WYLENGCO, Maria Constancia

2001-15366

Name: Antonita Quiñones (AQ) Age/Sex: 57/F

Location: W1 B24 Religion: Catholic
Residence: Bayanan, Muntinlupa Handedness: Right
Civil Status: Single Date of Admission: (ER) December 6,
2006
(Ward) December 7, 2006
HISTORY

CC: Facial and bipedal edema, anuria (nagmanas ang mukha at paa, at di maka-ihi)

History of Present Illness

17 years PTA
The patient was asked to undergo a medical clearance exam (for overseas work approval) and was incidentally found to
have Diabetes. Medications prescribed were Diamicron and Glucophage (metformin), which she took irregularly from first
administration to November 2006 (There were long intervals wherein the patient did not take her meds).

2 months PTA
The patient went to Muntinlupa Medical Center (MMC) for a check-up. She complained of dizziness and cough, as well as
to ask about her diabetes. Blood tests, urinalysis, urine culture, skin test and ECG were ordered. Blood sugar levels and cholesterol
levels were interpreted to be high. Urinalysis and skin test findings were unrecalled. Results of urine culture pointed to presence of
UTI (but the exact organisms were unrecalled). ECG results allegedly revealed a Left-sided enlargement of the heart. The patient’s
blood pressure was interpreted as hypertensive.
The patient was asked to return several times for continued check-ups and lab exams.

5 days PTA (December 3, 2006)

AQ experienced epigastric pain, which she described to have felt like having gas accumulation in her stomach/intestines.
This was accompanied by flatulence. She then went to Alabang Medical Clinic, where she was admitted and was confined for a day
and a half. Discharge was on December 5, 2006.
An X-ray was requested, and results allegedly revealed clear lung fields. An ultrasound was also performed because
appendicits was suspected. UTZ findings revealed enlarged kidneys (“maga ang bato”). Urinalysis and blood tests were also done,
results of which were unrecalled.
An unrecalled medication was prescribed for the enlarged kidneys.

3 days PTA (December 5, 2006)

The patient went to PGH-OPD (they decided to change hospitals due to financial restraints). They were asked to return on
December 8, 2006 for urine testing.

1 day PTA (December 7, 2006)

Bipedal edema, followed by facial edema, were noted. Anuria was also experienced, as well as hypogastric pain and chest
tightness. All of these were reported to be of acute onset.
Urine character and urination pattern prior to this day were described as: yellow color, but there were instances when the
urine was red; nocturia (~3x/night); polyuria, polydipsia.
The patient went to the PGH-ER. Blood tests and Xray were done. She stayed in the ER for one day.

December 8, 2006
The patient was transferred to Ward 1.

Course in the Wards

Blood pressure and body temperature were regularly checked.
Medications:
Ferrous Sulfate and Calcium Carbonate, TID.
Clonidine was prescribed to lower her BP.
3rd ward day (December 11, 2006): The patient underwent a dialysis and around 1 liter of fluids was drained. Marked
reduction of edema was noted.

ROS
(+) cough with phlegm, difficulty of breathing, fatigue, chest tightness, nausea, diarrhea (2 days before the interview),
difficulty of feeding (3x/day, 1Tbsp), weakness
(-) fever, blurring of vision, tinnitus, asthma, allergy, seizure, tics
Past Medical History
No other hospitalizations or previous surgeries.

Family Medical History

(+) TB and Lung Disease (father)
(+) Diabetes (mother) and heart disease
(-) cancer, kidney disease, stroke, hypertension, asthma

Menstrual History
The patient had her menopause when she was 45 years old. Menstruation prior to period cessation was described to be
heavy.

Personal/Social
The patient worked as a domestic helper in Lebanon for 20 years. She lives with her siblings and has a good relationship
with them. She is the 4th in a family of 6.

PHYSICAL EXAM

General: The patient is conscious, alert, awake, well developed and fairly nourished, not in cardiorespiratory distress.

Vital Signs:
BP 150/70 mmHg
PR 80 bpm
HR 72 bpm
RR 30/min
Temp: 37.2° C

Skin
Fair skin, smooth texture, good turgor.
(-) jaundice
(+) pallor

HEENT
Face: Symmetrical with appropriate affect; (-) paralysis
Eyes: pale conjunctivae; anicteric sclerae; pupils equal, 2mm; (-) direct and consensual reflex; full EOM; (-) ptosis,
exophthalmos
Ears: (-) discharge, tenderness
Nose; (-) alar flaring, septum not deviated; (-) discharge, tenderness
Throat: pink buccal mucosa and tongue; lips pale; (-) dryness or lip sores, uvula midline
Neck: (-) NVE

Chest and Lungs

(-) gross chest deformities
Decreased breath sounds at both basal lung fields
(+) rales
(-) wheeze, stridor, adventitious breath sounds

Cardiovascular
(-) deformities, lifts, heaves
PMI not noted
Apex beat not appreciated
Distinct S1, S2, (-) S3); normal hysiological splitting at 2nd L ICS MCL
(-) murmurs, bruits

Abdomen
Globular, with bloating
(-) scars, striae, hernias, lesions, masses
Hyperactive bowel sounds (1.5 hrs, post-prandial)
Deviated umbilicus (right)

Extremities
Warm extremities; (-) clubbing, cyanosis; full pulses
Neuro Exam
Patient is alert, coherent and oriented to person, time and place. Able to follow commands and responds appropriately to
questions.

Equal and intact light touch and pain sensation

Muscle Strength: 5

PATHOPHYSIOLOGY
The proposed pathophysiology of diabetes and associated renal failure in AQ is depicted in the following algorithm.

Diabetes
 gfr ↑ BUN/
hyperglycemia hyperlipidemia insulin resistance crea
metabolic
 renal waste
progressive
blood flow products
 NO production ↑ vascular permeability protein
electrolyte
↑ Angiotensin II accumulation in
blood flow abnormalities hypertension imbalance
sensitivity vessel walls

↑ blood flow vessel lumina salt and

endothelial
occlusion water
↑ intracapillary presssure dysfunction
retention

hyperfiltration oliguria/ RAAS

anuria ADH
protein leakage SNS
(albumin)
 effective
↑ albumin circulating
hypoalbuminemia volume
excretion rate
ascites /
 plasma
proteinuria edema
oncotic pressure
pulmonary
congestion/
edema

DIAGNOSTIC WORKUP
1. Urinalysis- Check for glucosuria, proteinuria, urine sodium and osmolality.
2. Blood Test-
a. Glycated Hemoglobin A1 measurements – elevated in patients with chronic DM; to check if glycemic
control is responsive to previously ingested anti-glycemic agents
b. BUN/Crea
c. ABG
d. Cholesterol
e. Plasma Electrolytes (Abnormalities of plasma sodium, potassium, bicarbonate, calcium, magnesium, and
phosphate are common in acute renal failure, and their determination and monitoring are an integral part of
the diagnosis and management of renal failure)
3. Lipoprotein abnormalities
4. Renal ultrasound provides an accurate means of measuring renal size (small kidneys are evidence of chronic renal
disease)
5.
MANAGEMENT PLAN
1. Blood pressure control. Multiple-drug therapy for hypertension include b-blockers, diuretics, and vasodilators, as well as
angiotensin-converting enzyme inhibitors, which are used not only in established diabetic nephropathy but also in non-hypertensive
patients with microalbuminuria.
2. Monitoring of diabetes control consists of the following.
a. HbA1c provides an integrated measure of blood glucose profile over the preceding 2–3 months; it should be obtained
approximately every 3 months.
b. Self-monitoring of blood glucose is an important tool of diabetes management and is recommended for all patients.
c. Urine glucose correlates poorly with blood glucose, is dependent on renal glucose threshold (150–300 mg/dl), and should
only be used for monitoring diabetes therapy if self-monitoring of blood glucose is impractical.
 d. Ketonuria grossly reflects ketonemia. All DM patients should monitor urine ketones using Ketostix or Acetest tablets
during febrile illness or persistent hyperglycemia, or if signs of impending DKA (e.g., nausea, vomiting, abdominal pain)
develop.
3. Patient education is integral to successful management of diabetes and its complications. Diabetes education should be reinforced
at every opportunity, particularly during hospitalization for diabetes-related complications.
4. Dietary modification. A balanced diet that provides adequate nutrition and maintains a healthy weight is desirable. Caloric
restriction is recommended for overweight persons. An allowance of 10–20% of total caloric intake as protein and less than 30% as
total fat (less than 10% saturated fat) is appropriate. Patients with diabetic nephropathy usually are allowed a protein intake of 0.8
g/kg/day. With deterioration in renal function, further restriction in protein intake (0.6 g/kg) can be considered in selected patients.
Carbohydrate allowance should be individualized based on glycemic control, plasma lipids, and weight goals.
5. Exercise improves insulin sensitivity, reduces fasting and postprandial blood glucose, and offers numerous metabolic,
cardiovascular, and psychological benefits in diabetic patients.
6. Medications that are used for treating diabetes include insulin and oral agents. Type 2 DM patients respond initially to oral
antidiabetic agents but may require insulin as the disease progresses. Medications for diabetes are most effective if instituted as part
of a comprehensive management approach that includes dietary and exercise counseling (Carey, et. al,2001).

Carey, CF., KF Woeltje and H Lee. (2001). The Washington manual (30th ed). USA: Lippincott Williams & Wilkins
Davison, A.M, et. al. (1998). Oxford Textbook of Clinical Nephrology (2nd edition). New York: Oxford University Press
Goldman, L., RL Cecil, and JC Bennett. (1999). Cecil textbook of medicine (21st ed). USA: W.B. Saunders Company.
Larsen, P.R. et. al.(2003). Williams textbook of endocrinology (10th ed). Philadelphia: Saunders.