Name of Patient: Jocelyn Ortega Hospital: DLS-UMC

Informant: Patient Department: Internal Medicine

Reliability: Good Preceptor: Dr. Jason See
Historian: Jolyn Naira G. Blasurca Date Taken: February 23, 2018
Group No.: 3B Date Submitted:

GENERAL DATA

JC, female, 55-years-old, Filipino, married, Roman Catholic, was born on March 26,
1962 in Bacoor City, and is currently residing in Burol II Dasmariñas, Cavite admitted for the first
time last February 16, 2018 in DLSUMC at 4:30 PM.

CHIEF COMPLAINT: “Nagsusuka at masakit ang ulo”

HISTORY OF PRESENT ILLNESS

The patient was apparently well until 3 years prior to admission, the patient felt
weakness and in pallor during their reunion in Cebu. It is associated with flank pain, pelvic pain
and post-prandial vomiting, non-bilious, non-bloody approximately 1 cup per vomitus. Patient
sought consult in a private institution wherein she was managed as a case of Kidney Failure
with hypertension. She was advised to undergo hemodialysis with fistula twice a week. Patient
was also prescribed with Amlodipine 10mg OD, Losartan 75 mg OD, Clopidogrel of unrecalled
dosage by the patient, Calcium Carbonate TID, and Ferrous Sulfate 320g BID from which the
patient was compliant. Patient also mentioned that every after dialysis, she urinates
approximately 1tbsp/day and half cup/day for the succeeding days.
Two days prior to admission, the patient experienced post-prandial vomiting, non-bilious,
non-bloody for 5 x approximately 1 cup per vomitus and has difficulty in sleeping.
One day prior to admission, there was persistence of vomiting but only once during that
day, non-bilious and non-bloody. Patient sought consult in Pagamutan ng Dasmarinas and was
advised to undergo blood transfusion due to low hemoglobin count of 32 g/L.
Few hours prior to admission, patient underwent hemodialysis in the morning. At 1pm in
the afternoon, patient had episodes of diffuse throbbing headache on the frontal area with an
intensity of 5/10 associated with dizziness and epigastric pain, which prompted the patient to
seek consult and was subsequently admitted in our institution.

PAST MEDICAL HISTORY

Patient is a known hypertensive 3 years prior to admission. She is maintained on

Amlodipine 10mg OD, Losartan 75 mg OD, and Clopidogrel of unrecalled dosage by the patient
to whom she is compliant. Her usual BP is 150/70 mmhg. Patient also stated that she usually
have knee pain attacks and was given Tramadol to relieve the pain. Patient stopped taking
Tramadol and used Naproxen (Skelan) instead. 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, no history of any
accident and has no adult immunization.

FAMILY HISTORY

The patient’s father was diagnosed with Bone CA, and her mother was diagnosed with
hypertension. Patient’s paternal grandmother has history of asthma. There is no family history of
diabetes, PTB, pulmonary, hematologic, and renal disease.

OB-GYNE HISTORY

The patient is a G5P5. Patient menopause is at 50 years old.

PERSONAL AND SOCIAL HISTORY

Patient finished grade 3 in elementary and is currently retired. She previously works as a
cook. Currently, patient has no other activities and does not do any household chores other than
eating. Patient’s financial assistance comes from her third child who works on an electric
company. She lives with 4 other household members in a one-storey concrete house with good
lighting and ventilation and has pour flush type of toilet. Patient has no preference in food but
rarely eats beans due to her arthritis. The patient’s drinking water is a mineral water and
sometimes tap water and their garbage are collected every week. She has no history of
smoking, a non-drinker and non-illicit drug abuser.

REVIEW OF SYSTEMS

General: (+) weakness, (+) low grade fever during admission, (+) weight loss (80kg to 66.7
kg), (+) 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 (OS 350, OD 300), (-) pain, (-) loss of left visual field (-) redness, (-)
discharge, (-) icteric sclera
Ears: (+) difficulty of hearing, (-) otalgia, (-) vertigo, (-) tinnitus
Nose and Sinuses: (+) discharge, (-) epistaxis, (-) obstruction
Mouth and Sinuses: (-) toothache, (-) hoarseness, (-) dysphagia, (-) ulcers, (-) tongue
fasciculation
Respiratory: (+) cough, (+) dyspnea, (-) hemoptysis, (-) tachypnea, (-) dyspnea
Cardiovascular: (+) palpitations, (+) orthopnea, (-) angina, (-) paroxysmal nocturnal dyspnea
GIT: (+) nausea, (+) vomiting, (-) anorexia, (-) diarrhea, (-) abdominal distention, (-) abdominal
pain, (-) constipation
GUT: (+) oliguria, (+) 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, (+) edema, (-) fracture, (-) back pain
CNS: (-) seizures, (-) syncope, (-) tremors, (-) slurring of speech

PHYSICAL EXAMINATION

GENERAL SURVEY

The patient is poorly nourished, fairly developed, conscious, coherent, oriented to time,
place, and person, in cardiorespiratory distress while seating, orthopneic, and appears to be her
stated chronological age of 55.

VITAL SIGNS
BP: 150/70 mmHg, sitting, right arm
PR: 96 beats/min
CR: 97 beats/min
RR: 26 cycles/min
T: 37.2 C, axillary

SKIN
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, prompt return after finger pressure, (+) dryness, soft and resilient
skin, (+) ecchymosis.

HEAD AND NECK

Hair is black and white 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 and reactive to direct and consensual light reflex (2mm), devoid of cornea
and lens opacities, and intact visual fields. Tonometry of both eyes was soft to palpate.

ENT
Ear
Pinna is mobile and devoid of masses, ulcerations or tenderness. Periauricular
areas likewise have no swelling or tenderness. Canal is patent and devoid of masses
and discharge, scanty cerumen is present. Tuning fork hearing test not done.

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. Stensen’s
duct and wharton duct are both patent. The tongue is in midline, and her uvula and
palate symmetrically rises.

CHEST AND LUNGS

Inspection: Chest and chest expansion is symmetrical, (-) deformities, (-) use of
accessory muscles, (-) clubbing, (-) prominent veins;
Palpation and Percussion: Equal thoracic expansion and equal tactile fremitus, resonant
Auscultation: Clear breath sounds, (-) adventitious sounds

CARDIOVASCULAR
Inspection: (-) precordial bulge
Palpation: (+) palpitations, (-) heaves/thrills, apex beat on 6th ICS left anterior axillary line
Auscultation: Heart rate of 97 bmn, regular rhythm, (-) extra heart sounds and murmur.

ABDOMEN
Inspection: Firm, globular and symmetrical abdomen, inverted umbilicus, (+) visible
pulsations, (-) scars, (-) discoloration, (-) visible mass, (-) visible peristalsis
Palpation: (+) CVA tenderness, (-) direct tenderness, (-) rebound tenderness on RUQ, (-)
palpable mass
Percussion: Tympanitic all over the abdominal quadrants
Auscultation: bowel sound of 11/min (normoactive)

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:
 55-years-old, female  Diffuse throbbing headache on the
 Family history of hypertension frontal area
(Mother)  Weakness/easy fatigability,
 History of hypertension palpitations
 Orthopneic, Dyspneic, and  Weight loss
Tachypneic  Pallor and ecchymosis
 Nausea and post-prandial vomiting  Oliguria and nocturia
(non-bilious, non-blood) and loss of  Flank Pains, (+) CVA Tenderness
appetite  Patient on NSAIDs and hypertensive
 Generalized pitting edema medications
(Anasarca)  Patient on dialysis 2x/week

PRIMARY IMPRESSION: ANEMIA SECONDARY TO CHRONIC KIDNEY DISEASE

SECONDARY TO HYPERTENSION

CASE DISCUSSION

This is a case of JO, a 55-years-old female who was admitted in our institution due to
diffuse throbbing headache on the frontal area and post-prandial vomiting associated with
nausea, weakness, easy fatigability, weight loss, pallor and ecchymosis. She also presented
with signs and symptoms of oliguria, nocturia and generalized pitting edema. Patient has a
history of hypertension and chronic kidney disease that was diagnosed three years prior to
admission. Patient also presented with knee pains (arthritis) and usually takes NSAIDs (Eskilan)
to relieve the pain.
Hypertension is one of the leading causes of CKD due to the deleterious effects that an
increased blood pressure has on kidney vasculature. A long term, uncontrolled, high blood
pressure causes hypertrophic response to glomerulus and kidney vasculature leading to intimal
thickening of large and small vessels. It significantly causes an increased intraglomerular
pressure and impaired glomerular filtration. Damage to the glomeruli lead to an increase in
protein filtration, resulting in abnormally increased amounts of protein in the urine
(microalbuminuria or proteinuria). It also impairs kidney’s ability to filter fluid and waste from the
blood, leading to an increase of fluid volume in the blood. Excess salt and water retention
increases the blood flow to the tissues, which sets in motion the phenomenon of autoregulation.
The tissue arterioles vasoconstricts to decrease the excessive blood flow. The resulting
vasoconstriction raises the peripheral vascular resistance, which are the cardinal most
consistent findings in HTN. Hypertension also enlarges the heart and causes it to weaken in the
chronic state. It is also perpetuated by dysbalance 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 hence presenting with anemia.
For this patient, she presented with diffuse throbbing headache on the frontal area and
post-prandial vomiting associated with nausea, weakness, easy fatigability, weight loss, pallor
and ecchymosis. In CKD, due to damage renal filtration there is an accumulation of urea and
toxins in the blood causing signs and symptoms of elevated urea such as headache, which is an
adverse effect of urea on the CNS. Ecchymosis may also be associated with uremia-induced
platelet dysfunction. Waste buildup in the blood can also cause nausea and vomiting to the
patient. Weight loss, pallor and easy fatigability presented by the patient may be associated with
loss of EPO release in the body causing anemia and decrease oxygen distribution to various
organs of the body. Weight loss may also be due to protein-energy malnutrition due to metabolic
acidosis in CKD patients. Palpitation may also be associated with hyperkalemia due to inability
of the kidneys to secrete potassium in urine. Generalized pitting edema, oliguria and nocturia
are caused by water retention due to a loss of GFR leading to sodium and fluid retention. Fluid
moves into the extravascular space, due to increased hydrostatic pressure, causing pitting
edema in the lower extremity. Orthopnea, and displaced apex beat is related to cardiomegaly
probably caused by hypertension and chronic kidney disease. Lastly, the family history of the
patient presenting with hypertension increases the risk of patient to develop HPN which, if left
untreated, may damage the kidneys and further lead to CKD.

Differential Diagnosis

Diseases Rule in Rule out

Peptic Ulcer Disease
NSAID induced CKD
Congestive Heart Failure
Systemic Lupus Chronic kidney insufficiency,
erythematosus
(+) Nausea and vomiting, (+)
epigastric pain/acid reflux, (+)
weight loss, (+) chronic intake
of NSAID (Skilan), (+) pallor
(+) chronic intake of NSAID
(Skilan), (+) renal
insuffieciency
(+) dyspnea, (+) fatigue and
weakness, (+) edema, (+)
orthopnea, (+) hypertension,
(+) anemia
(+) hematoma, (+) edema of
extremities
(+) non-bilious, non-bloody
vomitus, (-) pain improvement
after eating/drinking, (-) dark
bloody stools (melena)
Cannot be totally ruled out
(-) chest pain, cannot be
totally ruled out without
laboratory and further physical
examination
(-) 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
 Serum concentration of calcium, phosphorus, Vit D and PTH – to evaluate presence of
metabolic bone disease
  CBC – to assess anemia and other blood abnormalities
 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

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