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Samantha Gail V.

Cosalan 1 PCGH OPD Case Write-Up


HISTORY Identifying Data The patient is W.M., a 64 year old female, retired widow, from Pasig City. The source of history is the patient herself with 95% reliability. Chief Complaint The patient is a known diabetic and hypertensive, she arrived at the OPD for her regular follow-up History of Present Illness The patient is a diagnosed diabetic since she gave birth to her first son 38 years ago. Her current medications for her diabetes include Metformin 500mg TID and GLibenclamide 5mg TID. The patient is a diagnosed hypertensive since 2009 with her highest blood pressure reaching 160/120mmHg. Her current medications for hypertension include Nifedipine 30mg OD and Losartan 100mg OD. The patient is also diagnosed with having high cholesterol levels noted last 2010 and is currently taking Simvastatin 20mg OD. The patient claims that she has taken drastic measures to improve her overall health. She has started to exercise by walking an estimate of 5 blocks of every morning and has also watched her weight. She has currently lost 4kg from her last check-up that she attributes to her no rice diet. The patient however complains of recent episodes of weakness and lightheadedness that is relieved by lying down. There is however no associated episodes of dizziness, headaches and loss of consciousness. She also denies having episodes of nape pain, blurring of vision, chest tightness, nausea, and vomiting. The patient is also concerned about the growth of a skin lesion on her left shin, which was also starting on her right shin. She was prescribed an unrecalled ointment, which she claimed worsened the lesion. Patient claims that the lesion is non tender and is only itchy on a couple of occasions. Past Medical History (+) HTN, Diabetes, Dyslipidemia 2009 cataract operation, both eyes No known allergies (-) TB, heart disease, kidney disease OB History Patient is a G2P2(2002). Her eldest child was born via CS because the baby was large for his gestational age and weighed approximately 10lbs. The patient was diagnosed with gestational diabetes, which progressed to DM Type II. Her second child was born via NSD with a normal weight and no complications. Family History (+) HTN (-) Diabetes, cancer, TB, kidney disease Genogram Patients husband died from a stroke in 1997 Patients 2 son is also diagnosed with Diabetes
nd

Social and Personal History Patient is a non smoker, non alcoholic drinker, does not take any illicit drugs Patient is very particular about what she eats and watches her weight. She no longer eats fried foods and has limited her rice to 1 cup a day. Her exercise consists of stretching and walking in the morning. Review of Systems Skin: No lumps, dryness, color change or any changes in her hair or nails HEENT: No lightheadedness, blurring of vision, eye redness, eye tenderness, hearing loss, tinnitus, ear pain, sore throat, hoarseness, dry mouth Neck: No lumps, goiter, tenderness, stiffness Respiratory: No hemoptysis, dyspnea, wheezing Cardiovascular: No palpitations, orthopnea, edema Gastrointestinal: No dysphagia, change in bowel movements, rectal bleeding, abdominal pain, jaundice Urinary: No frequency, nocturia, urgency, dysuria, incontinence Musculoskeletal: No muscle or joint pains, stiffness, arthritis, gout Neurologic: No seizures, paralysis, numbing or loss of sensation, tingling, tremors, involuntary movements Hematologic: No easy bruising or bleeding Psychiatric: No depression, memory changes, suicide attempts PHYSICAL EXAMINATION General The patient is alert, awake, not in respiratory distress. Patient is currently not in pain and sitting comfortably in a monobloc chair. She appears well groomed and is wearing a blouse, shorts and rubber slippers. Vital Signs Vital Sign Temperature Heart Rate Respiratory Rate Blood Pressure HEENT Pink conjunctivae, anicteric sclera, pink oral mucosa. No tonsillopharyngeal congestion, no cervical lymphadenopathy. No neck enlargement, masses and stiffness. CardioPulmo Equal chest expansion, clear breath sounds with no rhoci/rales/wheezes, lungs are resonant th Adynamic precordium, normal heart rate with regular rhythm, distinct S1 and S2, no heaves or thrills, apex beat at 5 ICS LMCL Abdomen Soft, normoactive bowel sounds, nontender, no organomegaly or masses palpated Extremities No edema, atrophy, weakness. Full and equal pulses Nervous System Patient is alert and cooperative, GCS 15. Thought is coherent and oriented to person, place and time. Cranial nerves intact. Good muscle bulk and tone, 5/5 strength, reflexes +2. ASSESSMENT Hypertension, Controlled. Diabetes, Controlled. To consider Hypoglycemia. PLAN Shift Glibenclamide to Glimepiride 3mg BID Continue all other medications Labs to be done: FBS, HBA1C Next follow-up will be on December 16, 2011. Patients Value - not taken 83 17 120/70 mmHg Interpretation Normal Normal Normal

Samantha Gail V. Cosalan 3 PCGH OPD Case Write-Up


DISCUSSION Hypertension Hypertension is one of the most common diseases affecting individuals from all over the world. In the Philippines, the prevalence of Hypertension has been increasing due to lifestyle changes. Filipinos are now eating foods that are unhealthy and have also adopted a more sedentary lifestyle. The increase in health seeking behavior has also caused an increase in the number of diagnosed cases especially in the health center setting. Clinical criteria for diagnosing a patient with hypertension include an average of 2 or more seated blood pressure readings during each of 2 or more outpatient visits. The table below shows the blood pressure classification among individuals: Blood Pressure Classification Normal Pre-hypertension Stage I Hypertension Stage II Hypertension Isolated systolic hypertension Systolic, mmHg <120 120 - 139 140 159 >160 >140 Diastolic, mmHg <80 80 89 90 99 >100 <90

The mechanism of hypertension is related to the intravascular volume of an individual that is directly related to levels of sodium in the body. When intake exceeds the capacity of the kidneys to excrete the sodium, there is expansion of vascular volume and cardiac output increases. Hypertension may also be caused by an increase in sympathetic outflow, which is common among obese individuals. This is proven by potent antihypertensive drugs, which block the sympathetic nervous system. The Renin-Angiotensin-Aldosterone system also plays an important role in the regulation of arterial pressure through the vasoconstrictor properties of angiotensin II and the sodium retaining properties of aldosterone. The main treatment for hypertensive patients is pharmacologic therapy. Different drugs used in the treatment of hypertension include Diuretics (thiazides, loop, aldosterone antagonists), Beta Blockers (atenolol, metoprolol, propranolol), Alpha Antagonists (terazosin, prazosin), Sympatholytics (clonidine, methyldopa, captopril, losartan) and Calcium Antagonists (nifedipine, verapamil, diltiazam, hydralazine). Single or multi drug regimens may be used which is individualized for patients and constant monitoring of the blood pressure is needed. Lifestyle changes are also important for control of blood pressure. Patients should start eating a well balanced diet and should also start exercising regularly. If hypertension is left uncontrolled, there are numerous consequences and end organ damages associated with this. The most common leading cause of death among hypertensive patients is heart disease. Patients develop left ventricular hypertrophy, CHF, cardiac arrhythmias, etc. Another complication of hypertension that is also one of the most common causes of death among patients is stroke. As a conclusion, it is very important that hypertensive patients regularly monitor their blood pressure to ensure its control and to prevent complications. Gestational Diabetes Gestational Diabetes is defined as having a high blood sugar that is discovered while a woman is pregnant. Risk factors include age >25 years, (+) family history of diabetes, gave birth to a baby that is >9lbs, hypertensive, and being overweight. During prenatal check-ups, if patients have a plasma glucose >7.8mmol/L, a 100g oral glucose challenge with plasma glucose measurements obtained in the fasting state and at 1, 2 and 3 hours. Normal values are plasma glucose concentrations <5.8mmol/L, 10.5mmol/L, 9.1mmol/L and 8mmol/L. These women are at an increased risk of stillbirth, pre-eclampsia, and birth complications due to the delivery of a large for gestational age baby (birth lacerations, shoulder dystocia, brachial plexus injury). The babies are also at risk for hypoglycemia, hyperbilirubinemia and polycythemia. Treatment includes the patient having a proper diet and if this does not work, pharmacologic therapy such as metformin and insulin injections may be used to control the blood pressure. After delivery of the baby, these women should be regularly monitored in order to determine if the have developed permanent diabetes.