Nursing Case Study
Patient’s Initials: M.N.M
Age: 41 years old
Sex: Male
Civil Status: Married
Medical Diagnosis: CKD Secondary to Uremic Encephalopathy, Hypertensive Nephrosclerosis vs. Gouty Neuropathy
Attending Physician: Dr. Valdez, Dr. Manzon, Dr. Ocampo, Dr. Concepcion
I. CHIEF COMPLAINT
- General body weakness - Drowsiness - Pain on knees
II. NURSING HISTORY
The patient, MNM, has hypertension for 21 years, he’s not taking any medications until year 2008 when he was prescribed Nifedipine and Carvedilol. He also has gouty attacks for 14 years now and he is taking Allopurinol.
Four days PTC, patient verbalizes pain on his knees. He was then also noticed by his wife to be drowsy at all time and has melena in which they sought consult at a nearby hospital. Three days PTC during the stay in the hospital patient was noted to have episodes of epistaxis on which he was given a dose of tranexamic acid. One day PTC, patient’s hemoglobin decreased and was advised to have a transfusion of 2 ‘U’ of PRBC then they decided to transfer the patient in this institution.
III. PATHOPHYSIOLOGY
Modifiable Factors
- Lifestyle
- Diet
- Alcohol
- Smoking
- Chronic NSAID use
- Hypertension
Non Modifiable Factors
- Hereditary
- Age
- Sex
Renal tissue loses function
Renal function adaptation
Kidneys lose ability to maintain fluid and electrolyte homeostasis
Decrease in Glomelular Filtration Rate
Decrease ability to concentrate urine
Decrease ability to excrete toxins
Further decrease of GFR
Increase plasma concentration of creatinine and urea
CHRONIC KIDNEY DISEASE
-Uremia
-Azotemia
Oliguria
Serum Creatinine: 624
Decrease GFR
IV. LABORATORY AND DIAGNOSTIC
CT Scan (April 27, 2010)
Plain CT scan of brain was performed. Exam was studied with 1.25 mm thick section at 1.25mm intervals. All these are parallel to orbito-meatal line. No evidence of abnormal high or low density lesions throughout the brain. The brainstem as well as
Age: 41 years old
Sex: Male
Civil Status: Married
Medical Diagnosis: CKD Secondary to Uremic Encephalopathy, Hypertensive Nephrosclerosis vs. Gouty Neuropathy
Attending Physician: Dr. Valdez, Dr. Manzon, Dr. Ocampo, Dr. Concepcion
I. CHIEF COMPLAINT
- General body weakness - Drowsiness - Pain on knees
II. NURSING HISTORY
The patient, MNM, has hypertension for 21 years, he’s not taking any medications until year 2008 when he was prescribed Nifedipine and Carvedilol. He also has gouty attacks for 14 years now and he is taking Allopurinol.
Four days PTC, patient verbalizes pain on his knees. He was then also noticed by his wife to be drowsy at all time and has melena in which they sought consult at a nearby hospital. Three days PTC during the stay in the hospital patient was noted to have episodes of epistaxis on which he was given a dose of tranexamic acid. One day PTC, patient’s hemoglobin decreased and was advised to have a transfusion of 2 ‘U’ of PRBC then they decided to transfer the patient in this institution.
III. PATHOPHYSIOLOGY
Modifiable Factors
- Lifestyle
- Diet
- Alcohol
- Smoking
- Chronic NSAID use
- Hypertension
Non Modifiable Factors
- Hereditary
- Age
- Sex
Renal tissue loses function
Renal function adaptation
Kidneys lose ability to maintain fluid and electrolyte homeostasis
Decrease in Glomelular Filtration Rate
Decrease ability to concentrate urine
Decrease ability to excrete toxins
Further decrease of GFR
Increase plasma concentration of creatinine and urea
CHRONIC KIDNEY DISEASE
-Uremia
-Azotemia
Oliguria
Serum Creatinine: 624
Decrease GFR
IV. LABORATORY AND DIAGNOSTIC
CT Scan (April 27, 2010)
Plain CT scan of brain was performed. Exam was studied with 1.25 mm thick section at 1.25mm intervals. All these are parallel to orbito-meatal line. No evidence of abnormal high or low density lesions throughout the brain. The brainstem as well as