Nursing Case Study

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Patient’s Initials: M.N.M
Age: 41 years old
Sex: Male
Civil Status: Married
Medical Diagnosis: CKD Secondary to Uremic Encephalopathy, Hypertensive Nephrosclerosis vs. Gouty Neuropathy Attending Physician: Dr. Valdez, Dr. Manzon, Dr. Ocampo, Dr. Concepcion

I. CHIEF COMPLAINT

- General body weakness
- Drowsiness
- Pain on knees

II. NURSING HISTORY

The patient, MNM, has hypertension for 21 years, he’s not taking any medications until year 2008 when he was prescribed Nifedipine and Carvedilol. He also has gouty attacks for 14 years now and he is taking Allopurinol.

Four days PTC, patient verbalizes pain on his knees. He was then also noticed by his wife to be drowsy at all time and has melena in which they sought consult at a nearby hospital. Three days PTC during the stay in the hospital patient was noted to have episodes of epistaxis on which he was given a dose of tranexamic acid. One day PTC, patient’s hemoglobin decreased and was advised to have a transfusion of 2 ‘U’ of PRBC then they decided to transfer the patient in this institution.

III. PATHOPHYSIOLOGY

Modifiable Factors
- Lifestyle
- Diet
- Alcohol
- Smoking
- Chronic NSAID use
- Hypertension
Non Modifiable Factors
- Hereditary
- Age
- Sex
Renal tissue loses function
Renal function adaptation

Kidneys lose ability to maintain fluid and electrolyte homeostasis

Decrease in Glomelular Filtration Rate

Decrease ability to concentrate urine
Decrease ability to excrete toxins
Further decrease of GFR
Increase plasma concentration of creatinine and urea
CHRONIC KIDNEY DISEASE
-Uremia
-Azotemia
Oliguria
Serum Creatinine: 624
Decrease GFR

IV. LABORATORY AND DIAGNOSTIC

CT Scan (April 27, 2010)

Plain CT scan of brain was performed. Exam was studied with 1.25 mm thick section at 1.25mm intervals. All these are parallel to orbito-meatal line.
No evidence of abnormal high or low density lesions throughout the brain. The brainstem as well as cerebellum are unremarkable. No evidence of hemorrhage noted.
The ventricular system are well visualized and show no evidence of dilatation nor displacement.
There is no shift of midline sutures nor is there evidence of subdural or epidural hematoma formation.
The cerebellopontine angle, sella, orbits and bony calvarium are unremarkable. There are no hazy densities seen in ethmoid and sphenoid sinuses.
IMPRESSION: Unremarkable plain CT scan of brain. Follow-up study recommended poly sinusitis described.

Chest X-ray (April 27, 2010)

A right side CTT is seen in place with tip seen at level of the 3rd posterior rib. Tip of the subclavian catheter seen at level of the 7th posterior rib. No other significant changes noted.

Hematology

| Normal Val.| April 27, 2010| April 28, 2010| April 29, 2010| April 30, 2010| Hemoglobin| 140-175| 82| 76| 84| 73|
Hematocrit| 0.41-0.50| 0.24| 0.23| 0.25| 0.22|
WBC| | 8.2| 9.1| 16.7| |
Segmenters| | 0.90| 0.86| 0.90| |
Lymphocytes| | 0.06| 0.13| 0.05| |
Eosinophils| | 0.01| | | |
Monocytes| | 0.03| | 0.01| |
Stab Cells| | | | 0.03| |
Platelet Count| 150-450x109| 140| 140| 112| 116|
Bleeding Time | | | 2 mins30 secs| | |

Blood Chemistry (April 29, 2010)
| Normal Values| Result|
BUN| 2.50-7.10 mmol/L| 18.30|
Serum Creatinine| 58-110 umol/L| 624|
Na| 137-145 mmol/L| 143|
Ca| 2.10-2.55 mmol/L| 1.82|
K| 3.50-5.10 mmol/L| 3.10|
Albumin| 35-50 g/L| 22|

Urinalysis (April 26, 2010)
| Normal Values| Result|
Color| | Yellow|
Character| | Slightly cloudy|
Specific Gravity| | 1.020|
pH| | 6.0|
Albumin| | +2|
Sugar| | (-)|
WBC| | 6-10/HPF|
RBC| | 8-12/HPF|
Bacteria| | +1|
Epithelial Cells| | Few|

PT/PTT (April 25, 2010)
| Control| Result| Reference Value|
Prothrombin Time| 11.6 secs| 12.2| 10-14|
% Activity| | 92.1%| 70-120%|
INR| |...
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