Name of Patient: Marivic Cuevas Hospital: DLS-UMC

Informant: Patient Department: Internal Medicine

Reliability: Good Preceptor: Dr. Rubio-Bicol
Historian: Salvatore Juliano Elardo Date Taken: October 8, 2018
Group No.: 18B Date Submitted: October 10, 2018

GENERAL DATA

MC, female, 50-years-old, Filipino, married, Roman Catholic, was born on August 12,
1967 in Imus, Cavite and is currently residing in Bacoor, Cavite admitted for the first time last
October 1, 2018 in DLSUMC at 2:30 PM.

CHIEF COMPLAINT: “Nag edema”

HISTORY OF PRESENT ILLNESS

The patient was apparently well until 2 weeks prior to admission, the patient became ill
with cough, colds, and fever (not measured with thermometer) with yellow phlegm with no
associated symptoms. Patient’s illness subsided before their trip to China later that week. Patient
claims to have allergic rhinitis in the morning which aggravates her cough and colds. Patient used
acetaminophen (biogesic), sodium chloride (sniff) nasal spray, ciclesonide (omnaris) nasal spray,
saline (cycast) nasal spray to alleviate her symptoms.
5 days prior to admission patient complained of edema on both of her feet which caused
her discomfort and slight difficulty in walking. The edematous regions were numb but painful on
palpation and there were no other associated symptoms. Walking aggravated the edema, but was
relieved by using hot compress. This prompted the patient to seek consult.
During consultation, patient experienced prolonged palpitations accompanied with
difficulty of breathing and no other associated symptoms. This prompted admission for further
diagnosis. Patient was given diuretics (unrecalled) for her edema and unrecalled drugs for her
palpitations. Patient was also given oxygen for her difficulty of breathing.

PAST MEDICAL HISTORY

Patient is a known hypertensive and was diagnosed 14 years prior to admission. She was
maintained on Losartan but stopped taking it a few years prior to admission. Patient is also
maintained on Coveram (peridopril arginine/amlodipine) but was later changed to Amvasc
(amlodipine besilate) when she was diagnosed with chronic kidney disease. She was also found
to have a gallstone through ultrasound 2 years prior to consult. The gallstone was not obstructive
and the patient was prescribed with buscopan (scopolamine butylbromide) to treat her abdominal
pain.
Patient was found to be anemic and diagnosed with asymptomatic chronic kidney failure
7 months prior to admission. She is maintained on urinorm (febuxostat), renal vitamins, and
ketorel. She is not diagnosed with diabetes, PTB, pulmonary, hematologic, gastrointestinal, and
neurologic diseases. She has no allergies to food and medications. Patient stated that she has
no history of hospitalizations, other than her cesarean sections, no history of any accident and
has no adult immunization.

FAMILY HISTORY

The patient’s maternal family have a history of hypertension. Patient had a brother and
sister who was treated for TB but died of stroke secondary to chronic hypertension, two siblings
who died of myocardial infarction secondary to hypertension, two siblings who died of cancer, and
another brother who died of pneumonia. Patient is the youngest out of ten siblings. There is no
family history of diabetes, pulmonary, hematologic, and renal disease.

OB-GYNE HISTORY

The patient is a G5P4 (4014). Patient’s first pregnancy ended as an abortion, all
succeeding pregnancies were CS (unrecalled type). Patient was operated during 1992, 1994,
1996, and 1998 respectively. During her last pregnancy she was diagnosed with eclampsia.
Patient started menarche at 11years old and menopause is at 50 years old. Her last normal
menstrual period was during February 2017.

PERSONAL AND SOCIAL HISTORY

Patient has a college degree majoring in computer engineering and is currently

manages a pest control business. She has varying schedules for work and her daily
schedule consists mainly of doing household chores and managing her business with her
husband. Patient is well off financially. She lives in a household of 6 family members, her
house is two-storys, mostly concrete, has good lighting, and good ventilation, and is
located in a subdivision. Her diet consists mainly of fish and veggies and their drinking
water is purified from a water refilling station. Patient’s household segregates their trash
which is collected every week. Patient does not take illicit drugs, does not drink nor smoke
and is not fond of gambling.

REVIEW OF SYSTEMS

General: (+) weakness, (-) weight loss, (+) easy fatigability, (+) loss of appetite
Integument: (-) pallor, (-) hyperpigmentation, (-) wound, (-) rashes, (-) clubbing of nails
Head & Neck: (+) Headache, (-) stiffness, (-) neck vein distention, (-) mass, (-) dizziness, (-)
swelling
Eyes: (+) corrective lens (unrecalled lens power, for presbyopia), (-) pain, (-) loss of left visual
field (-) redness, (-) discharge, (-) icteric sclera
Ears: (+) difficulty of hearing (right ear), (-) otalgia, (-) vertigo, (-) tinnitus
Nose and Sinuses: (+) watery discharge, (+) epistaxis (after blowing nose), (-) obstruction
Mouth and Sinuses: (-) toothache, (-) hoarseness, (-) dysphagia, (-) ulcers, (-) tongue fasciculation
Respiratory: (+) cough, (+) dyspnea, (+) hemoptysis, (+) tachypnea, (+) pleuritic chest pain
Cardiovascular: (+) paroxysmal nocturnal dyspnea, (-) orthopnea, (-) angina
GIT: (+) nausea, (+) diarrhea, (-) vomiting, (-) anorexia, (-) diarrhea, (-) abdominal distention, (-)
abdominal pain, (-) constipation
GUT: (+) polyuria, (-) nocturia, (-) flank pains, (-) dysuria, (-) palpable mass
Vascular: (-) claudication, (-) ulcers
Hematologic: (+) pallor, (+) easy bruising, (-) easy bleeding
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) diaphoresis, (-) heat/cold intolerance
MSS/ Extremities: (+) joint pains (aggravated by cold), (-) fracture, (-) back pain
CNS: (-) seizures, (-) syncope, (-) tremors, (-) slurring of speech

PHYSICAL EXAMINATION

GENERAL SURVEY

The patient is fairly nourished, well developed, conscious, coherent, oriented to time,
place, weak but ambulatory, is in mild cardio-respiratory distress but relieved by pillows, and
appears to be her stated chronological age of 50.

VITAL SIGNS
BP: 140/90 mmHg, sitting, left arm
PR: 88 beats/min
CR: 102 beats/min
RR: 16 cycles/min
T: 37.2 C, axillary

SKIN
No remarkable findings. Inspection: (-) pallor, (-) generalized pitting edema, (-) jaundice,
(-) erythema, (-) hyperpigmentation/hypopigmentation, (-) lesions/scars, (-) hair loss/excess, (-)
nail dystrophy/deformities, (+) good capillary refill, (-) nail clubbing/koilonychia
Palpation: not febrile nor cool to touch, prompt return after finger pressure, (-) dryness,
soft and resilient skin.

HEAD AND NECK

Hair is black in color, normal density, soft and smooth in texture, (-) pattern of hair loss, (-
) infestations, (-) dandruff, (-) lumps, and (-) nevus. Skull is normocephalic, symmetrical, devoid
of lumps and tenderness. Face is symmetrical, (-) mass, (-) palpated lymph nodes, (-) enlarged
glands, (-) tenderness, her trachea is in midline.

EYES
Eyes are symmetrical, with pink palpebral conjunctiva, eyebrows are well distributed, and
pupils are equal. No redness observed.

ENT
 Ear
Pinna is mobile and devoid of masses, ulcerations or tenderness. Periauricular
areas likewise have no swelling or tenderness. Weber test was positive on the right ear
due to impacted cerumen.

Nose
External nose is symmetrical, aligned vertically with the midline and free of any
masses, deformities or tenderness. External nares are equal in size and shape. Vestibule
and the rest of the visible nasal cavity are free of masses, ulcerations, or discharge. Nasal
septum is in midline. Both nasal cavities are patent.

Mouth and Throat

Lips are symmetrical, pinkish, and devoid of masses or ulcerations. The oral
mucosa and gums are smooth, pinkish, and free of masses and ulcerations.

CHEST AND LUNGS

Inspection: Chest and chest expansion is symmetrical, (-) deformities, (-) use of accessory
muscles, (-) clubbing, (-) prominent veins; API on the 5th ICS
Palpation and Percussion: Equal thoracic expansion and equal tactile fremitus
Auscultation: (+) crackles on posterior basal part of both lungs

CARDIOVASCULAR
Inspection: (-) precordial bulge
Palpation: Not assessed
Auscultation: Not assessed.

ABDOMEN
Inspection: Firm, globular and symmetrical abdomen, (+) surgical scar on midline
hypogastric area, (-) discoloration, (-) visible mass, (-) visible peristalsis
Palpation: (+) succusion splash, (-) CVA tenderness, (-) direct tenderness, (-) rebound
tenderness on RUQ, (-) palpable mass,
Percussion: Not assessed
Auscultation: Not assessed

EXTREMITIES
Inspection: (-) atrophy, (-) tenderness, (-) edema, (-) clubbing/cyanosis of nail bed, (-) joint
pain in both knee and hips

NEUROLOGIC EXAM
The patient is awake, cooperative towards examiner, has a normal stream of talk,
conscious, oriented to time, place and person, is dressed appropriately according to age and
occasion and appropriate mood and thought content.
Cranial Nerves, sensory, motor, cerebellar, meningeals and higher cerebral functions
were unremarkable.
Salient features:
 50-years-old, female
 Family history of hypertension (Maternal)
 Anemia
 History of hypertension
 History of chronic kidney disease
 Multiple cesarean sections
 History of miscarriage
 History of eclampsia
 Chronic palpitation
 Edema
 Polyuria
 Patient on NSAIDs and hypertensive medications

PRIMARY IMPRESSION: CHRONIC KIDNEY DISEASE SECONDARY TO CHRONIC KIDNEY

DISEASE SECONDARY TO HYPERTENSION

CASE DISCUSSION

This is a case of MC, a 50-year-old female who was admitted in our institution due to
diffuse palpitation and difficulty of breathing during consult associated with edema. She also
presented with edema. Patient has a history of hypertension, diagnosed fourteen years prior to
admission and chronic kidney disease that was diagnosed seven months prior to admission.
Hypertension is one of the leading causes of CKD due to the deleterious effects an
increased blood pressure has on kidney vasculature. Long term, uncontrolled, high blood
pressure produces a hypertrophic response to glomerulus and kidney vasculature leading to
intimal thickening of large and small vessels. It significantly causes an increased intraglomerular
pressure as well as impaired glomerular filtration. Damaged glomeruli lead to an increase in
protein filtration, resulting in abnormally increased amounts of protein in the urine (proteinuria). It
also impairs kidney’s ability to filter fluid and waste from the blood, leading to an increase of fluid
volume. Excess salt and water retention increases the blood flow to the tissues, causing
autoregulation. The tissue arterioles then vasoconstrict to decrease the excessive blood flow. The
resulting vasoconstriction raises the peripheral vascular resistance, which is one of the most
consistent findings in hypertension. Hypertension also enlarges the heart and causes it to weaken
in the chronic state which can also be a cause for palpations or irregular heartbeat. It is also
perpetuated by imbalance in the effects of various vasoactive substances such as
activation/insufficient suppression of vasoconstriction systems (renin–angiotensin–aldosterone,
sympathetic system) and decreased production of vasodilatory agents (NO, prostaglandins).
Healthy, normal kidneys produces hormone called erythropoietin – a major erythropoiesis
stimulator, and releases it to the blood to help trigger or regulate bone marrow to produce red
blood cells. With chronic kidney disease, there is a loss of EPO release and decrease in RBC
production which results to anemia.
Patient MC presented with palpitations, difficulty of breathing, and anemia. In CKD, due
to damage renal filtration and de there is an accumulation of liquids and toxins in the blood and
tissues causing signs and symptoms of edema. CKD can also double a patient’s risk of atrial
fibrillation or irregular heartbeat due to the accumulation of toxins in combination with high blood
pressure circulating through the heart. The difficulty of breathing can also be attributed CKD
because when the kidneys are damaged they do not produce enough EPO which is needed for
the bone marrow to produce red blood cells. Anemia is often the result of bone marrow not
producing sufficient red blood cells due to lack of EPO production. The difficulty of breathing is an
associated symptom of anemia.

Differential Diagnosis

Diseases Rule in Rule out

Congestive Heart Failure (+) dyspnea, (+) palpitations,
(+) fatigue and weakness, (+)
edema, (+) hypertension, (+)
anemia
Chronic Dyspnea (+) dyspnea, (+) weakness,
(+) palpitations
Systemic Lupus Chronic kidney insufficiency,
erythematosus (+) hematoma, (+) edema of
extremities
(-) chest pain, cannot be
totally ruled out without
laboratory and further
physical examination
(-) chronicity of dyspnea, (-)
interstitial lung disease,
(-) joint pain, (-) malar/discoid
rash, (-) chest pain, (-) fever,
(-) neurologic disorders

Plan of Management:

Diagnostics:
 Further Physical Examination
 Serial measurements of renal function (Serum BUN/Creatinine) – to determine the pace
of renal deterioration
 Urinalysis – to assess for hematuria and proteinuria
 Renal ultrasound – to determine the symmetry, size and ruling out masses and obstruction
on the kidneys. It may also support diagnosis of CKD of long standing duration as the
kidney shrink due to further damage.
 CT Scan/MRI – to further investigate for renovascular disease.
 Renal biopsy – in early stage of CKD
 Serum concentration of calcium, phosphorus, Vit D and PTH – to evaluate presence of
metabolic bone disease
 CBC – to assess anemia and other blood abnormalities

Therapeutics:
 ACE Inhibitors and ARBs – it inhibits the angiotensin-induced vasoconstriction of the
efferent arterioles of the glomerular microcirculation causing sodium and fluid retention,
stimulates ADH and aldosterone release
  Hemodialysis – to improve patient’s survival and removal of metabolic waste
 Medications to control blood pressure and cholesterol

Non-pharmacologic:
 Lifestyle change – diet and improve physical activity
 Avoidance of IV contrast, NSAIDs and nephrotoxic drugs as these agents can potentially
induce an acute kidney injury (AKI) on the underlying kidney disease and therefore
exacerbate the baseline CKD.
 Intensive patient educational program for possible renal replacement and therapy
 Exploration of social support

Surgery:
 Kidney transplant

References:
 Harrison, T.R. (2015). In Kasper, D (Ed), Harrison's Principles of Internal
Medicine . New York, USA: McGraw Hill Education