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CASE STUDY, HTN AND RENAL IMPAIRMENT.pdf - GROUP 1 Case...

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GROUP 1 Case StudyCALILUNG, CatherineADORA-CATARROJA, Jana Xuxa MarikaFLORIANO, Siena Loren E.RAMOS, Joni MaeSALAMAT, John Paul1.General Patient Information:Patient Name: LoloAge: 73Gender: MaleStatus: WidowedDate of Admission: 03/31/18 4:15 pm2.Chief Complaint:Symptom –◦Is a subjective complaint that is noted by the person with the disorderDifficulty in breathing (symptom - subjective finding)And patient was initially assessed upon arrival in the hospitalBlood pressure: 110/70 mmHg -normalaccording to 2020 ISH GlobalHypertension Practice Guidelines - if a patient with diabetes and anelderly target BP is <130/80mmHg)Pulse rate: 112pulse/min -above the limitaccording to 2020 ISH GlobalHypertension Practice Guidelines - which could be a risk factor to hisdiagnosis that we will present later on.Respiratory rate: 27beats/min -normalTemperature: 37.5C -normalDuring Lolo’s physical assessment the following are the objective findings:Sign – objective◦A manifestation that is noted by the observer - elevated tem(+) Orthopnea - 2 pillows is a symptom of dyspnea (medical term forshortness of breath) that occurs when a person is lying flat, and is oftena sign of worsening heart failure– patient explained that it takes 2 pillowsto get rid of the symptomDoctors characterizes the severity of orthopnea by asking howmany pillows they need to fall asleep to get rid of the symptom(+) Exertional dyspnea – 4-5 stairsAccording to the American Thoracic Society the subjectivity ofdyspnea is to judge the exertion with the use of a number ofstairs to determine the severity. And, 4-5 stairs - is consideredsevere dyspnea(+) Paroxysmal nocturnal dyspnea - PND is a sensation of shortness ofbreath during sleep that awakens the patient, often after 1 or 2 hours ofsleep, and is relieved in the upright position.
Awake,coherent,withNIRD(non-inflammatoryrheumaticdisease),speaks in sentencesAnicteric sclerae - the white part of his eye is white. There's no yellowing,and it appears healthy.Pale palpebral conjunctiva - meaning there’s very little or no evidence ofred color on the anterior rim, which matched the fleshy color of theposterior aspect of the palpebral conjunctiva(-) NVE Neovascularization Elsewhere - if Lolo is positive for NVE whichis a hallmark of proliferative diabetic retinopathy (PDR) leading to visualloss in patients with diabetes.(-) CLADS Canine leukocyte adhesion deficiency (CLAD) is a primaryimmunodeficiency disease characterized by recurrent bacterial infectionsin the presence of marked leukocytosis.ECE - extraprostatic (extracapsular) extension of prostate cancer refersto local tumor growth of the prostate gland and is an established adverseprognostic factor for prostate cancer.(+)Useofaccessorymuscles(suchasabdominalmuscles whenbreathing, is an earliest signs of airway obstruction, this indicates thatLolo experiences severe disease and signifies acute exacerbation ofLower Tract Infection - this was assessed by palpation

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Term
Summer
Professor
N/A
Tags
Chronic kidney disease, Helicobacter pylori, Metronidazole

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