1. Maria Febi C. Billones January 13, 2010

2.  R.Q.  61 y/o  Female  Married  Bicutan

3.  Dyspnea

4.  Known diabetic x 15 years  Initially presented with 3 P’s & weight loss  Prescribed with Glibenclamide 5mg BID however with poor compliance

5.  Known hypertensive x 5 years  HBP 150/100  UBP 120/90  No medications taken

6.  1 year PTC  patient noticed easy fatigability usually after simple household chores associated with dyspnea on exertion  She also experienced occasional chest heaviness lasting almost the whole day aggravated by work and relieved temporarily by rest

7.  3 months PTC  noted worsening of symptoms hence had herself an ECG and Chest Xray in a nearby laboratory clinic  However, results revealed “within normal limits” on ECG and “Atheromatous Aorta” on Xray hence decided not to seek medical consult

8.  Persistence of dyspnea as well as easy fatigability prompted consult.  (-) cough, colds, orthopnea, PND, edema  (-)

9.  (-) weight loss  (-) dizziness  (+) headache, occasional  (+) nape pains, occasional  (-) blurring of vision  (-) nausea  (-) vomiting  (-) abdominal pain  (-) diarrhea  (-) constipation  (+) polyuria  (+) polydipsia  (+) nocturia  (-) oliguria  (-) paresthesias  (-) fever

10.  s/p Total Hysterectomy for multiple myoma, 1978 at UDMC  s/p breast cyst excision, 1972  (-) asthma, allergy, PTB

11. Diabetes PTB Hypertension Schizophrenia Brain Tumor

12.  previous smoker 1-2 sticks/day x 1 yr (1978)  occasional alcoholic beverage drinker  College Graduate, previously worked in a bank  Eventually lost her job and currently on financial crisis

13.  Nulligravid  Underwent total hysterectomy for multiple myomas at 28 y/o  Menarche at 16 y/o, monthly regular interval, 5 days duration, moderate amount, (-) dysmenorrhea

14. PHYSICAL EXAMINATION

15.  General Survey  Conscious, coherent, not in respiratory distress  Vital Signs  BP 150/90  HR 58  RR 22  Temp 37.1  Wt 70.3kgHt 161cm BMI 27

16.  HEENT  pink conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion  Neck  No anterior neck mass, no cervical lymphadenopathy, no neck vein engorgement

17.  Chest/Lungs  Equal chest expansion, no retractions, clear breath sounds  Heart  Adynamic precordium, bradycardic, regular rhythm, distinct heart sounds, apex beat at 5 th ICS LMCL, no murmur  Abdomen  Flabby, (+) incision scar, infraumbilical area, normoactive bowel sounds, soft, non-tender

18.  Extremities  Full and equal pulses, pink nailbeds, no edema, no cyanosis, no jaundice  Neuro Exam  Awake, alert, follows commands, oriented  Cranial Nerves  1 – N/A; 2 – pupils 3mm EBRTL; 3,4,6 – full & equal EOMs; 5 – brisk corneals; 7 – no facial asymmetry; 8 – intact gross hearing; 9,10 – good gag, 11 – good shoulder shrug, 12 – tongue midline

19.  Neuro Exam  MMT – 5/5 all extremities  Sensory – 100% intact  DTRs - ++  Cerebellars: no dysmetria  Meningeals: supple neck, no incontinence

20. t/c Chronic Stable Angina Pectoris DM Type 2, non-insulin requiring, Obese I t/c DM nephropathy Hypertension Stage 1, uncontrolled

21.  Diagnostic  FBS, BUN, Crea, Na, K, Cl, Ca, Mg  Urinalysis  12-L ECG  Therapeutics  Metformin 500mg BID  Losartan 50mg OD

22.  Lifestyle Modification  Low salt low fat diet, low protein high fiber diet  Daily BP monitoring, sugar monitoring  Refer to Ophtha

23.  Among diabetic patients, what is the sensitivity and specificity of 24 hr urine albumin vs urine micral test in early detection of DM nephropathy?

24.  P – patients with diabetes  I –24 hr urine albumin vs urine micral test  O – in early detection of DM nephropathy  M – cross sectional studies

25.  Among long term diabetic patients, which is more effective between ACE-inhibitor and Angiotensin-receptor blocker in delaying the progression of diabetic nephropathy?

26.  P – patients with long term diabetes (>10yrs)  I – ACE inhibitor vs ARB  O – in delaying the progression of diabetic nephropathy  M – randomized control trial

27. Thank you...