Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
COLLEGE OF MEDICINE
School Year 2019-2020
First Semester
Educational Attainment: Elementary Birthday: May 30, 1944 Birth place: Tapaz, Capiz
Date and Time of Admission: October 21, 2019 1PM Blood Type: A+ Handedness: Right
CHIEF COMPLAINT
25 years prior to admission, patient was diagnosed with diabetes and hypertension. She was given
Insulin M30/70 BID and Telmisartan 40mg OD as maintenance with good compliance.
20 years prior to admission, patient was subjected for surgical removal of stones in her left kidney.
The operation was successful and patient returned to her daily routine.
3 years prior to admission, patient's foot was injured with a nail and was prescribed with antibiotics.
She had unrecalled shots of tetanus toxoid which she claimed to have finished them. Due to her diabetes,
she had impaired wound healing and developed unhealed injuries in her feet. This led to her discomfort
with ambulation. Patient was bedridden from that day on and had developed atrophied limbs.
1 year prior to admission, patient experienced hematuria and shortness of breath and sought for
consultation. She was admitted in Corazon, Locsin Hospital in Bacolod and was diagnosed with pneumonia
and kidney stone obstruction in both kidneys. Patient was infused with 4 bags of pRBC and was
catheterized. Surgery was not performed due to her age. Patient was released a few days after, wheelchair
borne with relief of symptoms. She was given Erythropoietin 4000 units, 1 injection BID for two weeks with
good compliance.
3 months prior to admission, patient experienced hemoptysis and productive cough with yellow
phlegm. She had shortness of breath and dyspnea that was aggravated when lying down and relieved
when sitting up. Patient opted for nebulization with salbutamol BID for relief. She used three pillows then in
order to sleep. Patient sought for consultation with a nephrologist and was diagnosed with pneumonia. She
was admitted in Bato Hospital, Sagay City, Negros Occidental and was given 20 bags of pRBC and IV
medications unrecalled by the folk.
2 months prior to admission, patient’s condition worsened and was transferred by August 4 to
Corazon, Locsin Hospital in Bacolod. Upon admission, patient was comatose and was placed on
mechanical ventilation. Patient’s folks were advised by their attending physician on the 7th day to return
home. Patient’s folks refused and transferred the patient by August 11 to Medicus Hospital in Iloilo. Patient
was 50-50 upon admission, comatose and was immediately subjected to IV medications unrecalled by the
patient. Patient’s comatose was relieved.She was placed in the ICU and was subjected to different tests
including chest x-ray and was diagnosed with pulmonary edema, pneumonia and Chronic kidney disease
stage 5. She was then subjected to dialysis 3x a week with good compliance and was prescribed with IV
medications unrecalled by the folk. Patient’s condition improved after one month and was transferred to the
wards for another month. Patient was discharged on October 4, wheelchair borne with relief of symptoms.
Dialysis was continued 3x a week.
3 days prior to admission, patient experienced productive cough with yellow phlegm. No
interventions were done.
On the day of admission, patient experienced dyspnea with continuing productive cough and
sought consultation with her physician after dialysis. She was then admitted for hospitalisation.
Pertinent negatives: No vomiting, dizziness, fever, chest pain, diaphoresis, laryngospasm, and
history of choking
A. Childhood Illnesses
• Unrecalled childhood illnesses.
B. Adult Illnesses
• Hypertension, long standing for 25 years. Telmisartan OD 40mg for maintenance with
compliance
• Diabetes Mellitus Type II, diagnosed 25 years ago. M30 Insulin, 20 units in the morning and 10
units at night for maintenance with compliance. Last FBS: 250 mg/dL (13.9 mmol/L)(October
30,2019)
• History of Gouty Arthritis, 3 years ago. Prednisone 2 times a day for 1 week. Resolved.
C. Past Hospitalizations
• 2016. Sepsis. Due to infected wound on the sole of her right foot because the patient was
walking around without any footwear. Tazobactam and Cephalexine 500 mg 3 times a day for
1 week. Resolved but healing of the injury was slow.
• 2018. Kidney obstruction with hematuria. No operations were done to remove the obstruction
due to many complications. Patient was transfused with four bags of pRBC.
• August 11, 2019. Stage 5 Chronic Kidney Disease. On dialysis 3 times a week. Transfused
with 20 bags of pRBC
D. Surgical History
• 1999. Lithotomy. Left kidney. Kidney stone was branched and was 5cm in diameter. Kidney
stones recurred 5 years later but was not removed.
• 2015. Tetanus infection. Brought about by stepping on a nail. Injected with tetanus toxoid
vaccine intramuscularly once. Surgical removal of infected muscle was done for debridement.
Wound did not heal.
E. Psychiatric Disroders
• Patient has no history of psychiatric disorders.
F. Immunizations.
• No recalled immunizations
G. Maintenance Medications
• M30 Insulin (20 units AM; 10 units PM) BID
• Telmisartan 40mg OD
FAMILY HISTORY
Parents are both deceased, mother died of old aged at the age of 70 with a history of diabetes
mellitus while her father had history of hypertension died at the age of 47 due to cardiac failure.
Patient have 7 siblings, four died due to chronic kidney disease, tuberculosis, lung cancer and
heart failure. 3 of her siblings have hypertension, and 2 have diabetes mellitus.
Patient have 7 children, three died due to trauma, cardiac arrest and heart failure. One has
diabetes mellitus.
A. Exercise. Patient has no exercise regimen in the past. Patient is bed ridden for 3 years now
and is unable to sit without support
B. Sleeping Pattern. Patient has regular sleeping pattern. Sleeps 8-10 hours a day. Utilizes a
reclining bed. Patient has orthopnea and sleeps in semi fowler’s position.
C. Dietary Pattern. Diet are composed of vegetables, fish, fruits, small portions of meat and
consumes as little as 4 glasses of water per day. Food should be blended and taken via
nasogastric tube.
D. Elimination Pattern. Patient is on catheter and able to fill the catheter bag about 200mL a
day. Irregular bowel movement about twice a week with yellow goat like stools.
E. Vices. Patient was a chronic smoker, consumes 1 pack per day stopped at the age of 40.
H. Home and Environment. Patient lives with one of her daughter, son in law and
grandchildren. They’re renting an apartment, bungalow type, concrete with 3 rooms and 1
common bathroom. They have the typical flush type toilet and has its own septic tank. Water
supply is provided by public and community utilities. They purchase distilled water for drinking
purposes.
I. Financial Situation. Patient’s medications, daily food allowance, and hospital bills are
supported by her children and some of her grandchildren.
REVIEW OF SYSTEMS
FATIGUE ✓
HEAD (EYES) YES NO
FEVER ✓
VISION LOSS OR CHANGES ✓
CHILLS ✓ OD: Right eye operated for
cataract
WEAKNESS ✓ OS:
TROUBLE SLEEPING ✓ GLASSES OR CONTACTS ✓
APPETITE CHANGE ✓ PAIN ✓
REDNESS ✓
SKIN YES NO
BLURRY OR DOUBLE VISION ✓
COLOR CHANGES ✓
FLASHING LIGHTS ✓
DRY ✓
SPECKS ✓
RASHES ✓
GLAUCOMA ✓
PRURITUS ✓
CATARACTS ✓
LUMPS ✓
HEADACHE ✓ NOSEBLEEDS ✓
DIZZINESS ✓
MOUTH AND THROAT YES NO
LIGHT HEADEDNESS ✓
BLEEDING ✓
PAIN ✓
GASTROINTESTINAL YES NO
STIFFNESS ✓
TROUBLE SWALLOWING ✓
HEARTBURN ✓
BREAST YES NO
DECREASE IN APPETITE ✓
LUMPS ✓
DISCHARGES ✓ NAUSEA ✓
PAIN ✓ VOMITTING ✓
SELF-EXAMINATION ✓ IRREGULAR BOWEL ✓
BREAST FEEDING ✓ MOVEMENTS
KIDNEY STONES ✓
MUSCULOSKELETAL YES NO
URETERAL COLIC ✓
MUSCLE OR JOINT PAIN ✓
SUPRAPUBIC PAIN ✓
STIFFNESS ✓
INCONTINENCE ✓
BACK PAIN ✓
REDUCED CALIBER OR ✓
FORCE OF URINARY STREAM JOINT PAIN ✓
TRAUMA ✓
GENITAL YES NO WEAKNESS OF EXTREMITIES ✓
DYSMENORRHEA ✓
ENDOCRINE YES NO
PSYCHIATRIC YES NO
HEAT OR COLD ✓
INTOLERANCE NERVOUSNESS ✓
SWEATING ✓ STRESS ✓
MEMORY LOSS ✓
PHYSICAL ASSESSMENT
A. General survey
Patient MC is a 75 years old Filipino, female, with light brown skin. Body build is stocky, fat. Patient is in a
supine position. She is conscious, awake, but unresponsive. She is not oriented to time, date, place, and
person. She cannot maintain eye contact and is not responsive to questions. Patient has a neutral facial
expression, and mood cannot be gauged since patient does not respond to questions. Patient is dressed
in a hospital gown. She is well groomed, but with dirty nails on feet. Patient has nasogastric tube and
oxygen therapy, but no cardiac monitor and mechanical ventilation. Patient has a catheter. Patient is
restrained by the hands to the bed. Patient is bedridden, and has a scheduled time for changing positions
in bed to avoid bedsores. The special devices attached to the bed are side rails, frames, pulleys, call light,
no trapeze.
Head: Patient has thin hair, and thin eyebrows. There is a light scar over patient’s left eye. Hair of average
texture. Scalp without lesions, normocephalic, atraumatic. Patient’s skull is rounded, erect, without tremors,
no acromegaly, no hydrocephaly, no skull depressions from trauma, no visible lumps and masses. Face is
symmetrical, no melanoma, no macular rash, and no increased facial hair, no exophthalmos, no moon face.
Eyes: Patient has a cataract on the left eye. There is exotropia on the left eye. Bulbar conjunctiva is
transparent. Eyebrows are evenly distributed, intact skin, with thinning of hair, no scaling, no flakiness,
alignment equal, equal movement, not tattooed, black to gray in color. Eyelashes are equally distributed,
no loss of hair, thick, straight. Anicteric sclera. Iris is uniform in color, round, smooth, symmetrical. Pupil is
equal, round, reactive to light, and reactive to accommodation. Bony orbits of equal size, equal movement,
no exophthalmos.
Ears: are upright. Pinnae is uniform color, uniform shape, normal contour, in line with the canthus of the
eyes, mobile, elastic, good recoil, no pain, no tenderness, not cyanotic, no erythema, no edema.
Nose and Sinuses: Nose is uniform, symmetrical, color is the same of the face, not deviated. No lesions,
no redness, no masses. There is flaring observed.
Mouth and Throat: Lips are pink, smooth, soft, intact, moist, symmetrical, no swelling, no lesions, no
involuntary movement, no cracks, no fissures, not cyanotic, dry, no pallor, not reddish. Teeth are
incomplete.
C. Integumentary. Skin is light brown, no jaundice, not pale. Sunspots noted on skin, cyanosis present on
fingers. Presence of ulcerations and non-healing wounds on feet, with crusting, presence of patch on leg,
no macule, no papule, no plaque, no nodule, no tumor, no vesicle, no bulla, no wheal, no pustule, no cyst,
no erosion, no ulcer, no fissure, no scales, no keloid, no atrophy, no lichenification, no petechiae, no
ecchymosis, no hematoma, no cherry angioma, no spider angioma, no telangiectasia. Skin is warm to
touch, dry, wrinkled, elastic, and thin. Hair thin, straight, and evenly distributed. Scalp is smooth, clean,
intact, no lice, no flakes, no redness, no itching, no lesions, no bumps. Nails are long at feet, pale white nail
beds, hard, dry, not brittle, not cracked, not jagged, no clubbing, not cyanotic, no paronychia, no
onycholosis, no melanonychia.
D. Cardiovascular: Normal sinus rhythm, no murmurs. Lower limb with edema, nail bed slightly white to
pinkish and with discoloration, not cyanotic, warm extremities, non-tender. Good capillary refill.
E. Thorax and Lungs: Patient in supine position, breathing is labored, with use of accessory muscles in
breathing. Patient has a productive cough. Bronchial breath sounds heard in all lung fields. Bronchophony
loud in all lung fields. Coarse crackles noted on all lung fields.
F. Neurologic
Health care-Associated Pneumonia secondary to Stage 5 CKD secondary to Type 2 Diabetes Mellitus
and Hypertension
GENERAL MANAGEMENT
Regimens for early onset (<5 days since admission) no multi-drug resistance (MDR) risk factors:
• Ceftriaxone 2g IV or IM every 24 hours or
• Levofloxacin 750 mg IV or PO every 24 hours or
• Ampicillin-sulbactam 3g IV or IM every 6 hours or
• Ertapenem ig IV or IM every 24 hours or
• Aztreonam 2g IV every 8 hours
• Duration of therapy: 8 days
Regimens for late onset (>/5 days since admission), MDR risk factors present, or diagnosis of HCAP:
• Cefepime 2g IV every 8 hours or
• Ceftazimide 2g IV every 8 hours or
• Imipenem-cilastatin 500 mg IV every 6 hours or 1 g IV every 8 hours or
• Meropenem 1g IV every 8 hours or
• Piperacillin-tazobactam 4.5 g IV every 6 hours
PLUS
• Vancomycin 15mg/kg IV every 12 hours or
• Linezolid 600 mg IV every 12 hours
PLUS
• Ciprofloxacin 400 mg IV every 8 hours
• Levofloxacin 750 mg IV every 24 hours
Duration of therapy:
• If clinical improvement is noted in 48-72 hours and cultures are negative, consider stopping
antibiotics
• If clinical improvement is note 48-72 hours and culture are positive, adjust regimen per
susceptibilities and continue antibiotics for 7-8 days
• If there is no clinical improvement and cultures are negative, look for alternative diagnosis
• If there is not clinical improvement ad futures are positive, adjust regimen per susceptibilities
Stage 5 CKD
Early diagnosis and treatment of the underlying cause and.or institution of secondary preventive measure
is imperative in patients with CKD. These may slow, or possibly halt, progression of the disease. The
medical care of patients with CKD should focus on the following:
• Delaying or halting the progression of CKD: treatment of underlying condition, if possible, is
indicated
• Diagnosing and treating the pathologic manifestation of CKD
• Timely planning for long term renal replacement therapy
Microvascular (ie, eye and kidney disease) risk reduction through control of glycemia and blood pressure
Macrovascular (ie, coronary, cerebrovascular, peripheral vascular) risk reduction through control of lipids
and hypertension, smoking cessation
Recommendations for the treatment of type 2 diabetes mellitus from the European Association for the
Study of Diabetes (EASD) and the American Diabetes Association (ADA) place the patient's condition,
desires, abilities, and tolerances at the center of the decision-making process.
HCAP
• Clinical follow up after discharge-usually within 1 week to assess for resolution of pneumonia
• Follow up chest radiograph- 7 to 12 weeks following treatment of patients >50 YO
CKD
• Regular vaccinations to prevent infections
• Maintain adequate nutrition
DM2
• Adherence to diet and exercise