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Case Presentation

Case Presentation. Maria Febi C. Billones January 13, 2010. General Data. R.Q. 61 y/o Female Married Bicutan. Chief Complaint. Dyspnea. Patient Profile. Known diabetic x 15 years Initially presented with 3 P’s & weight loss

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Case Presentation

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  1. Case Presentation Maria Febi C. Billones January 13, 2010

  2. General Data • R.Q. • 61 y/o • Female • Married • Bicutan

  3. Chief Complaint • Dyspnea

  4. Patient Profile • Known diabetic x 15 years • Initially presented with 3 P’s & weight loss • Prescribed with Glibenclamide 5mg BID however with poor compliance

  5. Patient Profile • Known hypertensive x 5 years • HBP 150/100 • UBP 120/90 • No medications taken

  6. History of Present Illness • 1 year PTC  patient noticed easy fatigability usually after simple household chores associated with dyspnea on exertion • She also experienced occasional chest heaviness lasting almost the whole day aggravated by work and relieved temporarily by rest

  7. History of Present Illness • 3 months PTC  noted worsening of symptoms hence had herself an ECG and Chest Xray in a nearby laboratory clinic • However, results revealed “within normal limits” on ECG and “Atheromatous Aorta” on Xray hence decided not to seek medical consult

  8. History of Present Illness • Persistence of dyspnea as well as easy fatigability prompted consult. • (-) cough, colds, orthopnea, PND, edema • (-)

  9. Review of Systems • (+) polyuria • (+) polydipsia • (+) nocturia • (-) oliguria • (-) paresthesias • (-) fever • (-) weight loss • (-) dizziness • (+) headache, occasional • (+) nape pains, occasional • (-) blurring of vision • (-) nausea • (-) vomiting • (-) abdominal pain • (-) diarrhea • (-) constipation

  10. Past Medical History • s/p Total Hysterectomy for multiple myoma, 1978 at UDMC • s/p breast cyst excision, 1972 • (-) asthma, allergy, PTB

  11. Family Medical History Diabetes PTB Hypertension Schizophrenia Brain Tumor

  12. Personal Social History • previous smoker 1-2 sticks/day x 1 yr (1978) • occasional alcoholic beverage drinker • College Graduate, previously worked in a bank • Eventually lost her job and currently on financial crisis

  13. OB-GYN History • Nulligravid • Underwent total hysterectomy for multiple myomas at 28 y/o • Menarche at 16 y/o, monthly regular interval, 5 days duration, moderate amount, (-) dysmenorrhea

  14. PHYSICAL EXAMINATION

  15. Physical Examination • General Survey • Conscious, coherent, not in respiratory distress • Vital Signs • BP 150/90 • HR 58 • RR 22 • Temp 37.1 • Wt 70.3kg Ht 161cm BMI 27

  16. Physical Examination • HEENT • pink conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion • Neck • No anterior neck mass, no cervical lymphadenopathy, no neck vein engorgement

  17. Physical Examination • Chest/Lungs • Equal chest expansion, no retractions, clear breath sounds • Heart • Adynamic precordium, bradycardic, regular rhythm, distinct heart sounds, apex beat at 5th ICS LMCL, no murmur • Abdomen • Flabby, (+) incision scar, infraumbilical area, normoactive bowel sounds, soft, non-tender

  18. Physical Examination • Extremities • Full and equal pulses, pink nailbeds, no edema, no cyanosis, no jaundice • Neuro Exam • Awake, alert, follows commands, oriented • Cranial Nerves • 1 – N/A; 2 – pupils 3mm EBRTL; 3,4,6 – full & equal EOMs; 5 – brisk corneals; 7 – no facial asymmetry; 8 – intact gross hearing; 9,10 – good gag, 11 – good shoulder shrug, 12 – tongue midline

  19. Physical Examination • Neuro Exam • MMT – 5/5 all extremities • Sensory – 100% intact • DTRs - ++ • Cerebellars: no dysmetria • Meningeals: supple neck, no incontinence

  20. Assessment t/c Chronic Stable Angina Pectoris DM Type 2, non-insulin requiring, Obese I t/c DM nephropathy Hypertension Stage 1, uncontrolled

  21. Plan • Diagnostic • FBS, BUN, Crea, Na, K, Cl, Ca, Mg • Urinalysis • 12-L ECG • Therapeutics • Metformin 500mg BID • Losartan 50mg OD

  22. Plan • Lifestyle Modification • Low salt low fat diet, low protein high fiber diet • Daily BP monitoring, sugar monitoring • Refer to Ophtha

  23. Diagnostic Dillemma • Among diabetic patients, what is the sensitivity and specificity of 24 hr urine albumin vs urine micral test in early detection of DM nephropathy?

  24. Diagnostic Dillemma • P – patients with diabetes • I –24 hr urine albumin vs urine micral test • O – in early detection of DM nephropathy • M – cross sectional studies

  25. Therapeutic Dillemma • Among long term diabetic patients, which is more effective between ACE-inhibitor and Angiotensin-receptor blocker in delaying the progression of diabetic nephropathy?

  26. Therapeutic Dillemma • P – patients with long term diabetes (>10yrs) • I – ACE inhibitor vs ARB • O – in delaying the progression of diabetic nephropathy • M – randomized control trial

  27. Thank you...

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