a case presentation on
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A Case Presentation on
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Coronary Artery Disease,
Hypertensive Cardiovascular
Disease and Renal Cell Papillary Carcinoma with Prominent
Tubular Architecture with Left
Radical Nephrectomy.
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INTRODUCTION
Renal cell papillary carcinoma is the most common type of malignant kidney tumor and accounts for more than 90% of allrenal tumors. Renal cell carcinoma is more common in men thanwomen with about 60% of cases occurring in men and about 40% inwomen. Most cases of renal cell carcinoma occur in adults between
50 to 70 years of age. It is a type of kidney tumor characterized bythe development of finger-like projections in at least some of thetumor.
Coronary heart disease is the leading cause of death in the UnitedStates affecting more than 13 million Americans. Coronary arterydisease is a condition in which the coronary artery, the blood vessel
supplying oxygenated blood to the heart, becomes clogged withplaque build-up.Without adequate blood flow from the coronaryarteries, the heart becomes starved of oxygen and vital nutrients itneeds to work properly.
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Hypertensive cardiovascular disease also known ashypertensive heart disease occurs due to the complicationof hypertension or high blood pressure. In this condition
the workload of the heart is increased manifold and withtime this causes the heart muscles to thicken. The heartcontinues pumping blood against this increased pressureand over a period of time the left ventricle of the heartenlarges and this in turn causes the blood pumped by heart
to reduce.This is a case of patient RBC, 59- year old, married Filipino
male residing at 487- CP del Rosario Ext., Cebu City , Cebuwho was admitted for a scheduled operation last March 1,2011. The patient was admitted on March 1, 2011 atPerpetual Succour Hospital accompanied by his family. Hewas ambulatory with vital signs of T 37.2 degree Celsius,afebrile, P 78 bpm, R 16 cpm, BP 130 80 mmhg. Heunderwent his scheduled operation of left radicalnephrectomy last March 3, 2011.
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The group has chosen this case because theyfound it interesting to deal with a case onrenal disease and they found it as a goodavenue for learning more about the renalsystem. Some members of the group were
able to assist the patient in his scheduledoperation and he was under the groups carein his short stay in the medical intensive careunit. Though the group wasnt anticipating for
the case to be diagnosed as carcinoma, still,they consider it as an opportunity to learn inadvance the mechanisms of cancer.
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OBJECTIVES
The following primary objectives are the main goal of this study;
Discuss the normal anatomy and physiology of the cell, urinarysystem, integumentary system and cardiovascular system;
Determine the current health status of the patient throughthorough physical assessment, laboratory examinations and as wellas diagnostic procedures of which the patient has undergone;
Properly trace the pathogenesis of the disease processes startingfrom the precipitating and predisposing etiologic factors that causethe disease of the patient;
Relate concepts and theories with the actual data gathered from
the patient;
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Develop an effective and efficient nursing care planpre-, inta-, and post-operatively, including the primary
caregivers participation that could help the patient inrecovering fast, enhance the well-being of the patientand prevent post-operative complications;
Rationalize all medical, surgical and nursing actionsapplied to the patient;
Evaluate on the effectiveness of the interventionsincluding the medical and nursing care managementsrendered to the patient;
Develop an effective and efficient discharge planning
instructions for the primary caregiver to practicedirectly towards enhancement of the patients healthand sense of well-being.
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SCOPE AND LIMITATIONS
This clinical paper contains information related to the care andcondition of the patient. This paper also includes review of systems(pre-,intra-, and post-operatively), laboratory results with theircorresponding interpretations, background of the normal anatomy
and physiology of the affected part, the pathophysiology of thedisease, and different surgical, medical, pharmacologic and nursingmanagements rendered to the patient and from the moment thepatient is wheeled in to the Operating Room until the time he waswheeled out to the Surgical Intensive Care Unit, to the MedicalIntensive Care Unit and to the ward. The data gathered depends on
the honesty and cooperation of the patient, as well as the length of time we were interacting with the patient.
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The group had only two weeks exposure inPerpetual Succour Hospital, which includes 6 daysof clinical duty in the operating Room andMedical Intensive Care Unit by the group. Thegroup was only able to be in contact with thepatient for 1 day, after which, the patient was
already transferred in the ward. We only get tovisit our patient after our clinical duty in ourrespective areas.
In the process of making this clinical paper, thegroup encountered some limitations which arethe following:
Limited available resources, such as accessibleinternet stations.
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PATIENTS BIOGRAPHICAL DATA
Name: R. B. C.
Address: Del Rosario ext. Cebu City, Cebu
Contact Person: P. C. (Spouse)
Age: 59 y.o
Birth date: September 29, 1951
Birthplace: Asturias Cebu
Gender: Male
Religion: Roman Catholic
Nationality: Filipino
Attending Physician: Dr. C. Q.
Dr. E. M.Dr. E. T.
Source of History/Reliability: Patient 60%, chart 30%, S.O 10%
Reliability 100%
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Marital Status: Married
Number of Dependents: 3
Educational Attainment: College Graduate, AB
Philosophy
Occupation: General Manager of ElectricCooperative, Cebu City
Health Insurance: PhilHealth
Admission Date and Time: March 1, 2011,
2:58 pm @ Perpetual Succour Hospital
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HEALTH HISTORY
CHIEF COMPLAINT
Contemplated surgery
Nagpaadmit ko kay schedule nako ug opera saakong kidney as verbalized by the patient.
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HISTORY OF PRESENT ILLNESS
The patient was admitted on March 1, 2011 at
Perpetual Succour Hospital accompanied by
his family. He was ambulatory with vital signsof T 37.2 degree Celsius, afebrile, P 78 bpm,
R 16 cpm, BP 130 80 mmhg. He underwent
his scheduled operation of left radical
nephrectomy last March 3, 2011.
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C. PAST HEALTH HISTORY
Childhood Illness: He stated that he had experienced chickenpox,measles, mumps, flu, common colds and cough.
Immunization: He had complete immunization
Hospitalization:
His first hospitalization was during his college years. The patient wasadmitted due to urinary calculi in one of the hospitals in Bohol. Itlasted for one week but he couldnt remember the exact date andlocation of the said hospitalization. He also forgot the name of his
attending physician that time. The patient stated that the illnesswas resolved.
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His second hospitalization was on November 6, 2010 dueto Coronary artery disease at Perpetual Soccour
Hospital and he had undergone Coronary Artery BypassGraft. It started last October 2010, when the patientwas washing his car and doing his activities of dailyliving, he experienced dyspnea, excessive perspirationand numbness of the upper extremities. According to
him, the pain originated from the back radiating to hischest. He called his family doctor and narrated the saidevent. His doctor advised him to take Imdur ½ tabletand have himself admitted at Perpetual SoccourHospital. The patient rated the pain as 9 in a pain scale
of 10 with 0 as the lowest and 10 as the highest. Thepatient underwent Coronary Angiogram and found outthat he has Coronary Artery Disease. He underwentCoronary Artery Bypass Graft on November 6, 2010.
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His third hospitalization was last 2010. Last 2008,
patient experienced painless hematuria. Therewere no specific interventions done and he foundrelief from drinking more fluids. He wasndt ableto consult a physician. On September 2010, priorto admission, the patientds condition started asan onset of left flank pain associated withhematuria with the pain rated as 10 in a painscale of 0 as no pain and 10 as the most painful.There was no fever noted. He had ultrasounddone which showed renal masses. CT scan wasdone with the same finding. Patient was advisedfor surgery.
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Surgeries:
Coronary Artery Bypass Graft (2010)
Serious Injuries: There were no serious injuries experienced by the patient.
Chronic Illnesses: Hypertension, Gouty Arthritis, Coronary Artery Disease
Allergies:No known drug, food, or environmental allergies.
Medications: Cardiosel 50mg TID
Telmisartan 40mg OD
Aspirin 80mg
Digoxin ½ tab OD
* patient stated that he compliantly take these medication
Recent Travel: No recent travel outside Cebu City
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FAMILY HISTORY
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Interpretation:
Patients grandmother in his mother side died of a kidney problem and his grandfather died of an
unknown cause while his grandparents in hisfather side has a chronic illness of hypertension.Patients mother was hypertensive and his fatherdied of an accident. Patient may inherit his illnesssuch as renal papillary carcinoma and
hypertension from his parents and grandparents.Also, his younger brother died of a kidneyproblem.
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FUNCTIONAL HEALTH PATTERN
LIFESTYLE
Personal Habits Does not engage in any vices or use recreationaldrugs. Takes his maintenance medications and vitamins daily
Diet: Loves to eat meat especially the legs of the pig. He has household
helpers to cook for their daily meal during weekdays and onlyduring weekends, the patient cooks for the family. He loves cookinghumba, adobo,lechong paksiw and the like. Rarely eats vegetablesand fish. He usually drinks soda every after meal. The patient takeshis breakfast with 1 cup of coffee every day. After his CABG, heminimized eating meat and preferred to eat vegetables and fish and
drinks milk instead of coffee. Patientd
s weight decreased from 97kgs before his heart surgery to 81 kgs in the present. He has largebody built.
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Sleep and Rest Pattern: Sleeps well 8 to 9 hours
at night and has good sleeping habits. Doesnot have difficulty getting sleep. Able to getadequate rest and sometimes falls asleepwhile watching television.
Activity and Exercise: Work does not requirevigorous physical activity. Does walking as hisway of exercise during vacant periods.
After the operation on his heart, the patient hadunderwent rehab in Perpetual SuccourHospital for about 2 weeks.
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Typical day: Arises at 5 am. Eats his breakfast
before going to work. They have housekeepersdoing the household chores. Drive his own car
and begins his work at 8:00 am and works
until 5:00 pm. Drives home and relaxes. Takes
his dinner together with his family and watch
the news. He goes to bed by 8:00 pm every
night. After the operation on his heart, the
patient has his own personal driver and staysat home to take a rest and as advised by his
physician.
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Recreation, Pets and Hobbies: Enjoys teaching
and singing religious songs in their own parishevery Sunday. Likes to watch news and sports
during leisure time and loves taking care of his
grandchildren. Has 21 cats as pets and are welltaken care of.
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SOCIAL PATTERNRoles and Relationships: States that he is in a
good marriage that is supportive. Has close
family ties with the member of the family. Has
good relationship with friends and neighbors
and is well respected.
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Ethnic/Religious Pattern: A devoted RomanCatholic and an active choir member in their
parish. Goes to mass together with his family
every Sunday and usually they sponsor themass. No specific cultural influence that
affects patient's health care.
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Occupational Health Pattern: Works as a general
manager in an electric cooperative and statesthat there are no risks at work. Does not
consider work as stressful. According to the
patient his work is just to call for a meeting,supervise, and discuss some strategies and
plans in order to make their cooperative more
productive.
Economic Status: Patient belongs to the middle
class famiies.
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Home and Neighborhood: House is made out of
concrete material, a bungalow type and isnear to their perspective parish church andschool. It has a far distance to the market andplace of work estimated of 30 mins of travel.
Perceived their home as a place safe to live in.Patient states that his father and his eldest sonwas a smoker.Drives his own car in going towork but as of now he has his own personal
driver after the operation he had on his heart.Usually wears seatbelt in car.
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Psychological Data Patient is coherent with
clear, moderate voice tone and respondsappropriately with appropriate affect and
facial expression.
Patterns of healthcare financing: Has PhilHealthas their Health Insurance. Patient earns
enough for the family.
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PHYSICAL ASSESSMENT
System Assessed PRE- OPERATIVE PHASE
March 3, 2011
(7:30am-8:13am)
INTRA- OPERATIVE PHASE
March 3, 2011 (8:10am-
11:41)
POST- OPERATIVE PHASE
March 4 ,2011
(10:00pm-6:00am)
General Survey Awake and oriented
to time, place,
person and event
Informed consent
for the procedure
was duly signed by
the patient
Pre-operativemedications given by
the nurse on duty
In a supine position
Sedated and
unconscious
In a right lateral
position
Awake, irritable,
restless and oriented
to time, place,
person, and event
In a semi-fowlers
position
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LABORATORY EXAMINATION
Pre-Operative Laboratory Results
Urinalysis
Definition and purposeUrinalysis is a general examination of urine to
establish baseline information provides data
to establish a tentative diagnosis and
determines whether further studies are to be
ordered.
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Co mponent Results
February 02, 2011
@ 8:46 AM
Results
February 17, 2011
11:45:59 AM
Normal
Characteristic
Significance
Color Amber Amber Amber Yellow Normal
Appearance Cloudy Cloudy Clear/transparent Abnormal
Glucose Negative Negative Negative Normal
Protein ++ +2 Negative Abnormal
pH 6.0 6.0 4.0-8.0 Normal
Specific Gravity 1.020 1.015 1.003-1.030 Normal
Bilirubin Negative Negative Negative Normal
Urobilinogen Negative Negative Negative Normal
Urine Ketone Negative Negative Negative Normal
Nitrite Negative Negative Negative Normal
Leukocytes ++ ++ Negative Abnormal
Blood +++ +++ Negative Abnormal
Table 2: Macroscopic
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Interpretation: Since the patient is having UTI,
he is experiencing hematuria that resulted in
cloudy colored urine due to the presence of
sediments of blood. Protein and leukocytes
are also present in the urine since there is anincreased permeability thus resulting in the
escape of large molecules.
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CHAPTER III: LITERATURE REVIEW
ANATOMY AND PHYSIOLOGY
Figure 6: The cell and its structure