significant findings: Skin and appendages: Presence of IV catheter on left arm, CRT of > 2 seconds, (+) jaundice on skin , in palms of hand and soles of feet Eyes: pale palpebral conjunctivae Mouth and Throat: pale lips, presence of tooth decays, Extremities:presence of bent little finger at right hand DATE OF ASSESSMENT: June 30, 2007 General Appearance: 4pm> Seen sitting on bed, awake, conscious, responsive, coherent afebrile, with IVF of 1PNSS 1 liter @ 10 gtts / min, infusing well at left hand, with the following vital signs: Temperature: 36.5ºC/axilla Pulse Rate: 85 bpm Respiratory rate: 15 cpm BP:120/80 mmHG
  • 36. complaints of pain from his calves and was advised for admission for his rheumatoid arthritis. He was given celebrex 200mg BID and was discharged 3 days after without crutches and with condition improved. Family History: Herdofamilial diseases include cancer (cervix, prostate) in the mother’s side and DM, stroke and arthritis in the father’s side. Genogram: 1. Health perception - Health management Pattern Pt is a hypertensive, diabetic, non-asthmatic, occasional alcoholic beverage drinker amounting to 4 Significant findings: Skin and appendages: Presence of IV catheter on left arm, CRT>2 seconds, presence of nail clubbing Mouth and throat: presence of yellow teeth, presence of tooth decays Extremities: presence of bent little finger at right hand LABORATORY FINDINGS June 7, 2007 UREA BLOOD TESTING Urea blood testing is done to determine whether your kidneys are functioning normally. It also determines whether your kidney disease is getting worse. It monitors treatment of your kidney disease. It determines whether severe dehydration is present. It may also help determine whether decreased kidney function is the result of dehydration or kidney disease. Uric: 11.1 mg/dl ref range (2.3 – 8.2) ↑ Crea D: 6.2 mg/dl ref range (0.5 – 1.3) ↑ Urea: 50 mg/dl ref range (7 – 18) ↑ Implications: Uric acid ♦ Clinical problems associated with elevated serum uric acid levels arise from the limited solubility of this compound. Increase in uric acid in serum rises above, it begins to precipitate out of solution. May result Maternal Paternal Deceased female Deceased male female male patient Legend:
  • 37. glasses per day and a smoker for 5 yrs now consuming 1 pack per day and stopped 3 months ago with 5 pack yrs. R.M doesn’t have regular medical check-ups and only seeks medical attention when the need arises. Patient takes OTC drugs. If he has fever, he takes Biogesic (C: antipyretic and anti-inflammatory A: Inhibits the synthesis of prostaglandin that serve as mediators of pain and fever primarily in the CNS) and if he has colds, he takes Neozep and afforded relief. He takes Lomotil or Diatabs for diarrhea(c :antidiarrheals a: slow intestinal motility and propulsion). He takes vitamin c for vitamins (c: multivitamins a: serves as components of enzyme systems that catalyze numerous varied metabolic disorders). He takes herbal medicines (ROCH herbal capsule as herbal supplement 1 tab before going to sleep and is taking it for 1 month now), he claimed that he believes it can heal his rheumatoid arthritis. He does not believe in folk healers. He claimed he doesn’t know how to perform TSE. Patient claimed he is to gout, related to deposition of formation of stones in the kidney. Creatinine ♦ An increase significantly is alleged to have significant impairment of kidney function. Urea ♦ An increase in urea nitrogen is believed to cause in a wide variety of disorders which produce renal impairment. Sample entered 10:50 am 22 - June - 07 Report printed 10:50 am 22 - June - 07 Test name Result Code units Normal range ALT ↑48 # IU/L 0 – 41 Creatinine ↑10.8 #mg/dl .6 – 1.5 Sodium 138 #mmdl/L 136 – 142 Potassium 5.1 #mmo;/L A – 5.6 Implications: Alanine aminotransferase (ALT) ♦ An increase in ALT and AST (Aspartate aminotransferase) are related to liver damage. ALT is more elevated than AST in various inflammatory conditions of the liver reflecting its greater specificity as liver disease marker.
  • 38. not fully immunized , and goes to the dentist when need arises. His last dental check up was when he was still in his elementary yrs. 2. Nutritional-metabolic Pattern Patient eats 5 to 6 times a day with snacks in the morning, afternoon and evening. He claimed he eats mostly fatty, salty and sweet foods. He usually eats breakfast at 7 to 8 am comprising of egg, rice and milo. If rice is unavailable, he replaces them with bread. He takes his lunch at 12 pm and usually eats fried meat, at least 3cups of rice, “kinilaw”1 banana/mango and cold water. Dinner is taken at around 6:30-7 pm comprising of meat, at least 3 cups of rice and cold water. Patient's favorite food is “kinilaw” and prefers to drink cold water. He does not have intolerance to any type of food but has difficulty in chewing hard foods because of he has molars only in the upper teeth and has no difficulty in swallowing. He seldom takes vitamins and supplements and claimed he takes it only when they remember to buy vitamin c ( c: multivitamins a: boosts immune URINE EPITHELIAL MACROSCOPIC Granular – finely Color – yellow Coarsely 0 – 1/hpf Appearance – slightly cloudy waxy pH – 5.0 Mucous threads Specific gravity – 1.006 Amorphous material – urates few Protein – negative Bacteria – few Glucose – negative Crystals MICRO miscellaneous RBC/hpf 0 – 3/hpf Bence – jones protein WBC/hpf 2 – 4/hpf Calcium Epithelial cells 0 – 1/hpf Chloride CASTS Potassium Hyaline Sodium RBC 24 – hr protein WBC Heart and acetic *ketone negative Acid negative *blood negative *lab test 5 used UTZ Upper Abdomen This test is to confirm the diagnosis of
  • 39. system). Patient drinks at least 10-12 glasses of water/day. During hospitalization, his diet prescription was a full low salt, low cholesterol, low fat, low purine, diabetic diet at 1,800 calories per day divided into 3 meals and two snacks with the ff. specifications:CHO-270 grams,CHON-90 grams, Fat- 40grams. 3. Elimination pattern Pattern He voids 3 times in the morning and 3 times at night, amounting to 200ml per void. His urine is usually yellow in color. When patient experiences constipation, he just drinks lots of water and when experiences diarrhea, patient takes in Lomotil or Diatabs. During hospitalization, Patient urinates more than 1,000ml of urine per day with a dark yellow colored urine. He defecates every morning daily with brown, well formed stools and claims to have no difficulty defecating. During hospitalization, no changes in bladder and bowel habits were observed as claimed by cholelithiasis. It is also able to distinguish obstructive and non - obstructive jaundice. Examination reveals the liver is normal in size and echo pattern. There are no dilated intra hepatic ducts or masses noted. There is 8.00mm stone within gallbladder. The gallbladder wall is not thickened. The common duct is normal The spleen is normal Conclusion: gallbladder stone, no evidence of cholecystitis. Urinalysis 6 – 7 – 07 Urine is examined to know the various properties of urine, a routine procedure for every patient to determine any pathological disorders. MACROSCOPIC MICROSCOPIC Gross – yellow/clear WBC/ HPF 5 – 8 Specific gravity – 1.025 RBC/HPF 0 – 1 Reaction plt 6.0 Epith/HPF 0 – 2 Albumin 7 + 1 Bacteria few Heat and HAC negative Glucose negative Beneditel
  • 40. the patient. 4. Activity-exercise pattern Patient was a retired police man with a rank of SPO3. He retired in the year of 2001. His working hours before he retired was 24 hours starting from 8:00 am that morning until 8:00 am the next day. His daily routine before going to work was doing 20 push –ups, take a bath, eat breakfast and then off for work. During his off from work he usually visits his farm, stroll the town, go to the beach, visit other people or goes to sleep. He also takes afternoon naps. Before his hospitalization he frequently exercises such as doing push – ups about 20 repetitions. He occasionally jogs about an hour or more. Before his retirement he claimed that his job was stressful when he is not in his office. He also said that good thing he didn’t encounter any NPA in his area. Patient also claims that the situation have changed mainly during his hospitalization. negative Ketone negative Blood negative Casts. Hyaline/HPF negative Granular, coarsely negative Granular, finely negative Red cell negative Leukocyte negative Others negative Cyst : coax/HPF negative Triple negative Uric acid negative Amorphous urates few Serum Blood Test Blood is drawn to examine substances within it, such as drugs and hormones. Laboratory examination of blood provides
  • 41. 5. Sleep-rest pattern Patient takes afternoon naps sleeping aids include a pillow and a blanket. Before hospitalization, He usually wakes up at around 6am and sleeps at around 8-9pm. While hospitalized, he usually sleeps at around 8pm and claimed not to have enough rest and sleep due to the adjustment to the environment, he usually wakes up at 7am in the hospital. 6. Cognitive-perceptual pattern Patient wears reading glasses with unrecalled grade and does not have any hearing problems. He is oriented to time and place and can recall past events. Patient is a college graduate and graduated nautical from Cebu Political School in the year 1967. He went on training as a police apprentice and was promoted SPO3 in the year 1972. 7. Role-relationship pattern The patient, as described by his wife is a loving person, father and a responsible barangay captain valuable information about many disease processes and body systems. Complete blood count WBC 6.83 K/uL WBC 4.10 – 10.9 NEU 3.91 57.2 %N NEU 2.50 – 7.50 47.0 – 80.0 %N LYM 2.05 29.9 %L LYM 1.00 – 4.00 13.0 – 40.0 %L MONO .349 5.10 %M MONO .100 – 1.20 2.00 – 11.0 %M EOS .408 5.97 %E EOS 0.00 – . 500 0.00 – 5.00 %E BASO .12 1.81 %B BASO 0.00 – 1.00 0.00 – 2.00 %B PATIENTS LIMITS SET 2 RBC ↓3.59 m/uL RBC 4.00 – 5.20 HGB ↓9.62 g/dL HGB 12.0 – 16.0 HCT ↓29.6 % HCT 36.0 – 46.0 MCV 82.3 fL MCV 80.0 – 100 MCH 26.8 pg MCH 26.0 – 34 MCHC 32.5 g/dL MCHC 31.0 – 36.0 RDW 13.7 % RDW 11.6 – 18.0 PLT 258 k/uL PLT 140 – 440 MPV 7.51 fL MPV 1.00 – 100 COMMENTS: Mild hypochromia 7/01/07 7:40 pm blood urea nitrogen test
  • 42. of their town. He is also the comedian in the family. He is the eldest from his sibling. He is the provider in the family. He is in good terms with his parents, siblings, children and friends. He is happily married with his second wife for 8 years now. His first wife died from pelvic cancer in the year 1988 and had 3 daughters from her. Their eldest daughter graduated from mass-communications, the second works in Manila, their youngest daughter is in Cebu and is applying as an office administrator. 9. Sexuality-reproductive pattern Patient was circumcised at the age of 9 . Claimed that his first sexual contact was with his first girlfriend at the age of 16yrs old. Had several sexual partners during his adulthood being an apprentice as a seaman. Doesn’t practice the use of contraceptives. Patient claims to have no history of STD. Before hospitalized is sexually active and claims to do the act twice a week. Current illness affected sexual activities with his wife who claims that their last sexual contact was Crea D: 5.3 mg/dL (0.5 – 1.3)↑ Hematology 7/01/07 WBC 6.29 K/uL WBC 4.10 – 10.9 NEU 3.24 51.5 %N NEU 2.50 – 7.50 47.0 – 80.0 %N LYM 2.13 33.9 %L LYM 1.00 – 4.00 13.0 – 40.0 %L MONO 0.412 6.55 %M MONO .100 – 1.20 2.00 – 11.0 %M EOS 0.431 6.84 %E↑ EOS 0.00 – . 500 0.00 – 5.00 %E BASO 0.076 1.21 %B BASO 0.00 – 1.00 0.00 – 2.00 %B PATIENTS LIMITS SET 2 RBC ↓3.25 m/uL RBC 4.50 – 5.90 HGB ↓8.90 g/dL HGB 13.5 – 17.0 MCV 83.4 fL MCV 80.0 – 100 MCH 27.4 MCH 26.0 – 34 MCHC 32.8 g/dL MCHC 31.0 – 36.0 RDW 14.2 % RDW 11.6 – 18.0 PLT 217 k/uL PLT 140 – 440 MPV 8.67 fL MPV 1.00 – 100 Conclusion: Erythrocytes show mild hypochromia 7/04/07 Crea D: 4.6 mg/dL (0.5 – 1.3)↑ 7/4/07 WBC 7.63 K/uL WBC 4.1 0 – 10.
  • 43. 1month ago 10. Coping-stress pattern Defines stress as something that can make someone tired. Currently stressed because of current physical condition. Consults wife and family members in making decisions. Has a pleasant disposition in life despite of illness. Long term stressor include financial problems, and short term stressor include the problems in the community. Goes to farm to relieve short term stress and He Shares problem with family and his constituents especially in solving conflicts in the neighborhood. His daughters help in the financial problems. Support comes mainly from family and close relatives and seeks for friend's advices. He usually relieves stress by resting. 11. Self-Perception Self-Concept Pattern Patient described himself as a hardworking person. He is satisfied with his current position being the Brgy. Capt in their place. He is happy to have helped a lot of people and claimed to have implemented a lot of projects in their place. He 9 NEU 4.11 54. 1 %N NEU 2.5 0 – 7.5 0 47.0 – 80.0 %N LYM 2.57 33. 8 %L LYM 1.0 0 – 4.0 0 13.0 – 40.0 %L MONO 0.51 2 6.7 4 %M MONO . 100 – 1.2 0 2.00 – 11.0 %M EOS 0.40 0 5.2 7 %E EOS 0.0 0 – . 500 0.00 – 5.00 %E BASO 0.40 . 136 %B BASO 0.0 0 – 1.0 0 0.00 – 2.00 %B PATIENTS LIMITS SET 2 RBC ↓3.6 8 m/uL RBC 4.0 0 – 5.2 0 HGB ↓10. 3 HGB 12. 0 –
  • 44. claimed his happiness and contentment will be more felt if only his illnesses were absent. Contented to have provided his family with good life. 12.Value-belief pattern Patient is a Roman Catholic and sometimes goes to church on Sundays with his wife and claims to pray everyday. She values health and sees it as a wealth. Patient does not have any superstitious beliefs. Environmental history: Patient lives with his wife and a houseboy in Matabao, Tubigon Bohol in a 1-storey house made of mixed materials. They have 2 bedrooms, a separate room for the living room and the dining room. It has enough ventilation owing to 9 screened windows. Their house is furnished. It has a TV set and 3 electric fans. Water source is from the barangay waterworks in Tubigon Bohol. Electricity is from BOHECO. Drainage is closed. Toilet is water sealed type. Their garbage disposal is through motorized garbage collection. They live 1KM from the main road, 1 1/2KM from the market, police station, church and from the nearest Barangay Health Center. They live in a congested area, as claimed by the patient’s wife. g/dL 16. 0 HCT ↓31. 1 % HCT 36. 0 – 46. 0 MCV 27.9 pg MCV 80. 0 – 100 MCH 27.9 pg MCH 26. 0 – 34 MCHC 33.1 g/dL MCHC 31. 0 – 36. 0 RDW 14.5 % RDW 11. 6 – 18. 0 Conclusion: ♦ few hypochromic RBC noted ♦ rare presence of stomatocytes noted 6/29/07 UTZ KUB Right kidney measures 8.0 x 4.0 cm. cortical thickness 1.2 cm. left kidney measure 12.1 x 6.1 cm cortical thickness 2.1 cm. Examination reveals a right kidney is
  • 45. small and echogenic. There is a small stone at lower pole. There are no hydronephrosis seen. There is fluid surrounding right kidney. The left kidney “blank” a 1.1 cm stone at the lower pole. The calyces are dilated. ♦ The ureters are remarkable ♦ The urinary bladder is remarkable ♦ Prostate gland is enlarged Conclusions: ♦ Small right kidney ♦ Echogenic right kidney ♦ Fluid surrounding kidney ♦ Stone in right kidney ♦ 1.1 cm stone left kidney, associated with hydronephrosis ♦ Enlarged prostate gland Lipid Panel Test (June 27, 2007) Result Normal Value Cholesterol 140 mg/DL 131-239 Glucose 111 mg/D 75-116 HDL-Chlesterol 23 mg/DL >35 Triglycerides 169 mg/DL 0-200 LDL-Cholesterol l12 mg/DL 118-187
  • 46. VLDL 34 mg/DL up to 40 >lipid panel is done to have a reliable prediction of the amount of risk an individual has for heart ailments > a decrease in HDL suggests that there is poor transport of cholesterol in liver to be secreted as bile June 27, 2007 Glycosylated Hemoglobin = 7.3% (normal value 4.5%-6.3%) > a reliable assessment of glucose level in patients over a period of 1 month.  an elevated level suggests that the glucose levels have been high for the past few weeks, this suggests that the therapy is not working or there is poor compliance with the therapy Hepatitis Tests ( June 28, 2007) >to test for the presence of Hepadna Virus in blood >to test for the presence of small RNA virus in the family Picorna Viridae Result Interpretation Anti-HepC 1.00 0,22 non-reactive
  • 47. (anti-HCV MEIA) June 7, 2007 Chest PA Examination reveal the lung fields are clear. The thoracic aorta and pulmonary vessels are unremarkable. The trachea is in the midline. There are no abnormalities Essentially Negative chest >x-ray is done to demonstrate any cartilage abnormalities, abnormal bony growth, and to demonstrate the location and size of the organs. June 7, 2007 Ultrasound Report (UA) Sonologic Findings Liver Span: 13.70 cm Gallbladder lumen: 1.96 cm (<4.0cm) Spleen (length): 10.99cm (<12anl) Abdominal Aorta: 1.75 cm Findings: Unremarkable Pancreas: Unremarkable Spleen: Unremarkable Abd Aorta: Unremarkable Incidentally, there is a bright ethogenic foci with distal acoustic shadowing seen in the left kidney. The left renal calyces and pelvices are dilated.
  • 48. Conclusions: 1) Cholelithiasis, as prescribed above. 2) Presence of non-shadowing oval lesions adherent to the wall of the GB polyps are considered 3) Incidental findings of left nephrolithiases with marked pelvocaliectasia 4) Unremarkable liver, spleen, pancreas, abdominal aorta sonographically >valuable when esophagus, gastric, or duodenal abnormalities or inflammatory of infections are suspected, this procedure can also be used to evaluate esophageal and gastric motility and to select secretions and tissue specimen for further analysis. June 7, 2007 Upper Gastrointestinal Endocopoy Post-endoscopic Dx: Chronic Erosive
  • 49. Summary of Significant Findings: 1. Heredofamilial disease includes and cancer and DM, stroke and arthritis on the paternal side. 2. Px consumes 10-12 glasses per day 3. Px voids 3 times per day and 3 times per night amounting to 200ml per void. 4. He usually prefers fatty, salty and sweet foods. Gatropathy, Diffuse Enterogastric Bile Reflux Findings: Esophagus N0 CESX N0 Fundus,Body, Antrum, Pylorus The mucosal surface of the entire stomach appeared rough with diffused hyperemic mucosa with diffusely scattered erosion. Abundant bile leak. >performed to delineate the size, shape, and position of the organ to reveal any abnormalities such as stones, cysts, tumor, displacements, and surrounding tissues. PHYSICAL EXAMINATION: DATE OF ASSESSMENT: June 28, 2007 Skin and appendages: Presence of IV line on left arm, Presence of jaundice on skin and soles of feet and palms with good skin turgor, no edema, no lesions, long fingernails and toenails with pale nail beds, with presence of nail clubbing, with CRT >2 secs, no cyanosis. Head: presence of dandruff Eyes: pale palpebral conjunctivae and wears reading glasses with unrecalled grade Mouth and throat: lips are symmetrical but pale
  • 50. Abdomen: (+) liver hook test,(-)kidney punch, (-) Murphey’s sign Extremities: presence of bent little finger at right hand DATE OF ASSESSMENT: June 29, 2007 Significant findings: Skin and appendages: Presence of IV catheter on left arm, CRT of > 2 seconds, (+) jaundice on skin , in palms of hand and soles of feet Eyes: pale palpebral conjunctivae Mouth and Throat: pale lips, presence of tooth decays, Extremities:presence of bent little finger at right hand DATE OF ASSESSMENT: June 30, 2007 Significant findings: Skin and appendages: Presence of IV catheter on left arm, CRT>2 seconds, presence of nail clubbing Mouth and throat: presence of yellow teeth, presence of tooth decays Extremities: presence of bent little finger at right hand LABS: June 7, 2007 Upper Gastrointestinal Endocopoy Post-endoscopic Dx: Chronic Erosive Gatropathy, Diffuse Enterogastric Bile Reflux
  • 51. Findings: Esophagus N0 CESX N0 Fundus,Body, Antrum, Pylorus The mucosal surface of the entire stomach appeared rough with diffused hyperemic mucosa with diffusely scattered erosion. Abundant bile leak Implication: June 7,2007 Ultrasound Report (UA) Sonologic Findings Liver Span: 13.70 cm Gallbladder lumen: 1.96 cm (<4.0cm) Spleen (length): 10.99cm (<12anl) Abdominal Aorta: 1.75 cm Incidentally, there is a bright ethogenic foci with distal acoustic shadowing seen in the left kidney. The left renal calyces and pelvices are dilated. Conclusions: 5) Cholelithiasis, as prescribed above. 6) Presence of non-shadowing oval lesions adherent to the wall of the GB polyps are considered 7) Incidental findings of left nephrolithiases with marked
  • 52. pelvocaliectasia June 27, 2007 Glycosylated Hemoglobin = 7.3% (normal value 4.5%-6.3%)  an elevated level suggests that the glucose levels have been high for the past few weeks, this suggests that the therapy is not working or there is poor compliance with the therapy Lipid Panel Test (June 27, 2007) Result Normal Value HDL-Chlesterol 23 mg/DL >35 LDL-Cholesterol l12 mg/DL 118-187  a decrease in HDL suggests that there is poor transport of cholesterol in liver to be secreted as bile Complete blood count
  • 53. PATIENTS LIMITS SET 2 RBC ↓3.59 m/uL RBC 4.00 – 5.20 HGB ↓9.62 g/dL HGB 12.0 – 16.0 HCT ↓29.6 % HCT 36.0 – 46.0 COMMENTS: Mild hypochromia6/29/07 UTZ KUB Right kidney measures 8.0 x 4.0 cm. cortical thickness 1.2 cm. left kidney measure 12.1 x 6.1 cm cortical thickness 2.1 cm. Examination reveals a right kidney is small and echogenic. There is a small stone at lower pole. There are no hydronephrosis seen. The left kidney “blank” a 1.1 cm stone at the lower pole. The calyces are dilated. ♦ The ureters are remarkable ♦ The urinary bladder is remarkable ♦ Prostate gland is enlarged Conclusions: ♦ Small right kidney ♦ Echogenic right kidney ♦ Fluid surrounding kidney ♦ Stone in right kidney
  • 54. ♦ 1.1 cm stone left kidney, associated with hydronephrosis ♦ Enlarged prostate gland UTZ Upper Abdomen There is 8.00mm stone within gallbladder. Conclusion: gallbladder stone June 7, 2007 UREA BLOOD TESTING Uric: 11.1 mg/dl ref range (2.3 – 8.2) ↑ Crea D: 6.2 mg/dl ref range (0.5 – 1.3) ↑ Urea: 50 mg/dl ref range (7 – 18) ↑ Implications: Uric acid ♦ Clinical problems associated with elevated serum uric acid levels arise from the limited solubility of this compound. Increase in uric acid in serum rises above, it begins to precipitate out of solution. May result to gout, related to deposition of formation of stones in the kidney. Creatinine ♦ An increase significantly is alleged to have significant impairment of kidney function. Urea ♦ An increase in urea nitrogen is believed to cause in a wide variety of disorders
  • 55. which produce renal impairment. Sample entered 10:50 am 22 - June - 07 Report printed 10:50 am 22 - June - 07 Test name Result Code units Normal range ALT ↑48 # IU/L 0 – 41 Creatinine ↑10.8 #mg/dl .6 – 1.5 Implications: Alanine aminotransferase (ALT) ♦ An increase in ALT and AST (Aspartate aminotransferase) are related to liver damage. ALT is more elevated than AST in various inflammatory conditions of the liver reflecting its greater specificity as liver disease marker.
  • 56. DISCHARGE PLAN M: Instructed the patient to take the following medications at the right dose, time, route : Taught patient on the importance of following the medication regimen. 1) Valsaktan (Diovan) 1 tab once a day orally after.. breakfast 2) Retoanalouge (Ketosteril) 2 tab three times a day orally after meals 3) NaHCO3 GR X 1 tab three times a day orally after meals 4) MV + Fe+ FA (Iberet Folic) 1 tab once a day orally after meals 5) Metformin (Glucophage) 500mg/tab 1 tab twice a day orally 6) Glipizide (Minidiab) 5mg/tab 1 tab once a day orally 7) Cefuroxime (Zinnat) 500mg/tab 1 tab twice a day orally 8) Potassium Citrate (Akalka) 1 tab three times a day orally after meals E: Instructed patient to keep environment clean and free from dust. Instructed the S.O to keep environment quite so that the patient can sleep well. Instructed patient to keep sharp objects such as knives out of reach to prevent untoward injury. T: Advised patient to have regular check ups in order to monitor his condition. H: Instructed patient to follow the prescribed course of the drug. Encouraged patient to do relaxation techniques. Encouraged patient to achieve a normal body weight. Taught patient on the importance of handwashing before and after meals Instructed patient to do oral hygiene 3 times a day Instructed patient on proper foot care. Encourage patient to maintain fluid intake Encouraged to do mild exercise such as brisk walking at least 30 minutes a day.
  • 57. O: Instructed patient to consult the doctor when the following symptoms develop: • Elevated blood sugar levels • Elevated BP for three consecutive days • Pain in the right upper quadrant of the abdomen • Severe pain when urinating • Swelling, pain, stiffness and redness in joints D: Instructed patient to eat a balanced diet with enough protein and calcium. Advised to eat foods low in sodium and sugar Advised to reduce alcohol intake Encouraged to eat fish and to consume a moderate amount of protein S: Encouraged to hear mass every Sunday Encouraged to believe that God can heal all illness Encouraged to have close relationship with God
  • 58. Appendix A DRUG STUDY 1. Vancomycin 65mg IV infusion over 1H q 6H Classification: Anti-Infective Indication: serious or severe infections when other antibiotics are ineffective or contraindicated, including those caused by methicillin-resistant Staphylococcus aureus, S. epidermidis or dephtheroid organisms Action: Hinders bacterial cell wall synthesis, damaging the bacterial plasma membrane and making the cell more vulnerable to osmotic pressure. Also interferes with RNA synthesis Adverse reactions: CNS: fever, pain CV: thrombophlebitis at injection site, hypotension EENT: ototoxicity GI: nausea, pseudomembranous colitis GU: nephrotoxicity RESPI: wheezing, dyspnea Contraindications: hypersensitivity Nursing considerations: 1. Tell patient to take entire amount of drug exactly as directed, even after he feels better 2. Tell S.O to report adverse reactions immediately 3. Monitor patient for any signs and symptoms of super infection 4. Monitor patient carefully for signs of red-man syndrome, which can occur if drug is infused too rapidly. S/S include maculopapular rash on face, neck, trunk and limbs and pruritus and hypotension caused by histamine release. 5. if wheezing, urticaria or pain and muscle spasm of the chest and back occur, notify physician. 2. ibuprofen (Dolan) 100/5 2mL q 6H RTC Classification: NSAIDS Indication: Fever, mild to moderate pain, juvenile arthritis, rheumatoid arthritis, osteoarthritis Action: Unknown. May inhibit prostaglandin synthesis to produce anti-inflammatory, analgesic and antipyretic effects. Adverse reactions: GI: epigastric distress, nausea, occult blood loss, peptic ulceration, diarrhea, constipation, abdominal pain, bloating, GI fullness, dyspepsia, flatulence, heartburn, decreased appetite. Hematologic: prolonged bleeding time, anemia, neutropenia, pancytopenia, thrombocytopenia, aplastic anemia, leukopenia, agranulocytosis. Respiratory: bronchospasm Skin: pruritus, rash, urticaria, stevenson-johnson syndrome
  • 59. Contraindications: > contraindicated in patients hypersensitive to drug and in those with angioedema, syndrome of nasal polyps, or bronchospastic reation to aspirin or other NSAIDs. > contraindicated in pregnant women > use cautiously in patients with GI disorders, history of peptic ulcer disease, hepatic or renal disease, cardiac decompensation, hypertension, preexisting asthma, or known intrinsic coagulation defects. Nursing Considerations: > check renal and hepatic function periodically in patients on long term therapy. stop drug if abnormalities occur and notify prescriber. > tell patient to take with meals or milk to reduce adverse GI reactions > tell patient that full therapeutic effect for arthritis may be delayed for 2 to 4 weeks. although pain relief occurs at low dosage levels, inflammation doesn’t improve at dosages less than 400 mg QID > caution patient that use with aspirin, alcohol or corticosteroids may increase risk of GI adverse reactions > teach patient to watch for and report to prescriber immediately s/s of GI bleeding, including blood in vomit, urine or stool; coffee-ground vomit, and black tarry stool. > tell patient to contact prescriber before using this drug if fluid intake hasn't been adequiate or if fluids have been lost as a result of vomiting or diarrhea. 3. vitamin C (Ceelin) drops 0.3 mL OD Classification: vitamin C supplement Indication: >RDA > Frank and subclinical scurvy >Extensive burns, delayed fracture or wound healing, postoperative wound healing, severe febrile or chronic disease states > to prevent vitamin C deficiency in patients with poor nutritional habits or increased requirements > to acidify urine Action: stimulates collagen formation and tissue repair; involved in oxidation-reduction reactions Adverse reactions: GI: diarrhea, heartburn, nausea, vomiting CNS: faintness, dizziness Contraindications: >contraindicated in patients with an allergy to tartrazine or sulfites > contraindicated in large doses in pregnant patients. Nursing Considerations: > when giving for urine acidification, check urine pH to ensure efficacy > protect solution from light and refrigerate ampules > stress proper nutritional habits to prevent recurrence of deficiency. > inform patient that vitamin C is readily absorbed from citrus fruits, tomatoes, potatoes, and leafy vegetables
  • 60. > advise smokers to increase intake of vitamin C 4. multivitamins (Nutrilin) drops 0.3 ml OD Vitamin A Indication: RDA, severe vitamin A deficiency, maintenance dose to prevent recurrence of vitamin A deficiency Action: a coenzyme that stimulates retinal function, bone growth, reproduction, and integrity of epithelial and mucosal tissues. Adverse reactions: GI: anorexia, epigastric pain, vomiting, polydipsia Skin: alopecia, dry, cracked, scaly skin, pruritus, lip fissures, erythema, inflamed tongue, lips and gums, massive desquamation, increased pigmentation, night sweats Contraindication: > contraindicated orally in patients with malabsorption syndrome; if malabsorption is from inadequate bile secretion, oral route may be used together with bile salts >contraindicated in patients hypersensitive to any ingredient in product and in those with hypervitaminosis A. Nursing Considerations: > assess patients vitamin A intake from all sources. consider dietary intake. > warn patient not to take megadoses of vitamins without specific indications, to avoid toxicity. >stress that prescribed vitamins shouldn’t be shared with others >instruct patient to protect drug from air and light > teach patient about good food sources of vitamin a, such as green and yellow vegetables, cantaloupe, and liver > advise patient that liquid product can be mixed with food >tell patient to notify prescriber of signs of overdose (nausea, vomiting, appetite loss, malaise, dry and cracking skin and lips, irritability, headache) Thiamine hydrochloride (Vitamin B1) Classification: vitamin supplement Indication: RDA, beriberi, wernicke's encephalopathy Action: combines with adenosine triphosphate to form a coenzyme needed for carbohydrate metabolism Adverse reactions: CV: cyanosis GI: nausea, hemorrhage Respiratory: pulmonary edema Skin: feeling of warmth, pruritus, urticaria, diaphoresis Contraindications: contraindicated in patients hypersensitive to thiamine products Nursing considerations: > thiamine malabsorption is most likely in alcoholism, cirrhosis, and GI disease
  • 61. > thiamine deficiency can occur after about 3 weeks of totally thiamine-free diet > thiamine deficiency usually requires concurrent treatment for multiple deficiencies > stress proper nutritional habits to prevent recurrence of deficiency > instrct patient to protect oral doses from light Pyridoxine hydrochloride (Vitamin B6) Classification: vitamin supplement Indication: RDA, dietary vitamin B6 deficiency, seizures related to vit.b6 deficiency, antidote for isoniazid poisoning Action: acts as a coenzyme that stimulates various metabolic functions, including amino acid metabolism Adverse reactions: CNS: paresthesia, unsteady gait, numbness, headache Skin: photoallergic raction Contraindications: >contraindicated in patients hypersensitive to drug > don’t use drug in patients with heart disease Nursing Considerations: >patients taking high doses ( 2-6 g daily) may have difficulty walking because of diminished proprioceptive and sensory function >carefully monitor patient's diet. excessive protein intake increases daily pyridoxine requirements. >stress importance of compliance and of good nutrition if drug is prescribed for maintenance therapy to prevent recurrence of deficiency. >advise patient taking levodopa alone to avoid multivitamins containing pyridoxine because of decreased levodopa effect. >warn patient that there may be burning at injection site Cyanocobalamin (Vitamin B12) Classification: vitamin supplement Indication: RDA, vitamin b12 deficiency from inadequate diet, subtotal gastrectomy, or other condition, disorder or disease, except malabsorption, related to pernicious anemia or other GI disease. also indicated for methylmalonicaciduria, schiling test flushing dose Action: a coenzyme that stimulates metabolic function and is needed for cell replication, hematopoisesis, and nucleoprotein and myelin synthesis. Adverse reaction: GI: transient diarrhea Respi: pulmonary edema skin: itching, transitory exanthema, urticaria Contraindications: >contraindicated in pxs hypersensitive to Vit.b12 or cobalt and in those with early Leber's disease (hereditary optic nerve atrophy) > use cautiously in anemic patients with coexisting cardiac, pulmonary or hypertensive disease > use cautiously in premature infants; product may contain benzyl alcohol which may cause "gasping syndrome"
  • 62. Nursing Considerations: >don’t mix parenteral preparations in same syringe with other drugs > drug is physically incompatible with dextrose solutions, alkaline or strongly acidic solutions, oxidizing or reducing agents, heavy metals, chlorpromazine, phytonadione, and other drugs > don’t give large doses of vitamin b12 routinely; drug is lost through excretion > deficiencies are more common in patients who are strict vegetarians and in their breastfed infants. > stress need for patient with pernicious anemia to return for monthly injections or weekly use of intranasal form > teach patient using intranasal form how to administer drug >stress importance of follow-up visits and laboratory studies. >teach patient health dietary habits > instruct patient not to take folic acid as a replacement for vit. b12; folic acid may ease blood-related symptoms of pernicious anemia, but neurologic complications will progress.
  • 63. Appendix B Betty Neuman’s Systems model
  • 64. The client system is represented by Maslow’s hierarchy of needs, namely: physiologic, psychologic, sociocultural, developmental, and spiritual needs. The person, nursing, environment, and health all affect the said client system Appendix C Betty Neuman’s Systems Model
  • 65. CHAPTER THREE SUMMARY OF FINDINGS Gordon’s *Heredofamilial disease includes and cancer and DM, stroke and arthritis on the paternal side. *Px consumes 10-12 glasses per day *Px voids 3 times per day and 3 times per night amounting to 200ml per void. *He usually prefers fatty, salty and sweet foods. Physical Examination June 28, 2007 Skin and appendages: Presence of IV catheter on left arm, with good skin turgor, no edema, no lesions, long fingernails and toenails with pale nail beds and nail clubbing, CRT >2 secs, no cyanosis, (+) jaundice. Eyes : symmetrical, anicteric sclerae, smooth, moist and pale palpebral conjunctivae and clear bulbar conjuctivae, (-)discharges, equal distribution of eyebrows and eyelashes, (+) Pupils Equally Round and Reactive to Light and Accomodation, Mouth and throat: lips are symmetrical but pale, no ulcerations and no lesions, buccal mucosa pale, pinkish gums with no ulcerations, tongue located at midline, uvula at midline, 14 left on teeth Chest: Symmetrical, no lesions, equal chest expansion, presence of CTT incision on left anterior lower chest. Lungs: Equal lung expansion, Extremities: symmetrical, (+) ROM for all extremities, no lesions, presence of bent little finger on right hand May 10, 2007 Significant findings: Skin and appendages: Presence of IV catheter on right arm
  • 66. Eyes: pale palpebral conjuntivae Mouth and Throat: pale lips Lungs: rales still heard upon auscultation of left lower lung fields. CTT still attached to left anterior lower chest Extremities: pulse oximeter still attached to right toe May 11, 2007 Significant findings: Skin and appendages: Presence of IV catheter on right arm Eyes: pale palpebral conjuntivae Lungs: rales still heard upon auscultation of left lower lung fields. CTT still attached to left anterior lower chest Laboratory Results CBC This is a basic screening test in all patients and is one of the most frequently ordered laboratory procedure. The significant findings in the CBC gives valuable information about patient’s diagnosis, response to treatment and recovery WBC 23.7 K/uL NEU 14.9 63.0 %N LYM 3.47 14.7 %L MONO 3.40 14.4 %N EOS .972 4.11 %E BASO .914 3.86 %B RBC 4.11 M/uL HGB 10.1 g/dL HCT 29.5% MCV 71.9 fL MCH 24.7 pg MCHC 34.3 g/dL RDW 18.6% PLT 477.6 K/uL MPV 7.57 fL (see Laboratory entry for implications)
  • 67. CONCLUSION After making our assessment, and gathered data necessary for the case, we concluded that the patient acquired his illnesses through some inappropriate lifestyle or habits. Since we have gone over through the 5 diseases, we learned that his Diabetes Mellitus Type 2 developed from his non-choosy habits of eating foods varying from those sweet, salty, and fatty ones. Over the years, this damaged his pancreas and its insulin secreting ability, which caused his increase glucose in the blood. Aside from this, he developed a complication of secondary hypertension stage 2, since the blood in his circulation is more viscous due to the accumulation of fats, which caused occlusions in his blood vessels, thus, constricting the passage of blood and increase its pressure. Another complication that developed was his cholelithiasis, which is the formation of stone in the gall bladder, due to the accumulation of fat precipitates constituting the stone. He also recently had nephrolithiasis, the formation of a stone or stones within the urinary tract, usually a potential complication of many different diseases. With his lab results of urea blood test, his uric acid, creatinine and urea were high from their normal levels, which would signify impairment in his kidney or renal function. He was also advised to have a dialysis to help the body perform the functions of a failed or impaired kidney, but declined such intervention. And for the rheumatoid arthritis, which is said to be of unknown cause, must have developed as an autoimmune disease. Since arthritis is a heredofamilial disease, the patient may have been able to acquire the disease from familial genes. The main organs affected by the diseases usually involve the pancreas, gall bladder, liver, kidneys, heart; along with the cardiovascular system. Because of such conditions, holistic nursing care is indeed needed by the patient, as well as the whole family, in order to cope up and improve their lifestyle or way of living, and preserve their health for the better. Such changes may include modification of his diet or food intake to no pork, low fat and low salt diet, increase activities, and hobbies. These changes must be complied with in order to avoid the recurrence of the illness and development of other further complications. With that, the student nurses must be able to assess carefully, and reinforce needed information. And after 8 days of continued nursing intervention and medical managements, our patient was able to recover and discharged regaining his optimum well being and functioning RECOMMENDATIONS Based on the findings and the interpretations made, the researchers would like to recommend this case study to the following: 1. For the client, his primary healthcare givers, and family members, to have a better grasp of his current disease processes and understand the implications these make to his lifestyle modifications or long-term management.
  • 68. 2. For the entire medical team and healthcare staff, to enhance their understanding on the disease processes of Diabetes Mellitus Type 2, Nephrolithiasis, Cholelithiasis, Hypertension stage 2, and Rheumatoid Arthritis. This study also provides insight on suitable medical regimens to promote client’s maximum level of wellness and optimum level of functioning. 3. For the clinical instructors of the faculty of nursing, that they will be able to further advance their knowledge of the diseases mentioned in the case study, and thus be able to impart additional information to students in the clinical area, as well as become even more effective and confident in their practice of nursing profession. 4. For the student nurses, so they may be able to render genuine, competent and holistic nursing care to the clients in light of deeper understanding of the disease processes. And that they will also be able to formulate appropriate nursing care plans and be able to apply these successfully in the area, thus enhancing ones skills, knowledge and even ones attitudes towards the patients and the health team. 5. For the future researchers, that they will be able to utilize this study as a basis for future researches, studies, or articles related to the disease processes mentioned in the case study. This is to ensure a continuous research that will lead to advancements in the prevention, treatment, and cure of the different diseases. Bibliography: Black, Joyce and Jane Hokanson Hawkes. Medical-Surgical Nursing. 7th Philippines: Elsevier Saunders, 2004. Davis Drug Handbook for Nurses Fischbach, Frances. A Manual of Laboratory and Diagnostic Test. 7th edition. New York: Lippincott Williams & Wilkins, 2004. Marieb, Elaine. Essentials of Human Anatomy & Physiology. 7th edition. Singapore: Pearson Education, 2004. Smeltzer, Suzzane C. and Brenda G. Bare. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 10th edition. Philedelphia: Lippincott Williams & Wilkins, 2004.
  • 69. Yuan, Sarah. Handbook of Diseases. 3rd edition: Philadelphia: Lippincott Williams & Wilkins,2003.