Case Analysis

On
Diabetes Mellitus

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 INTRODUCTION

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar

(glucose) levels that result from defects in insulin secretion, or its action, or both. Diabetes
mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a
disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated
levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term
sweet urine.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by
the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for
example, after eating food), insulin is released from the pancreas to normalize the glucose level.
In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia.
Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a
lifetime.

There are two major types of diabetes, called type 1 and type 2. Type 1 diabetes was also
formerly called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus.
In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is
rendered incapable of making insulin. Abnormal antibodies have been found in the majority of
patients with type 1 diabetes. Antibodies are proteins in the blood that are part of the body's
immune system. The patient with type 1 diabetes must rely on insulin medication for survival.

Type 2 diabetes

Type 2 diabetes was also previously referred to as non-insulin dependent diabetes

mellitus (NIDDM), or adult onset diabetes mellitus (AODM). In type 2 diabetes, patients can still
produce insulin, but do so relatively inadequately for their body's needs, particularly in the face of
insulin resistance as discussed above. In many cases this actually means the pancreas produces
larger than normal quantities of insulin. A major feature of type 2 diabetes is a lack of sensitivity
to insulin by the cells of the body (particularly fat and muscle cells).

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 In addition to the problems with an increase in insulin resistance, the release of insulin by
the pancreas may also be defective and suboptimal. In fact, there is a known steady decline in
beta cell production of insulin in type 2 diabetes that contributes to worsening glucose control.
(This is a major factor for many patients with type 2 diabetes who ultimately require insulin
therapy.) Finally, the liver in these patients continues to produce glucose through a process called
gluconeogenesis despite elevated glucose levels. The control of gluconeogenesis becomes
compromised.

While it is said that type 2 diabetes occurs mostly in individuals over 30 years old and the
incidence increases with age, we are seeing an alarming number patients with type 2 diabetes who
are barely in their teen years. Most of these cases are a direct result of poor eating habits, higher
body weight, and lack of exercise.

While there is a strong genetic component to developing this form of diabetes, there are
other risk factors - the most significant of which is obesity. There is a direct relationship between
the degree of obesity and the risk of developing type 2 diabetes, and this holds true in children as
well as adults. It is estimated that the chance to develop diabetes doubles for every 20% increase
over desirable body weight.

Regarding age, data shows that for each decade after 40 years of age regardless of weight
there is an increase in incidence of diabetes. The prevalence of diabetes in persons 65 years of age
and older is around 27%. Type 2 diabetes is also more common in certain ethnic groups.
Compared with a 7% prevalence in non-Hispanic Caucasians, the prevalence in Asian Americans
is estimated to be 8%, in Hispanics 12%, in blacks around 13%, and in certain Native American
communities 20% to 50%. Finally, diabetes occurs much more frequently in women with a prior
history of diabetes that develops during pregnancy (gestational diabetes).

Diabetes can occur temporarily during pregnancy, and reports suggest that it occurs in
2% to 10% of all pregnancies. Significant hormonal changes during pregnancy can lead to blood
sugar elevation in genetically predisposed individuals. Blood sugar elevation during pregnancy is
called gestational diabetes. Gestational diabetes usually resolves once the baby is born. However,
35% to 60% of women with gestational diabetes will eventually develop type 2 diabetes over the
next 10 to 20 years, especially in those who require insulin during pregnancy and those who
remain overweight after their delivery. Patients with gestational diabetes are usually asked to
undergo an oral glucose tolerance test about six weeks after giving birth to determine if their
diabetes has persisted beyond the pregnancy, or if any evidence (such as impaired glucose
tolerance) is present that may be a clue to the patient's future risk for developing diabetes.

"Secondary" diabetes refers to elevated blood sugar levels from another medical
condition. Secondary diabetes may develop when the pancreatic tissue responsible for the

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production of insulin is destroyed by disease, such as chronic pancreatitis (inflammation of the
pancreas by toxins like excessive alcohol), trauma, or surgical removal of the pancreas.

Diabetes can also result from other hormonal disturbances, such as excessive growth
hormone production (acromegaly) and Cushing's syndrome. In acromegaly, a pituitary gland
tumor at the base of the brain causes excessive production of growth hormone, leading to
hyperglycemia. In Cushing's syndrome, the adrenal glands produce an excess of cortisol, which
promotes blood sugar elevation.

In addition, certain medications may worsen diabetes control, or "unmask" latent

diabetes. This is seen most commonly when steroid medications (such as prednisone) are taken
and also with medications used in the treatment of HIV infection (AIDS).

SIGNS AND SYMPTOMS

 The early symptoms of untreated diabetes are related to elevated blood sugar levels, and
loss of glucose in the urine. High amounts of glucose in the urine can cause increased urine
output and lead to dehydration. Dehydration causes increased thirst and water consumption.
 The inability of insulin to perform normally has effects on protein, fat and carbohydrate
metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and
protein.
 A relative or absolute insulin deficiency eventually leads to weight loss despite an
increase in appetite.
 Some untreated diabetes patients also complain of fatigue, nausea and vomiting.
 Patients with diabetes are prone to developing infections of the bladder, skin, and vaginal
areas.
 Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated
glucose levels can lead to lethargy and coma.

DIAGNOSIS
The fasting blood glucose (sugar) test is the preferred way to diagnose diabetes. It is easy
to perform and convenient. After the person has fasted overnight (at least 8 hours), a single
sample of blood is drawn and sent to the laboratory for analysis. This can also be done accurately
in a doctor's office using a glucose meter.
 Normal fasting plasma glucose levels are less than 100 milligrams per deciliter (mg/dl).
 Fasting plasma glucose levels of more than 126 mg/dl on two or more tests on different
days indicate diabetes.
 A random blood glucose test can also be used to diagnose diabetes. A blood glucose level
of 200 mg/dl or higher indicates diabetes.

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 When fasting blood glucose stays above 100mg/dl, but in the range of 100-126mg/dl, this is
known as impaired fasting glucose (IFG). While patients with IFG do not have the diagnosis of
diabetes, this condition carries with it its own risks and concerns, and is addressed elsewhere.

The oral glucose tolerance test

Though not routinely used anymore, the oral glucose tolerance test (OGTT) is a gold
standard for making the diagnosis of type 2 diabetes. It is still commonly used for diagnosing
gestational diabetes and in conditions of pre-diabetes, such as polycystic ovary syndrome. With
an oral glucose tolerance test, the person fasts overnight (at least eight but not more than 16
hours). Then first, the fasting plasma glucose is tested. After this test, the person receives 75
grams of glucose. There are several methods employed by obstetricians to do this test, but the one
described here is standard. Usually, the glucose is in a sweet-tasting liquid that the person drinks.
Blood samples are taken at specific intervals to measure the blood glucose.

For the test to give reliable results:

 The person must be in good health (not have any other illnesses, not even a cold).
 The person should be normally active (not lying down, for example, as an inpatient in a
hospital), and
 The person should not be taking medicines that could affect the blood glucose.
 The morning of the test, the person should not smoke or drink coffee.

The classic oral glucose tolerance test measures blood glucose levels five times over a
period of three hours. Some physicians simply get a baseline blood sample followed by a sample
two hours after drinking the glucose solution. In a person without diabetes, the glucose levels rise
and then fall quickly. In someone with diabetes, glucose levels rise higher than normal and fail to
come back down as fast.

People with glucose levels between normal and diabetic have impaired glucose tolerance
(IGT). People with impaired glucose tolerance do not have diabetes, but are at high risk
for progressing to diabetes. Each year, 1% to 5% of people whose test results show impaired
glucose tolerance actually eventually develop diabetes. Weight loss and exercise may help people
with impaired glucose tolerance return their glucose levels to normal. In addition, some
physicians advocate the use of medications, such as metformin (Glucophage), to help
prevent/delay the onset of overt diabetes.

Research has shown that impaired glucose tolerance itself may be a risk factor for the
development of heart disease. In the medical community, most physicians are now understanding
that impaired glucose tolerance is nor simply a precursor of diabetes, but is its own clinical
disease entity that requires treatment and monitoring.

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Evaluating the results of the oral glucose tolerance test
Glucose tolerance tests may lead to one of the following diagnoses:
 Normal response: A person is said to have a normal response when the 2-hour glucose
level is less than 140 mg/dl, and all values between 0 and 2 hours are less than 200 mg/dl.
 Impaired glucose tolerance: A person is said to have impaired glucose tolerance when
the fasting plasma glucose is less than 126 mg/dl and the 2-hour glucose level is between
140 and 199 mg/dl.
 Diabetes: A person has diabetes when two diagnostic tests done on different days show
that the blood glucose level is high.
 Gestational diabetes: A pregnant woman has gestational diabetes when she has any two
of the following:, a fasting plasma glucose of 92 mg/dl or more, a 1-hour glucose level of
180 mg/dl or more, or a 2-hour glucose level of 153 mg/dl, or more.

TREATMENT

Findings from the Diabetes Control and Complications Trial (DCCT) and the United
Kingdom Prospective Diabetes Study (UKPDS) have clearly shown that aggressive and intensive
control of elevated levels of blood sugar in patients with type 1 and type 2 diabetes decreases the
complications of nephropathy, neuropathy, retinopathy, and may reduce the occurrence and
severity of large blood vessel diseases. Aggressive control with intensive therapy means
achieving fasting glucose levels between 70-120 mg/dl; glucose levels of less than 160 mg/dl
after meals; and a near normal hemoglobin A1c levels (see below).

Studies in type 1 patients have shown that in intensively treated patients, diabetic eye
disease decreased by 76%, kidney disease decreased by 54%, and nerve disease decreased by
60%. More recently the EDIC trial has shown that type 1 diabetes is also associated with
increased heart disease, similar to type 2 diabetes. However, the price for aggressive blood sugar
control is a two to three fold increase in the incidence of abnormally low blood sugar levels
(caused by the diabetes medications). For this reason, tight control of diabetes to achieve glucose
levels between 70 to120 mg/dl is not recommended for children under 13 years of age, patients
with severe recurrent hypoglycemia, patients unaware of their hypoglycemia, and patients with
far advanced diabetes complications. To achieve optimal glucose control without an undue risk of
abnormally lowering blood sugar levels, patients with type 1 diabetes must monitor their blood
glucose at least four times a day and administer insulin at least three times per day. In patients
with type 2 diabetes, aggressive blood sugar control has similar beneficial effects on the eyes,
kidneys, nerves and blood vessels.

STATISTICS

Worldwide

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 A 2011 Centers for Disease Control and Prevention (CDC) report estimated that nearly
26 million Americans have diabetes. Additionally, an estimated 79 million Americans have
prediabetes.

Diabetes affects 8.3% of Americans of all ages, 11.3% of adults aged 20 years and older,
and 25% of persons age 65 and older, according to the National Diabetes Fact Sheet for 2011.
About 27% of those with diabetes—7 million Americans—do not know that they have the
disease. About 215,000 people younger than 20 years had diabetes (type 1 or type 2) in the
United States in 2010.

Prediabetes affects 35% of adults aged 20 years and older. Prediabetes, as defined by the
American Diabetes Association, is that state in which blood glucose levels are higher than normal
but not high enough to be diagnosed as diabetes. It is presumed that most persons with
prediabetes will subsequently progress to diabetes. The CDC estimated that in 2010, 79 million
Americans aged 20 years or older had prediabetes—35% of US adults aged 20 years or older and
50% of those aged 65 years or older.

The International Diabetes Federation predicts that the number of people living with
diabetes will to rise from 366 million in 2011 to 552 million by 2030. The top 10 countries in
number of people with diabetes are currently India, China, the United States, Indonesia, Japan,
Pakistan, Russia, Brazil, Italy, and Bangladesh.

In the Philippines
The incidence of diabetes is growing around the world. It is in the top ten leading causes
of deaths. Filipinos are not an exemption to this incidence as the disease affects more and more
Filipinos. In fact, the last 2008 survey was alarming enough to conclude that one out of every five
Filipinos have diabetes. That means that around 20% of the population have diabetes and this has
significantly increase from only 4% in 1998.

Another cause for alarm is that Filipinos diagnosed with diabetes are getting younger.
Children as young as 5-years old have been diagnosed with type 2 diabetes. With this trend, the
Philippines is expected to belong on the top 10 countries with the most people with diabetes 15
years from now.

At the rate diabetes cases are increasing in the country, there will be some 6.16 million
diabetic Filipinos by 2030, health experts warned the other day. According to Dr. Joey Miranda,
secretary of the American Association of Clinical Endocrinology-Philippines, there were 3.4
million diabetes cases in the country in 2010, representing a prevalence rate of 7.7 percent.

Citing data from the World Health Organization and International Diabetes Foundation,
he said that by 2030, the prevalence rate is projected to rise to 8.9 percent or 6.16 million cases.
These figures represent an increase of 15.6 percent and 84.2 percent in prevalence rate and the
number of cases, respectively.

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 PATIENT’S PROFILE

Name: GGC

Age: 58 years old

Gender: Male

Birth date: November 6, 1959

Home Address: Caloocan City

Birth place: Botolan,Zambales

Nationality: Filipino

Religion: Roman Catholic

Occupation: Teacher

Chief Complaint: Dizziness; Easy Fatigability;DOB

Admission Date: August 23, 2017

Admitting Vital Signs:

BP: 150/90 mmHg

T: 36.9OC

P: 89 bpm

R: 27 cpm

SpO2: 91-94%

GCS: 15

Admitting Weight: 75.4 kgs

Admitting Height: 5’4”

Admitting Diagnoses:

Diabetes Mellitus Type 2;

Chronic Kidney Disease;

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 Pneumonia

Final Diagnoses:

Diabetes Mellitus Type 2;

Chronic Kidney Disease;

Community Acquired Pneumonia – Moderate Risk

Attending Physician/s:

Dr. Gimenez

Dr. Rivera

Dr. Reyes

NURSING HISTORY

Chief Complaint
GGC experienced difficulty of breathing accompanied by easy fatigability.

History of Present Illness

3 days prior to admission, the patient experienced severe knee pain. He described the pain
as a tightening type of pain and rated it 6/10. The symptom first occurred while he was still in the
United States of America on November 28, 2014, when he ate bulalo in a certain restaurant. Few
hours after eating the said dish, his knee became painful. The following day was his trip to the
Philippines but he cannot walk anymore because of severe knee pain that prompted his relatives
to get a wheelchair. The patient self-medicated with Arcoxia 60 mg per orem which provided
relief. RAM had no fever, nausea and vomiting, nor abdominal pain.

Few hours prior to admission, patient RAM was noted to have difficulty of breathing
accompanied by easy fatigability, hence the subsequent admission at Notre Dame de Chartres
Hospital with an initial diagnosis of Diabetes Mellitus 2, CKD, and Pneumonia.

Past Health History

According to RAM, he was diagnosed with CKD and arthritis last 2009. He was
diagnosed with Diabetes Mellitus in the year of 1981 when he was still working at Saudi Arabia.
RAM’s maintenance medication for his diabetes is Metformin.

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 RAM had mumps, measles, and chicken pox when he was a child. There were no other
childhood illnesses mentioned by him. When RAM was still 1-year-old, he was confined for a
day at a hospital in Baguio due to fever and chills. Paracetamol was given to him complemented
by tepid sponge bath. In addition, RAM has not undergone any surgery before. When asked
about the vaccinations, RAM doesn’t remember them. RAM doesn’t remember if he had BCG,
DPT, OPV, Hepatitis B and Measles vaccine.

As to allergies, RAM is allergic to seafood, most especially to shrimps. He is also allergic

with cats and dogs. Rashes appear all over RAM’s body accompanied by difficulty breathing
when he develops allergies. His personal doctor prescribed RAM with Prednisone to control his
allergies.

Family Health History

When asked about the diseases common in their family, RAM mentioned the following:
hypertension, asthma and arthritis. RAM’s mother and father have hypertension. The
grandparents of RAM from his mother’s side have Hypertension and Arthritis. Moreover, RAM’s
father has Asthma and Diabetes. Many of his cousins from the father’s side have the same illness
as well. He doesn’t know if there is cancer that runs in their family. Lastly, the grandfather of
RAM from the mother’s side had tuberculosis.

GORDON’S FUNCTIONAL HEALTH PATTERNS

1. Health Perception/ Health Management Pattern

Before Hospitalization:
RAM’s understanding of health is being able to eat healthy in line with his diabetic diet.
“Yung kakain ng mga masusustansiyang pagkain” said RAM. According to him, he is healthy
because he can control his blood glucose levels. Whenever RAM becomes ill, his wife or

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daughter buys OTC drugs such as paracetamol and lets RAM rest; but when RAM doesn’t
recover for at least two days, they bring RAM to the doctor. According to RAM, he eats
vegetables for him to be healthy but most of the time, RAM refuses to. Since he dislikes
vegetables, RAM’s wife and daughter buys him fruits. He is fond of eating meat.

During Hospitalization:
RAM does not consider himself to be healthy. In order for him to recover, RAM buys all
the drugs prescribed by the doctor and follows the instructions given by the nurses. He also
consented in having dialysis for him to relieve his edema and remove the toxins in his body
which his kidney can’t remove anymore. When given treatments such as nebulization and blood
transfusion, RAM participates actively.

2. Nutritional/ Metabolic Pattern

Before Hospitalization:
RAM’s typical food intake is 2 cups of rice per meal. He is fond of eating meat especially
chicken. He seldom eats vegetables because he doesn’t like the taste of vegetables. He likes
chopsuey. He loves fruits including banana and papaya which is his favorite. MM usually drinks
13-14 glasses of water a day. He drinks ensure brought to him by his daughter. The daughter and
wife of RAM are the ones who prepare his food specifically breakfast, lunch and dinner.
According to him, he always buys soft drinks and biscuits for snacks. RAM said he doesn’t
experience any difficulty in chewing and swallowing.
RAM isn’t aware of his height and weight but his height and weight were taken during
admission.

During Hospitalization:
RAM’s diet in the hospital is full diabetic, chronic kidney diet, low salt, low cholesterol
diet. The diet is 2100 kcal/day that is breakdown into carbohydrates- 305g/day, protein- 44g/day,
fats- 88g/day. He eats whatever is given by the hospital. He still consumes as much as 1 cup of
rice and 1 glass of water per meal. RAM continues to drink milk (ensure for diabetics) with the
same amount and time of drinking. According to RAM, he doesn’t have a problem with chewing
and swallowing. His admitting weight was 73.8 kg.
RAM was asked if he is happy with his weight, he said, “Hindi. Gusto kong pumayat at
mawala na tong manas sa katawan ko”.

3. Elimination Pattern

Before Hospitalization:

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 RAM defecates once a day. Usually, he defecates in the morning but sometimes he does
after lunch. The usual color of his stool is brown. When asked about the quantity, RAM’s mother
said it is as much as a handful. As to urination, RAM urinates 6-7 times a day. The usual color of
his urine is translucent yellow and the usual quantity is about 2 cups (480mL) as estimated by
RAM. When RAM feels like urinating, he goes to the comfort room immediately. RAM doesn’t
have any problem with regards to bladder control. He can delay urinating for a while as he goes
to the comfort room. In addition, RAM said he doesn’t feel any pain when defecating as well as
when urinating. RAM said he always perspires especially if he works and feels anxious. He
doesn’t have any foul body odor. To avoid body odor, RAM takes a bath in the morning and in
the afternoon and usually applies powder on his back.

During Hospitalization:
From the time of admission until the time he was handled, RAM urinated 8-9 times a day
and usually defecates at least once daily. The daughter of RAM described the color and quantity
of RAM’s urine as translucent yellow and about 1 cup. When asked if he felt pain when urinating,
RAM answered, “Hindi masakit.”

4. Activity/ Exercise Pattern

Before Hospitalization:
The usual activities that RAM does starting from the time he wakes up to the time he
goes to bed are the following: eating breakfast, taking a bath, exchanging stories with his
relatives, watching TV, eating dinner and sleeping. Sometimes he goes walking around in the
neighborhood. Almost everyday, RAM does reading. Whenever he has free time, RAM drives
just to kill time. He said, “Minsan namimiss ko din magdrive. Dati kasi akong driver noon sa
Saudi Arabia”. According to RAM, there is no problem with his gait or the way he walks. When
RAM feels tired, he sleeps in order to relax. RAM exercises together with his wife when he was
still in the United States. As to how long the exercise is, RAM said, “Matagal. Nilalakad naming
buong barangay doon”. Furthermore, RAM doesn’t feel any pain when exercising or walking;
however, he usually gets tired easily. “Hinihingal ako” said RAM. Lastly, RAM doesn’t do any
household chores. He only does them when something in their home is for repair like when their
house is for repainting and rebuilding.

During Hospitalization:
RAM just stays on his bed because he does not want to get tired. During his stay in the
hospital, he has difficulty in breathing and experiences chest pain when he coughs out his
phlegm. He is on complete bed rest without bathroom privileges. RAM exchanges stories with the
nurses always for him not to get bored. RAM said “Gusto ko nang umuwi para makapaglakad
lakad ng kaonti”.

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 5. Sleep/ Rest Pattern

Before Hospitalization:
RAM usually sleeps at around 9-10 in the evening. During weekdays, he wakes up at 5
am. During weekends, he wakes up at 7 am. RAM takes a nap in the afternoon for 2-3 hours. The
wife of RAM is the one sleeping with him. RAM doesn’t want to sleep alone. “Lagi kasi akong
nananaginip ng masama.” said RAM. Before sleeping, RAM usually drinks 1 bottle of milk
(ensure) first. According to RAM, he always has dreams. Sometimes, those dreams include his
friends, family, and relatives. There are also times when he dreams of ghosts and wakes up
screaming. According to RAM’s daughter, he is easily awakened by noise.

During Hospitalization:
RAM is sometimes disturbed by the noise of other patients and the equipment in the ICU,
which are very noisy. RAM said, “nagigising ako pag may umiiyak o kaya pag may masamang
panaginip. Noong isang araw nga sumisisigaw ako kasi sa panaginip ko may babaeng humahabol
at bumabato sakin. Sabi ko doon sa babae may sakit na nga ako binabato niyo pa ako”. RAM
sleeps when he gets tired and wakes up after 1-2 hours. He said, “hindi ako masyadong
makatulog dito sa hospital”.

6. Cognitive/ Perceptual Pattern

Before Hospitalization:
RAM does not have problems about his senses. He can easily distinguish different
images, sounds, tastes, textures and odors. He also added that the easiest for him to learn is when
he sees and hear it. He said that sickness impedes him to learn. RAM can speak Ilocano, Tagalog
and English. He knows a little about Saudi Arabian language.

During Hospitalization:
He responds clearly and well understood. He has no sensory deficit. In addition to that,
he responds appropriately to verbal and physical stimuli and obeys simple commands. As to his
senses, nothing changed markedly during hospitalization.

7. Self-perception/Self-concept Pattern

Before Hospitalization:

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 RAM describes himself as “Mabuting asawa at tatay sa mga anak. Kaya nga ako
nagtrabaho sa ibang bansa para makatapos yung dalawang anak ko. Driver ako nuon sa Saudi
Arabia pero kahit nasa malayo ako, hindi ako tumingin ng ibang babae.” When he was asked if
there’s something he wants to improve or change with regards to his physical appearance, he said
“Wala naman.” With regards to his attitude, “Hindi naman ako madaling magalit. Hindi ko
pinagbubuhatan ng kamay ang asawa at mga anak ko. Mahal na mahal ko sila. Iniintindi kong
mabuti ang mga problemang hinaharap ng pamilya ko at sama sama naming hahanapan yun ng
solusyon”, he said. He said that he finished elementary and highschool in Baguio and finished
Accountancy at De la Salle University in Manila. He worked at a government institution before
he went to work abroad.

During Hospitalization:
He still describes himself as “Mabuting asawa at tatay sa mga anak.” According to him,
“Ayaw ko lang itong dry skin ko na parang buhangin na sa gaspang. Pero okay lang, nawawala
naman na yung dry skin ko dahil sa lotion na binigay sa akin. Yung atopiclair lotion at lagi naman
akong binebed bath.”

8. Role-Relationship Pattern

Before Hospitalization:
RAM lives with his eldest daughter together with his wife which is two years older than
him. When asked what role does he portray in the family, he said, "Mabuting asawa at tatay sa
mga anak." He said, "Mabuti din akong kaibigan. Nagpapautang ako noon sa mga kapwa ko
pinoy sa Saudi Arabia. Kapag kailangan kasi ng pmailya nila ng pera wala silang maibigay dahil
nagagastos nila sa sugal at babae." He said that gambling and girls can destroy a man. One should
always think of his family.

During Hospitalization:
He had more time to bond with his younger daughter. "Namiss ko rin yang bunso ko.
Buti nga at umuwi kami dito sa Pilipinas. Naiwan yung panganay ko sa US kasi madaming
inaasikaso. Supervisor nurse kasi siya ng dialysis unit doon," he said.

9. Sexuality/Reproductive Pattern

According to RAM, he was circumcised when he was 10 years old. He was in high
school when he had his first girlfriend. When he was in college, he said that he never had any
serious relationships with women until he met his wife. At the age of 25, they got married and
they had 2 children, one boy and one girl.

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 10. Coping-stress Tolerance

Before Hospitalization:
When RAM was asked for the things that make him feel lonely, he said, "Noong
pinagnursing ko yung pangalawang anak ko after niyang makatapos ng commerce. Ayun, hindi
parin nakakapasa ng examination kaya nagpatayo nalang ng restaurant." He also said that he feels
angry if he or his family was wronged. When asked about what makes him happy, "His wife,
daughters, and grandchildren" he said. He said that the thing that usually causes disappointment is
when his parents gets angry with him when they were still alive. He makes himself feel better by
just talking with his wife.

During Hospitalization:
According to the patient, it makes him sad if he feels that he has so many complications
because of his diabetes. However, he still spends his talking with the nurses and telling his stories
for him not feel sad.
11. Value-Belief Pattern

Before Hospitalization:
RAM is a Roman Catholic. "Naniniwala ako kay Jesus. Nagpe-pray ako at nagaattend ng
mass. Pinagpe-pray ko na sana bigyan kami ng blessings at gumaling ako.", he said. According to
RAM, they consult a doctor instead of an albularyo. They believe in superstitions like "atang” and
healing prayers.

During Hospitalization:
“Minsan po, nakakalimutan ko mag-pray.”, as verbalized by RAM. He still believes,
however, that God is still there.

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 PHYSICAL ASSESSMENT

Date Assessed: August 20, 2015

Time Assessed: 10 am – 12 pm

Vital Signs:
BP – 130/80 mmHg
T – 37.1OC
P – 110 bpm
R – 24 cpm
SpO2 – 95-98%
GCS – 15

Body Measurements:
Weight: 70 kgs

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 Height: 5’6”

GENERAL APPEARANCE
Patient appears well and alert with a GCS score of 15. The patient has an IVF infusion of
# 3 PNSS 1LxKVO patent and infusing well at right metacarpal vein and dopamine drip: PNSS
250 ml + 400 mg Dopamine patent and infusing well at the left metacarpal vein.

AREA ASSESSED TECHNIQUE NORMAL ACTUAL ANALYSIS

FINDING FINDINGS
Body build, weight, Inspection Proportionate Proportionate Normal
height, in relation to the
patients age, lifestyle
,health

Posture, gait, sitting, Inspection Relaxed, Relaxed, Normal

standing, walking coordinated coordinated
movements, erect movements,
posture erect posture

Client’s hygiene and Inspection Clean and neat Clean and Neat Normal
grooming

Body, breath odor Inspection No body odor or No body or Normal

breath odor breath odor

Signs of distress in Inspection No distress noted No distress Normal

posture and facial noted
expression

Client’s attitude Inspection Cooperative, able Cooperative, Normal

to follow able to follow
instructions instructions

Quantity of speech, Inspection Understandable, Understandable. Normal

quality and organization Moderate pace, Moderate pace,
of thoughts clear tone and clear tone and
inflection inflection

Affect or mood Inspection Appropriate to Appropriate to Normal

situation situation

Relevance and Inspection Logical Logical Normal

organization of thought sequence, make sequence, make
sense sense

SKIN
AREA ASSESSED TECHNIQUE NORMAL ACTUAL ANALYSIS

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 FINDINGS FINDINGS
Color Inspection Varies to light to Light brown Normal
deep brown;
from rudy pink;
from yellow over
tones to olives

Uniformity in skin color Inspection Generally Uniform in color Normal

uniform except
for area expose to
sun

Edema Palpation No edema (+) Pitting Due to

edema on both diffused
legs glomerular
sclerosis
causing Na+
wasting.

Skin lesions Inspection Freckles, some Scars on feet, no Scars due to

birthmarks, some abrasions or allergies
flat and raise lesions, some
nevi, no nevi noted.
abrasions and Presence of
lesions tattoo on the left
arm

Skin moisture Inspection Moisture in skin Dry skin Due to

folds and the diabetes
axillae (varies mellitus
with
environmental
temperature and
humidity, body
temp. and
activity)
Skin temperature Palpation Uniform; within Temp: 36.8 Normal
normal range Celsius

Skin turgor Palpation When pinch, skin When pinch,

springs back to skin springs
previous state back but in a
slow state

NAILS
Fingernail plate Inspection Convex Convex Normal
curvature; angle curvature

53
 of nail plate of
about 160
degress

Nail texture (fingers and Inspection Smooth texture Smooth Normal

toes)

Nail bed color Inspection Highly vascular Pink nail bed Normal
and pink=light
skinned clients;
Dark
skinned=brown
or black
pigmentation

Tissue surrounding nails Inspection Intact epidermis Intact skin Normal

Capillary refill time Inspection Prompt return of 2 seconds Normal
pink or usual
Palpation
color(generally
less than
seconds)

HEAD
Hair
Evenness of growth Inspection Evenly Not evenly Due to Aging
distributed hair distributed
Thickness or thinness Inspection Thick hair Thin hair on Due to Aging
some area

Texture and oiliness Inspection and Silky, resilient Fine and silky Normal
palpation hair; fine to hair
coarse, pliant

Presence of infection or Inspection No infection or No infection/ Normal

infestation infestation infestation

Amount of body hair Inspection Variable Normal

Scalp: Inspection and Symmetrical Symmetric Normal

palpation
Symmetry

Texture Palpation Smooth, firm Smooth, firm Normal

with palpable
soft anterior
fontanel

Lesions Inspection Absence of None Normal

54
 lesion

Skull and Face

Size, shape and Inspection Rounded Normocephalic Normal
symmetry of skull (normocephalic
and symmetric,
with frontal,
parietal and
occipital
prominences);
smooth skull
contour

Nodules or masses and Palpation Smooth, uniform Smooth; absence Normal

depressions in skull consistency; of nodules and
absence of masses
nodules and
masses

Facial features Inspection Symmetric or Slightly Normal

slightly asymmetric
asymmetric facial facial features;
features; palpebral
palpebral fissures fissures equal in
equal in size; size; symmetric
symmetric nasolabial folds
nasolabial folds

Edema and hollowness Inspection None Absence of Normal

of eyes edema

Symmetry of facial Inspection Symmetric facial Symmetric Normal

movements movements movements

Eye Structures and Visual Acuity

Hair distribution and Inspection Hair evenly Intact skin Normal
alignment and skin distributed; skin
Eyebrow
quality and movement intact
symmetrically
of eyebrows
Eyebrows aligned: equal
symmetrically movement
aligned; equal
movement
Evenness of distribution Inspection Evenly Distributed Normal
and direction of curl of distributed; evenly; curled

55
 eyelashes curled slightly slightly outward
outward

Surface characteristics, Inspection Skin intact; no Skin intact; Normal

position in relation to discharge; no absence of
cornea, ability and discoloration discharge and
frequency of blinking of discoloration
Lids close
eyelids
symmetrically Lids closed
symmetrically
Approximately
15 to 20 blinks 16 blinks per
per minute; minute
bilateral blinking
When lids open,
no visible sclera
above corneas,
and upper and
lower borders of
cornea are
slightly covered
Bulbar conjunctiva Inspection Transparent; Transparent; Normal
capillaries sclera appears
sometimes white
evident; sclera
appears white

Palpebral conjunctiva Inspection Shiny, smooth, Shiny, smooth Normal

and pink or red and pink
Lacrimal gland Inspection and No edema or Absence of Normal
palpation tenderness over edema and
lacrimal gland tenderness in the
lacrimal gland

Lacrimal sac and Inspection and No edema or Absence of Normal

nasolacrimal duct palpation tearing edema

Clarity and texture of Inspection Transparent, Shiny and Normal

cornea shiny, and smooth; iris
smooth; details slightly visible
of the iris are
visible

Transparency and depth Inspection Transparent Transparent Normal

of anterior chamber
No shadows of Absence of light
light on iris on iris
Depth of about

56
 3mm 3 mm

Color, shape, and Inspection Black in color; Black in color; Normal

symmetry of size of equal in size; equal in size; 2
pupils normally 3 to 7 mm in diameter;
mm in diameter; round smooth
round, smooth border, iris flat
border, iris flat and round
and round

Pupils reaction to Inspection Pupils constrict Pupils constrict Normal

accommodation when looking at when looking at
near object; near object and
pupils dilate dilate when
when looking at looking at far
far object; pupils objects
converge when
near object is
moved toward
nose
Visual fields Inspection When looking Can see objects Normal
straight ahead, in the periphery
client can see when looking
objects in the straight ahead.
periphery

Extraocular muscle test Inspection Both eyes Both eyes Normal

coordinated, coordinated with
move in unison, parallel
with parallel alignment
alignment
Location of light reflex Inspection Light falls Light falls Normal
(Hirschberg test) symmetrically on symmetrically
both pupils on both pupils

Cover test Inspection Uncovered eye Uncovered eye Normal

does not move does not moved

Ears and Hearing

Color, symmetry of size, Inspection Color same as Color same as Normal
and position of auricle facial skin facial skin
Symmetrical Symmetric
Auricle aligned Auricle aligned
with outer with outer
canthus of eye, canthus of eye,
about 10˚ from about 10˚

57
 vertical vertically

Texture, elasticity, and Palpation Mobile, firm, and Pinna recoils Normal
areas of tenderness of not tender; pinna after it is folded,
auricle recoils after it is firm and mobile
folded

Gross Hearing Acuity Inspection Normal voice Responds to Normal

Test tones audible normal voice
tone

Watch-Tick Test Inspection Ticking of watch Ticking of watch Decreased

audible slightly hearing due
inaudible to aging

Nose and Sinuses

Shape, size or color of Inspection Symmetric and Symmetric and Normal
external nose and flaring straight straight
or discharge from the
No discharge or Uniform color
nares
flaring
Uniform color

Areas of tenderness, Palpation Not tender; no Absence of Normal

masses, and lesions lesions
displacements of bone
and cartilage of the
external nose

Nasal cavities Inspection Mucosa pink Pink mucosa Normal

Clear, watery Absence of
discharge lesions
No lesions

Nasal septum Inspection Intact and in Intact and in Normal

midline midline

Presence of tenderness Inspection No tenderness Absence of Normal

on maxillary and frontal tenderness
sinuses

Mouth and Oropharynx

Symmetry of contour, Inspection Uniform pink Uniform pink Normal
color, and texture of color color
outer lips
Soft, moist, Soft, moist,
smooth texture smooth texture
Symmetry of Symmetry of

58
 contour contour
Ability to purse
lips

Inner lips and buccal Inspection and Uniform pink Uniform pink Normal
mucosa (color, moisture, palpation color color
texture, and presence of
Moist, smooth, Moist, smooth,
lesions)
soft, glistening, soft, glistening,
and elastic and elastic
texture texture

Teeth and Gums Inspection 32 adult teeth, 32 adult teeth, Normal

smooth, shiny smooth, shiny
tooth enamel, tooth enamel,
pink gums, moist pink gums,
firm textures to moist firm
gums textures to gums

Surface of tongue Inspection Central position Central position Normal

(position, color, texture)
Pink color; Pink color;
moist; slightly moist; slightly
rough; thin rough; thin
whitish coating whitish coating
Smooth, lateral Smooth, lateral
margins; no margins;
lesions Absence of
lesions
Raised papillae

Tongue movement Inspection Moves freely; no Moved freely; Normal

tenderness absence of
tenderness

Base of tongue, mouth Inspection Smooth tongue Smooth tongue Normal

floor, and frenulum base with
prominent veins

Tongue and floor of Palpation Smooth with no Smooth and Normal

mouth (nodules, lumps, palpable nodules absence osf
or excoriated areas) lesions

Salivary duct openings Inspection Same as color of Absence of Normal

(swelling or redness) buccal mucosa redness and
and floor of swelling
mouth

Hard and soft palate Inspection Light pink, Light pink, Normal
(color, shape, texture, smooth, soft smooth, soft

59
and the presence of bony palate palate
prominences)
Lighter pink hard Lighter pink
palate, more hard palate,
irregular texture more irregular
texture

Position and mobility of Inspection Positioned in Positioned in Normal

uvula midline of soft midline of soft
palate palate

Color and texture of Inspection Pink and smooth Pink and smooth Normal
oropharynx posterior wall posterior wall

Neck
Neck muscles Inspection Muscles equal in Head centered; Normal
size; head muscles equal
centered in size

Head movement Inspection Coordinated, Smooth Normal

smooth movements
movements with with absence
no discomfort of discomfort,
Head flexes 45˚
Head
hyperextends 60˚
Head laterally
flexes 40˚
Head laterally
rotates 70˚
Muscle strength Inspection Equal strength Equal strength Normal

Lymph nodes Palpation No palpable Absence of Normal

masses masses

Trachea Palpation Central Central Normal

placement in placement in
midline of neck; midline of
spaces are equal neck
on both sides

Thyroid gland Inspection Not visible on Not visible Normal

inspection
Glands
Gland ascends ascends during
during swallowing
swallowing but is

60
 not visible but not visible

Smoothness of thyroid Palpation Lobes may not Lobes not Normal

gland be palpated palpated
If palpated, lobes
are small,
smooth, centrally
located, painless,
and rise freely
with swallowing

Bruit Auscultation No bruit Absence of Normal

bruit

Carotid arteries Palpation Symmetric pulse Full Normal

volume pulsations,
thrusting
Full pulsations,
quality
thrusting quality
Quality remains
same when client
breathes, turns
head, and
changes from
sitting to supine
position
Elastic arterial
wall
Carotid artery Auscultation No sound heard Absence of Normal
on auscultation sounds upon
auscultation
Jugular veins Inspection Veins not visible Not visible Normal
(indicating right veins
side of heart is
functioning
normally)

UPPER EXTREMITIES

Muscles
Size Inspection Equal size on Equal in both Normal
both sides of sides of the
body body
Contractures of muscles Inspection No contractures Absence of Normal

61
 and tendons contractures

Tremors Inspection No tremors Absence of Normal

tremors
Muscle tonicity Palpation Normally firm Slightly Decreased
Flaccid Muscle tone
due to Aging

Smoothness of Inspection Smooth Smooth Normal

movements coordinated coordinated
movements movements

Muscle strength Inspection Equal strength to Equal strength Normal

each body side to both sides
of the body

Bones
Structure Inspection No deformities Absence of Normal
deformities

Areas of edema or Palpation No tenderness or Absence of Normal

tenderness swelling tenderness and
swelling

Joints
Swelling Inspection No swelling Absence of Normal
swelling

Tenderness, Smoothness Palpation No tenderness, Absence of Normal

of movement, swelling, swelling, tenderness,
crepitation, and presence crepitation, or swelling,
of nodules nodules crepitation or
Nodules

Reflexes
Brachioradialis Refex Inspection +2 normal +2 response Normal
response
Biceps Reflex
Triceps Reflex

CHEST AND BACK

Posterior Thorax
Shape and Inspection Chest symmetric Chest Normal

62
symmetry(posterior and symmetric
lateral)

Spinal alignment Inspection Spine vertically Spine Normal

aligned vertically
aligned

Lateral deviation Inspection Spinal column is Spinal column Normal

straight, right and is straight,
left shoulders and right and left
hips are the same shoulders and
height hips are the
same height

Respiratory Excursion Palpation Pull and Decreased Due to limited

symmetric chest chest expansion of
expansion, 3-5 expansion; 2 the lungs
cm thumbs cm
separation

Vocal (tactile) fremitus Palpation Bilateral Fremitus Due to lung

symmetry of increased consolidation
vocal fremitus that occurs in
Pneumonia

Thorax Percussion Percussion notes Dullness over Due to lung

resonant, except the lung tissue consolidation
over scapula that occurs in
Pneumonia
Diaphragmatic Percussion Excursion is 3-5 Decreased Due to limited
excursion cm; bilaterally in diaphragmatic expansion of
women excursion the lungs
Breath Sounds Auscultation Vesicular and (+) Crackles Due to
bronchovesicular increased
(+) Wheezes
breath sounds mucous
secretion and
bronchospasm
respectively

Bulges, tenderness or Palpation Chest wall intact: Chest wall Normal

abnormal movements. no tenderness; no intact; absence
masses of masses and
tenderness

Anterior Thorax
Breathing pattern Inspection Quiet, rhythmic, Loud, Due to
and effortless rhythmic increased
dyspnea and mucous

63
 respirations tachypnea secretions and
bronchospasm;
Due to
compensation
from decreased
oxygen
ventilation.

Costal Angle Inspection Less than 90 Less than 90 Normal

degrees and the degrees, ribs
ribs insert in to insert in to the
the spine and spine 5 degree
approximately 5 angle
degress angle

ABDOMEN
Skin integrity Inspection Unblemished Uniform color Normal
skin
Uniform color
Silver-white
striae or surgical
scars

Contour and symmetry Inspection Flat, rounded Rounded Normal

(convex) or
scaphoid
(concave)
Movements associated Inspection Symmetric Symmetric Normal
with respiration, movements movements
peristalsis, or aortic caused by
pulsation respiration.
Visible
peristalsis in very
lean people.
Aortic pulsations
in thin persons at
epigastric area

Tenderness and Palpation (deep No tenderness; Absence of Normal

and light) relaxed abdomen tenderness
muscle guarding
with smooth,
consistent
tension

64
 Enlargement Palpation May not be Absence of Normal
palpable enlargement
Border feels
smooth

Bladder Palpation Not palpable Not palpable Normal

PERIPHERAL VASCULAR SYSTEM

Peripheral pulses Palpation Symmetric pulse Symmetric Normal
volume, full pulse volume,
pulsation full pulsation

Peripheral Perfusion in Inspection Skin Color is Light brown Due to chronic

Hands and Feet pink to light kidney disease
Palpation Skin warm
brown secondary to
 Color diabetes
(+) edema
 Temperature Skin temp. not
mellitus and
 Edema excessively warm Skin is dry and xerosis
 Skin changes or cold with allergies
No edema
Skin texture is
resilient and
moist

HEART AND CENTRAL VESSELS

Aortic and Pulmonic Inspection No pulsations No pulsations Normal
areas Palpation
Tricuspid Area Inspection No pulsation No pulsation Normal
Palpation No lift or heave No lift or
heave

Apical Area Palpation No lift or heave No lift or Normal

heave

NEUROLOGIC SYSTEM
Language Inspection No difficulty in No difficulty Normal
speaking in speaking
Orientation Inspection Knows the time, Mentally Normal
place, and person oriented

Level of consciousness Inspection Alert and Alert and Normal

oriented oriented

Gross Motor Test and Balances

65
 Walking gait Inspection Upright posture, Upright Due to arthritis
steady gait posture,
Unsteady gait
Walks unaided
Walks unaided
Maintaining
balance Maintaining
balance

Fine Motor Test

Finger-Nose Test Inspection Repeatedly and Repeatedly Normal
symmetrically and
touches the nose symmetrically
touches the
nose

Attending supination Inspection Can alternately Can alternately Normal

and pronation of hand supinate and supinate and
and knees pronate hands pronate hands
and knees and knees

Fingers-to-Fingers Inspection Performs with Performs with Normal

accuracy and accuracy and
speed speed

Lower Extremities
Light-Touch Sensation Inspection Light tickling Light tickling Normal
sensation or sensation or
touch sensation touch
sensation
Pain sensation Inspection Able to Able to Normal
discriminate discriminate
sharp to dull sharp to dull
objects objects

Temperature sensation Inspection Able to Able to Normal

discriminate hot discriminate
and cold hot and cold

Tactile Discrimination
Stereognosis Inspection Recognizes Recognizes Normal
common objects common
objects
Able to identify
written numbers Able to
or letters on palm identify
written
numbers or

66
 letters on palm

MUSCULOSKELETAL SYSTEM
Muscle size Inspection Equal in size on Equal in size Normal
both sides of the on both sides
body of the body

Contractures Inspection No contracture No contracture Normal

Tremor Inspection No tremor No tremor Normal

Muscle tonicity Palpation Normally firm Normally firm Normal

Muscle movement Inspection Smooth Decreased Due to

coordinated presence of
movement
movement Arthritis
Muscle strength Palpation Equal strength on Decreased Due to
each body side strength on presence of
each body side Arthritis

Bones and joints Palpation and No deformities, (+)Tenderness Due to

Inspection tenderness or and swelling presence of
swelling of joints of joints and Arthritis
and moves with difficulty
smoothly in movement

67
 LABORATORY EXAMINATIONS

Hematology Reports
Date Requested: August 18, 2015
Date Released: August 18, 2015

Test Actual Findings Normal Values Analysis

Increased
White Blood Cells 12.4 4.0 – 10.0 x 10 /uL
3
due to presence of
infection

68
 Increased
Neutrophils 0.79 0.40 – 0.70 due to presence of
infection

Decreased
Lymphocytes 0.16 0.20 – 0.40 due to presence of
infection

Monocytes 0.02 0.00 – 0.06 Normal

Eosinophils 0.03 0.00 – 0.04 Normal

Decreased
due to insufficient
Red Blood Cells 2.87 3.5 – 5.0 x 10 /uL
6 hormones necessary to
produce red blood
cells causing anemia
secondary to CKD

Decreased
due to insufficient
Hemoglobin 85 110 – 150 g/L hormones necessary to
produce red blood
cells causing anemia
secondary to CKD

Decreased
due to insufficient
Hematocrit 0.27 0.37 – 0.48 L/L hormones necessary to
produce red blood
cells causing anemia
secondary to CKD

Platelet Count 226 150 – 450 x 103 /uL Normal

Atypical Cells 0.00

Date Requested: August 20, 2015

Date Released: August 20, 2015

Test Actual Findings Normal Values Analysis

Increased
White Blood Cells 11.1 4.0 – 10.0 x 10 /uL
3
due to presence of
infection

69
 Increased
Neutrophils 0.73 0.40 – 0.70 due to presence of
infection

Decreased
Lymphocytes 0.18 0.20 – 0.40 due to presence of
infection

Monocytes 0.05 0.00 – 0.06 Normal

Eosinophils 0.03 0.00 – 0.04 Normal

Decreased
due to insufficient
Red Blood Cells 2.33 3.5 – 5.0 x 10 /uL
6 hormones necessary
to produce red blood
cells causing anemia
secondary to CKD

Decreased
due to insufficient
Hemoglobin 90 110 – 150 g/L hormones necessary
to produce red blood
cells causing anemia
secondary to CKD

Decreased
due to insufficient
Hematocrit 0.30 0.37 – 0.48 L/L hormones necessary
to produce red blood
cells causing anemia
secondary to CKD

Platelet Count 250 150 – 450 x 103 /uL Normal

Atypical Cells 0.00

Blood Typing
Date Requested: August 18, 2015
Date Released: August 18, 2015

Result

ABO Compatibility “O” Rh positive

70
 Clinical Chemistry Reports
Date Requested: August 18, 2015
Date Released: August 18, 2015

Test Actual Findings Normal Values Analysis

Decreased
due to fluid and
electrolyte imbalance
which is evident in
Sodium 126 135 – 148 mmol/L Diabetic patients.
There is sodium ions
wasting due to
diffuse glomerular
sclerosis.

Increased
due to fluid and
electrolyte imbalance
which is evident in
Potassium 5.95 3.5 – 5.3 mmol/L Diabetic patients.
There is potassium
ion retention due to
diffuse glomerular
sclerosis.

Date Requested: August 18, 2015

Date Released: August 18, 2015

Test Actual Findings Normal Values Analysis

Increased
due to diffuse
glomerular sclerosis
that causes protein to
be low
Creatinine 6.94 0.70-0.120 mg/dL

There is already
problems in the
kidney which is a
complication of

71
 diabetes.

Increased
due to inability of the
kidney to filter urea
Urea 83.49 6-20 mg/dL in the blood, thus,
can’t excrete them in
the body through the
urine.

Increased
due to inability of the
kidney to excrete uric
acid in the blood that
Uric 16.56 3.4-7.0 mg/dL causes gouty arthritis
and kidney disease
which are
complications of
diabetes.

Decreased
due to insulin
resistance.
Insulin stimulates the
Magnesium 1.51 0.70-1.050 mg/dL
transport of
magnesium from the
extra-cellular to the
intracellular
compartment.

Clinical Chemistry Reports

Date Requested: August 18, 2015
Date Released: August 18, 2015

Test Actual Findings Normal Values Analysis

Incresed
Troponin I 0.052 < 0.02 ng/mL due to recent cardiac
injury

CKMB 16.00 0 – 24 u/L Normal

D-Dimer Increased
3.48 0.063 – 0.070 ng/mL
- is a fibrin due to presence of

72
 degradation product, blood clots which is
a small protein usually present in
fragment present in diabetic patients. The
the blood after a breakdown of fatty
blood clot is degraded acids and glycerol
by fibrinolysis. can cause
hyperlipidemia that
may cause
atherosclerosis
because of formation
of fatty deposits on
the walls of the blood
vessels.

Arterial Blood Gas

Date Requested: August 18, 2015
Date Released: August 18, 2015

Test Actual Findings Normal Values Analysis

pH 7.38 7.35 – 7.45 Normal

pCO2 25 35 – 45 mmHg Decreased

HCO3 14.3 22 – 28 mEq/L Decreased

PaO2 84 75 – 100 mmHg Normal

SaO2 94% 94 – 100% Normal

Interpretation:
Metabolic Acidosis, Fully Compensatory
Metabolic acidosis is common in Diabetic patients because of the presence of ketone bodies in
the general circulation.

Clinical Chemistry Report

Date Requested: August 18, 2015
Date Released: August 18, 2015

Test Actual Findings Normal Values Analysis

Increased
HbA1C 8.6% 4.3 – 6.4%
Due to poor control

73
 of diabetes

Method ION – Exchange HPLC

Chest X-ray AP/L View

Date Requested: August 18, 2015

Actual Findings:

 Streaky infiltrates are seen at the right lower lobe.

 Pulmonary vascularity appears prominent.
 Heart appears enlarged.
 Aorta is sclerotic.
 Other upper mediastinal structures are intact.
 Diaphragm is elevated.
 No pleural reactions nor abnormal bony changes of the thoracic cage discerned except for
thoracic osteophytes.

Impression:
 Right lower lobe Pneumonia
 Pulmonary congestion not excluded
 Suggest clinical correlation
 Cardiomegaly, true vs. Apparent
 Atherosclerotic Aorta
 Elevated diaphragm
 Thoracic osteophytes

Echocardiography
Date Requested: August 18, 2015

Actual Findings:
 Dilated left ventricle with relative wall thickness of 0.40 cm and left ventricular mass
index of 127 g/m2 with mild hypokinesia of the anterior interventricular septum from mid
to apex.
 Normal right ventricular dimension with adequate wall motion and contractility.
 Dilated left atrium volume index of 44.88 cc/m2.
 Normal right atrial dimension.
 Thickened mitral valve leaflets without restriction of motion.
 Thickened aortic cusps with discrete calcifications at the margins of non-coronary cusp
with mild restriction of motion.

74
  Aortic annular calcification.
 Structurally normal tricuspid valve and pulmonary valve.
 Normal main pulmonary artery and pulmonary artery pressure.
 Normal aortic root dimension.
 Minimal pericardial effusion.
 Greater than 50% inferior vena caval collapse on deep inspiration.
 Trivial mitral and tricuspid regurgitations
 Reversed E/A inflow velocity ratio.
 Pulmonary artery pressure is 23 mmHg by tricuspid regurgitant jet

Conclusion:

 Eccentric left ventricular hypertrophy with segmental wall motion abnormality with
adequate systolic dilated left atrium with severely elevated left atrial volume index
 Thickened mitral valve leaflets with trivial mitral regurgitation
 Aortic stenosis, degenerative, mild to moderate with aortic valve area of 1.2 cm2 with
mean gradient of 10.7 mmHg
 Trivial tricuspid regurgitations
 Minimal pericardial effusion

ANATOMY AND PHYSIOLOGY OF THE PANCREAS

PANCREAS

The pancreas is a glandular organ in the upper

abdomen, but really it serves as two glands in
one: a digestive exocrine gland and a hormone-
producing endocrine gland. Functioning as an
exocrine gland, the pancreas excretes enzymes
to break down the proteins, lipids,
carbohydrates, and nucleic acids in food.
Functioning as an endocrine gland, the pancreas
secretes the hormones insulin and glucagon to
control blood sugar levels throughout the day.
Both of these diverse functions are vital to the
body’s survival.

Gross Anatomy

75
 The pancreas is a narrow, 6-inch long gland that lies posterior and inferior to the stomach
on the left side of the abdominal cavity. The pancreas extends laterally and superiorly across the
abdomen from the curve of the duodenum to the spleen. The head of the pancreas, which
connects to the duodenum, is the widest and most medial region of the organ. Extending laterally
toward the left, the pancreas narrows slightly to form the body of the pancreas. The tail of the
pancreas extends from the body as a narrow, tapered region on the left side of the abdominal
cavity near the spleen.

Glandular tissue that makes up the pancreas gives it a loose, lumpy structure. The
glandular tissue surrounds many small ducts that drain into the central pancreatic duct. The
pancreatic duct carries the digestive enzymes produced by endocrine cells to the duodenum.

Microscopic Anatomy

The pancreas is classified as a heterocrine gland because it contains both endocrine and
exocrine glandular tissue. The exocrine tissue makes up about 99% of the pancreas by weight
while endocrine tissue makes up the other 1%. The exocrine tissue is arranged into many small
masses known as acini. Acini are small raspberry-like clusters of exocrine cells that surround tiny
ducts. The exocrine cells in the acini produce digestive enzymes that are secreted from the cells
and enter the ducts. The ducts of many acini connect to form larger and larger ducts until the
products of many acini run into the large pancreatic duct.

The endocrine portion of the pancreas is made of small bundles of cells called islets of
Langerhans. Many capillaries run through each islet to carry hormones to the rest of the body.
There are 2 main types of endocrine cells that make up the islets: alpha cells and beta cells. Alpha
cells produce the hormone glucagon, which raises blood glucose levels. Beta cells produce the
hormone insulin, which lowers blood glucose levels.

Digestion

The exocrine portion of the pancreas plays a major role in the digestion of food. The
stomach slowly releases partially digested food into the duodenum as a thick, acidic liquid called
chyme. The acini of the pancreas secrete pancreatic juice to complete the digestion of chyme in
the duodenum. Pancreatic juice is a mixture of water, salts, bicarbonate, and many different
digestive enzymes. The bicarbonate ions present in pancreatic juice neutralize the acid in chyme
to protect the intestinal wall and to create the proper environment for the functioning of
pancreatic enzymes. The pancreatic enzymes each specialize in digesting specific compounds
found in chyme.

 Pancreatic amylase breaks large polysaccharides like starches and glycogen into smaller
sugars such as maltose, maltotriose, and glucose. Maltase secreted by thesmall

76
 intestine then breaks maltose into the monosaccharide glucose, which the intestines can
directly absorb.

 Trypsin, chymotrypsin, and carboxypeptidase are protein-digesting enzymes that break

proteins down into their amino acid subunits. These amino acids can then be absorbed by
the intestines.

 Pancreatic lipase is a lipid-digesting enzyme that breaks large triglyceride molecules into
fatty acids and monoglycerides. Bile released by the gallbladderemulsifies fats to increase
the surface area of triglycerides that pancreatic lipase can react with. The fatty acids and
monoglycerides produced by pancreatic lipase can be absorbed by the intestines.

 Ribonuclease and deoxyribonuclease are nucleases, or enzymes that digest nucleic acids.
Ribonuclease breaks down molecules of RNA into the sugar ribose and the nitrogenous
bases adenine, cytosine, guanine and uracil. Deoxyribonuclease digests DNA molecules
into the sugar deoxyribose and the nitrogenous bases adenine, cytosine, guanine, and
thymine.

Blood Glucose Homeostasis

The endocrine portion of the pancreas controls the homeostasis of glucose in the
bloodstream. Blood glucose levels must be maintained within certain limits so that there is a
constant supply of glucose to feed the cells of the body but not so much that glucose can damage
the kidneys and other organs. The pancreas produces 2 antagonistic hormones to control blood
sugar: glucagon and insulin.

 The alpha cells of the pancreas produce glucagon. Glucagon raises blood glucose levels by
stimulating the liver to metabolize glycogen into glucose molecules and to release glucose
into the blood. Glucagon also stimulates adipose tissue to metabolize triglycerides into
glucose and to release glucose into the blood.

 Insulin is produced by the beta cells of the pancreas. This hormone lowers blood glucose
levels after a meal by stimulating the absorption of glucose by liver, muscle, and adipose
tissues. Insulin triggers the formation of glycogen in the muscles and liver and triglycerides
in adipose to store the absorbed glucose.

Regulation of Pancreatic Function

The pancreas is controlled by both the autonomic nervous system (ANS) and the
endocrine system. The ANS has 2 divisions: the sympathetic and the parasympathetic.

 Nerves of the sympathetic division become active during stressful situations, emergencies,
and exercise. Sympathetic neurons stimulate the alpha cells of the pancreas to release the
hormone glucagon into the bloodstream. Glucagon stimulates the liver to begin the
breakdown of the energy storage molecule glycogen into smaller glucose molecules.
Glucose is then released into the bloodstream for the organs, especially

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 the heart and skeletal muscles, to use as energy. The sympathetic nerves also inhibit the
function of beta cells and acini to reduce or prevent the secretion of insulin and pancreatic
juice. The inhibition of these functions provides more energy for other parts of the body
that are active in dealing with the stressful situation.

 Nerves of the parasympathetic division of the ANS become active during restful times
and during the digestion of a meal. Parasympathetic nerves stimulate the release of insulin
and pancreatic juice by the pancreas. Pancreatic juice helps with the digestion of food
while insulin stores the glucose released from the digested food in the body’s cells.

The endocrine system uses 2 hormones to regulate the digestive function of the
pancreas: secretin and cholecystokinin (CCK).

 Cells in the lining of the duodenum produce secretin in response to acidic chyme
emerging from the stomach. Secretin stimulates the pancreas to produce and secrete
pancreatic juice containing a high concentration of bicarbonate ions. Bicarbonate reacts
with and neutralizes hydrochloric acid present in chyme to return the chyme to a neutral pH
of around 7.

 CCK is a hormone produced by cells in the lining of the duodenum in response to the
presence of proteins and fats in chyme. CCK travels through the bloodstream and binds to
receptor cells in the acini of the pancreas. CCK stimulates these cells to produce and
secrete pancreatic juice that has a high concentration of digestive enzymes. The high levels
of enzymes in pancreatic juice help to digest large protein and lipid molecules that are
more difficult to break down.

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