CASE PRESENTATION on CVD Cerebrovascular Disease

BSN3Y2-6 GRP 463 A/B

INTRODUCTION

Cerebrovascular disease is a group of brain dysfunctions related to disease of blood vessels supplying the brain. Hypertension is the most important cause that damages the blood vessel lining endothelium exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect. Sustained hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed and uneven which are more vulnerable to fluctuations of blood pressure.

A fall in blood pressure during sleep can lead to m a r k e d r e d u c t i on i n b l o o d f lo w i n t h e n a r r o w e d b l o o d v e s s e l s ca u s i n g i s c h e m i c s t r o k e i n t h e morning whereas a sudden rise in blood pressure c a n c a u s e t e a r ing o f t h e b l o o d v e s s e l s c a u s i n g i n t r a c r a ni a l h em o r r h a g e d u r i n g e x c i t a t i on a t daytime. Primarily people who are elderly, d i a b e t i c , s m o k e r , o r h a v e i s c h e m ic h e a r t d i s e a s e , h a v e c e r e b r o v a s cu l a r d i s e a s e . A l l d i s e a s e s r e l a t e d t o a r t e r y d y s f u n c t i o n c a n b e c l as s i f i e d u n d e r a disease as known as macrovascular disease.

This is a simplistic study by which arteries are blocked by fatty deposits or by a blood clot. The results of cerebrovascular disease can include a stroke, or even sometimes a hemorrhagic stroke. Ischemia or other blood vessel dysfunctions can affect one during a cerebrovascular accident. CVD is the most disabling of all neurologic diseases. Approximately 50% of survivors have a residual neurologic deficit and greater than 25% require chronic care. Cardiovascular disease mortality in the philippines was studied from the existing vital statistics for 20002008. Death rates from cerebrovascular diseases increased enormously both in men and women.

This increase in mortality was seen in all age groups. The age-standardized mortality rate in men rose from 33.3 in 2000 to 78.0 in 2005, and that of women from 15.4 to 34.5. The male to female ratios in the age-standardized death rates increased during this 9-year period. Agestandardized mortality increased clearly in the male population but decreased in the female population of the philippines. This excess mortality in males is mostly due to the increased cardiovascular disease death rate. This is a clear example of how chronic non-communicable diseases are becoming major health problems in countries where they previously have not been prevalent. Immediate preventive measures are needed in order to control cardiovascular diseases in countries, such as ours, where disease rates are rapidly increasing.

We chose this case as the main subject of this presentation because we were greatly alarmed with the sudden increase of the number of people having the said disease. We want to find out what makes it such a horrifying disease. We also wanted to come up with a thorough study so as to hasten and develop our critical thinking by utilizing the different nursing theories and principles that we learned from our discussion. It is then through this case presentation that we will be able to apply the things we were taught to.

NURSING HEALTH HISTORY

PERSONAL DATA: Patient A is a 49 years old male born on march 11, 1962 in leyte. He is a f i l i pi n o c i ti z en r e s i d i n g i n c a vi t e. H i s r e l i g i o n i s r o m a n c a t h o l ic . H e i s married with two (2) children. CHIEF COMPLAINT: Left sided numbness, weakness

HISTORY OF PRESENT ILLNESS: Eight days prior to admission, patient noted weakness of left lower extremities, slurred speech, dizziness and epigastric pain consulted at E.R with diagnosis of PUD and was discharged. Five days prior to admission, persistent left sided weakness and developed numbness and positive (+) of difficulty in urinating. FINAL DIAGNOSIS: Cerebrovascular disease (CVD) completed probably 2o to thrombotic infarct right middle cerebral artery (MCA) with left hemiplegia deficit T/C low urinary tract symptoms (LUTS)

History of past illness: In a year 2009 the patient has been hospitalized in cavite and had been diagnosed with cerebrovascular disease, by the year 2011 patient was been hospitalized at pnpgh and has been diagnosed with cerebrovascular disease.

Socio-economic status: He is living with his family. He is a roman catholic and tries to go to church whenever he had time before hospitalization. He is a police superintendent (PSUPT). Family health history: Patient A family has known history of hypertension on his father side. Other than that they were no family history of any diseases.

ANATOMY & PHYSIOLOGY

There is nothing in the universe to compare with the human brain. This mysterious three-pound squishy tissue controls all necessary functions of our physical body, receives information from the outside world and makes it understandable, and goes beyond that which is understandable to embody the essence of our mind and soul. Intelligence, creativity, emotion, love, memories are but a few of the many things the brain does. The weight of the brain changes from birth through adulthood. At birth, the average brain weighs about one pound, and grows to about two pounds during childhood. The average weight of an adult female brain is about 2.7 pounds, while the brain of an adult male weighs about three pounds.

T h e b r a i n r e c ei ve s i n f o r m a t i o n th r o u g h o u r f i v e senses: sight, smell, touch, taste, and hearing o f t e n m a n y a t on e t i m e . I t p u t s t o g e t h e r t h e messages in a way that has meaning for us, and c a n s t o r e t h a t i nf o r m a t i o n in o u r m e m o r y . O u r b r a i n c on t r o l s o u r t h o u g h t s , m e m o r y a n d s p e e c h , the movements of our arms and legs and the f u n c t i on o f m a n y o r g a n s w i t h i n o u r b o d y . I t a l s o determines how we respond to stressful s i t u a t i o n s ( i . e . , W r i t i n g o f a n e x am , l o s s o f a j o b , illness) by regulating our heart and breathing rate.

NERVOUS SYSTEM
y Central nervous system (CNS)

is composed of the brain and spinal cord y Peripheral nervous system (PNS) is composed of spinal nerves that branch from the spinal cord and cranial nerves that branch from the brain. The PNS includes the autonomic nervous system, which controls our vital internal functions such as respiration, digestion, heart rate, and secretion of hormones.

BRAIN
The brain is composed of the cerebrum, cerebellum, and brainstem

The brain is composed of three parts: the brainstem, cerebellum, and cerebrum. The cerebrum is divided into four lobes: frontal, parietal, temporal, and occipital.  Brainstem - includes the midbrain, pons, and medulla. It acts as a relay center connecting the cerebrum and cerebellum to the spinal cord. It performs many automatic functions such as breathing, heart rate, body temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and swallowing. Ten of the twelve cranial nerves originate in the brainstem. The brainstem is the lower extension of the brain, located in front of the cerebellum and connected to the spinal cord. It consists of three structures: the midbrain, pons and medulla oblongata. It serves as a relay station, passing messages back and forth between various parts of the body and the cerebral cortex. Many simple or primitive functions that are essential for survival are located here.

Midbrain - is an important center for ocular motion Pons - is involved with coordinating eye and facial movements, facial sensation, hearing and balance. Medulla oblongata - controls breathing, blood pressure, heart rhythms and swallowing. Messages from the cortex to the spinal cord and nerves that branch from the spinal cord are sent through the pons and the brainstem. Destruction of these regions of the brain will cause "brain death." Without these key functions, humans cannot survive. The reticular activating system is found in the midbrain, pons, medulla and part of the thalamus. It controls levels of wakefulness, enables people to pay attention to their environments, and is involved in sleep patterns. Originating in the brainstem are 10 of the 12 cranial nerves that control hearing, eye movement, facial sensations, taste, swallowing and movements of the face, neck, shoulder and tongue muscles. The cranial nerves for smell and vision originate in the cerebrum. Four pairs of cranial nerves originate from the pons: nerves 5 through 8.

Cerebrum - the largest part of the brain and is composed of right and left hemispheres. It is separated from the cerebrum by the tentorium (fold of dura). The cerebrum, which forms the major portion of the brain, is divided into two major parts: the right and left cerebral hemispheres. The cerebrum is a term often used to describe the entire brain. A fissure or groove that separates the two hemispheres is called the great longitudinal fissure. The two sides of the brain are joined at the bottom by the corpus callosum. The corpus callosum connects the two halves of the brain and delivers messages from one half of the brain to the other. The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex

Cerebellum - located under the cerebrum. Its function is to coordinate muscle movements, maintain posture, and balance. The cerebellum fine tunes motor activity or movement, e.G. The fine movements of fingers as they perform surgery or paint a picture. It helps one maintain posture, sense of balance or equilibrium, by controlling the tone of muscles and the position of limbs. The cerebellum is important in one's ability to perform rapid and repetitive actions such as playing a video game. It performs higher functions like interpreting touch, vision and hearing, as well as speech, reasoning, emotions, learning, and fine control of movement.

The cerebral cortex appears grayish brown in color and is called the "gray matter." The surface of the brain appears wrinkled. The cerebral cortex has sulci (small grooves), fissures (larger grooves) and bulges between the grooves called gyri. Beneath the cerebral cortex or surface of the brain, connecting fibers between neurons form a whitecolored area called the "white matter."
The cerebral hemispheres have several distinct fissures. By locating these landmarks on the surface of the brain, it can effectively be divided into pairs of "lobes." Lobes are simply broad regions of the brain. The cerebrum or brain can be divided into pairs of frontal, temporal, parietal and occipital lobes. Each hemisphere has a frontal, temporal, parietal and occipital lobe. Each lobe may be divided, once again, into areas that serve very specific functions. The lobes of the brain do not function alone they function through very complex relationships with one another.

Lobes of the brain

 Frontal lobe y Personality, behavior, emotions y Judgment, planning, problem y y y  y y y

 Occipital lobe y Interprets vision (color,

solving Speech: speaking and writing (Brocas area) Body movement (motor strip) Intelligence, concentration, self awareness Parietal lobe Interprets language, words Sense of touch, pain, temperature (sensory strip) Interprets signals from vision, hearing, motor, sensory and memory Spatial and visual perception

light, movement)  Temporal lobe y Understanding language (Wernickes area) y Memory y Hearing y Sequencing and organization

y Messages within the brain are delivered

in many ways. The signals are transported along routes called pathways. Any destruction of brain tissue by a tumor can disrupt the communication between different parts of the brain. The result will be a loss of function such as speech, the ability to read, or the ability to follow simple spoken commands. Messages can travel from one bulge on the brain to another (gyri to gyri), from one lobe to another, from one side of the brain to the other, from one lobe of the brain to structures that are found deep in the brain, e.G. Thalamus, or from the deep structures of the brain to another region in the central nervous system.

Deep structures

Deep structures
y Hypothalamus - the hypothalamus is located in the

floor of the third ventricle and is the master control of the autonomic system. It plays a role in controlling behaviors such as hunger, thirst, sleep, and sexual response. It also regulates body temperature, blood pressure, emotions, and secretion of hormones. y Thalamus - the thalamus serves as a relay station for almost all information that comes and goes to the cortex. It plays a role in pain sensation, attention, alertness and memory.

Deep structures
y Basal ganglia - The basal ganglia include the

caudate, putamen and globus pallidus. These nuclei work with the cerebellum to coordinate fine motions, such as fingertip movements. y Limbic system - The limbic system is the center of our emotions, learning, and memory. Included in this system are the cingulate gyri, hypothalamus, amygdala (emotional reactions) and hippocampus (memory).

Cranial nerves
The brain communicates with the body through the spinal cord and twelve pairs of cranial nerves ten of the twelve pairs of cranial nerves that control hearing, eye movement, facial sensations, taste, swallowing and movement of the face, neck, shoulder and tongue muscles originate in the brainstem. The cranial nerves for smell and vision originate in the cerebrum.

Cranial nerves

Blood supply
Blood is carried to the brain by two paired arteries, the internal carotid arteries and the vertebral arteries. The internal carotid arteries supply most of the cerebrum. The vertebral arteries supply the cerebellum, brainstem, and the underside of the cerebrum. After passing through the skull, the two vertebral arteries join together to form a single basilar artery. The basilar artery and the internal carotid arteries communicate with each other at the base of the brain called the circle of willis.

The communication between the internal carotid and vertebral-basilar systems is an important safety feature of the brain. If one of the major vessels becomes blocked, it is possible for collateral blood flow to come across the circle of willis and prevent brain damage.

The Circle of Willis

y The Circle of Willis or the Circulus Arteriosus is an

arterial polygon where the blood carried by the two internal carotid arteries and the basilar system comes together and then is redistributed by the anterior, middle, and posterior cerebral arteries. The posterior cerebral artery is connected to the internal carotid artery by the posterior communicating artery.

Internal Carotid System

y The internal carotid artery divides into two main

branches called the middle cerebral artery and the anterior cerebral artery. The middle cerebral artery supplies blood to the frontoparietal somatosensory cortex. The anterior cerebral artery supplies blood to the frontal lobes and medial aspects of the parietal and occipital lobes. Before this divide, the internal carotid artery gives rise to the anterior communicating artery and the posterior communicating artery.

y Vertebral Artery y The two vertebral arteries run along the medulla and fuse at the

pontomedullary junction to form the midline basilar artery, also called the vertebro-basilar artery. Before forming the basilar artery, each vertebral artery gives rise to the posterior spinal artery, the anterior spinal artery, the posterior inferior cerebellar artery (PICA) and branches to the medulla.
y Basilar Artery y At the ponto-midbrain junction, the basilar artery divides into the two

posterior cerebral arteries. Before this divide, it gives rise to numerous paramedian, short and long circumferential penetrators and two other branches known as the anterior inferior cerebellar artery and the superior cerebellar artery.

PATHOGENESIS
y In an ischemic brain attack, there is disruption of the cerebral

blood flow due to obstruction of the cerebral blood flowdue to obstruction of a blood flow. This disruption in a blood flow flow initiates a complex series of cellular metabolic events reffered to as the ischemic cascade. y The ischemic cascade begins when cerebral blood flow decreases to less that 25 ml per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphospate (ATP) to fuel the depolirazation processes. The membfrane pumps that maintain electrolyte balanaces begin to fail, and the cells cease to function.

y Early in the cascade, an area of low cerebral blood flo,

reffered to as the penumbre region, exist around the area of infraction. The penumbra region is ischemic brain tisuue that may be salvaged with timely intervention. The ischemic cascade treathens cells in the penumbre because membrane depolarization of the cell wall leads to an increase in intracellular calcium and the release of glutamate. The influx of calcium and the release of glutamate, if continued, activate a number of damaging pathways that result in the destruction of the cell membrane, the release of more calcium and glutamate, vasoconstriction, and the generation of the free radicals. These processes enlarge the area of infarction into the penumbra, extending stroke. A person experiencing as stroke typically loses 1.9 million neurons each minute that a stroke is not treated, and the ischemic brain ages 3.6 years each hour without treatment.

Each step in the ischemic cascade represents an opportunity for intervention to limit the exrent of secondary brain damage caused by a stoke the penumbra area mayn be revitalize by a administration of tissue plasminogen activator. Mediaction that protects the brain from secondary injury are called neuroprotectants. A number of ongoing clinical trials focus on neuroprotective medication and strategies to improve stroke recovery and survival.

DRUG NAME

ACTION

INDICATION

CONTRAINDICATI ON Containdicated in: uncompensated CHF: Pulamonary edema: Cardiogenic shock: Bradycardia or Heart attack -Used cautiously in Renal Impairment; Hepatic impairment

ADVERSE REACTION -CNS: fatigue, weakness. Anxiety, depression, dizziness, drowsiness, insomnia, nervousness -EENT: blurred vision, snuff nose. -Resp: wheezing, bronchospasm -CV: Bradycardia, CHF, pulmonary edeme, hypotension, peripheral vasoconstriction -GI: constipation, diarrhea, dry mouth, flatulence, gastric pain, nausea and vomiting -GU: Erectile dysfunction, urinary frequency, -Derm: rashes Endo: hyperglycemia, and hypoglycemia.

NURSING CONSIDERATION -Monitor BP and pulse -Monitor VS q15 during and for several hours -Monitor I & O ratio and daily weight -Assees routinely for s/sx of CHF (dyspnia, crackles, weigh gain, pheriperal edema -P.O take apical pulse before administering. -Administer Metoprolol with meals or directly eating

Brand Name: Betaloc Durules, Beloc Generic Name: Metoprolol Classification: Therapeutic Antianginals, & Antihypertensives Pharmacologic: Beta blockers

-Block stimulation of beta1 (myocardial) adrenergic receptors. Does not usually affect beta2 (pulmonary vascular, uterine) adrenergic receptor sites. Therapeutic Effects: Decrease blood pressure and heart rate . Decrease frequency of attacks of Angina Pectoris. Decrease rate of cardiovascular mortality and hospitalization in patients with heart failure.

-Hypertension, Angina Pectoris -Prevention of M.I Decrease mortality in patient with recent M.I -Management of stable symptomatic (class II & III) heart failure due to ischemic, hypertensive or cardiomyopathic origin (may be used with ACE inhibitors, diuretics and digoxin).

DRUG NAME Brand Name: Plavix Generic Name: Clopidogrel Classification: -Therapeutic -anti platelet agent Pharmacologic: -Platelet aggregation inhibitors.

ACTION -Inhibitors aggregation by irreversibly inhibiting the binding of ATP to platelet receptors.

INDICATION -Reduction of atherosclerotic events (MI, stroke, vascular death) in patients at risk for such events including recent MI, acute coronary syndrome (angina/ non-Q- wave MI) stoke or peripheral vascular disease.

CONTRAINDICATI ON hypersensitivity; pathologic bleeding (peptic ulcer, intracranial hemorrhage)

ADVERSE EFFECT CNS: depression, dizziness, fatigue, headache EENT: epistaxis RESP: cough CV: chest pain, edema, hypertension GI: GI bleeding, abdominal pain, diarrhea, dyspepsia, gastritis DERM: pruritus, purpura, rash HEMAT: bleeding, neutropenia, thrombotic thrombocytopenic purpura. METAB: hypercholesterolemi a MS: arthralgia, back pain MISC: fever, hypersensitivity reactions

NURSING CONSIDERATION -assess pt. for symptoms of stroke peripheral vascular disease, or MI periodically during therapy. -monitor pt. for signs of thrombotic thrombocytic purpura (thrombocytopenia, microangiopathic hemolytic anemia , neurologic findings , renal dysfunction, fever) -PO: Administer once daily w/o regard to food -Instruct pt. to take medication exactly as directed. -Advise pt. to notify health care professional promptly if fever chills , sore throat , or unusual bleeding or bruising occurs.

Before Hospitalization - He takes a less than a pack of cigarette - He drinks alcohol occasionally - He has an allergy on peanuts, reaction to him are rashes. - He used to read news papers and answering word search. - He is independent in doing his daily activities.

During Hospitalization - He quit in smoking and drinking alcohols.

Interpretation - Because of his condition, he was restricted in smoking and taking an alcohol.

Health Maintained Perception Pattern

Activity Exercise Pattern

- He needs assistance from other in doing his daily activities, especially in ambulating and stair climbing.

- Because of his illness, he cant do by himself some of his daily activities.

Nutrition Metabolic Pattern

- He takes more salty and fatty foods.

- He is vegetarian, he limit taking fatty and salty foods.

- Because of his condition, he was restricted on fatty and salty foods. - No discomfort in elimination pattern.

Elimination Pattern

- He can urinate and defecate without any discomfort.

- He can urinate and defecate without any discomfort.

Sleep Rest Pattern

- He can sleep takes 5 to 6 hours of sleep and sometimes he takes a nap at PM.

- He can take 5 to 6 hours of sleep and take a nap at PM.

- The patient can sleep well because he has no work.

Cognitive Perception Pattern

- He is alert. - He able to read, comprehends, and communicates to others.

- He was still able to communicates, comprehends, and read.

- The patient was able to communicate effectively to others.

- Sexually active Sexuality Reproductive Pattern

- Not sexually active

- Because of his condition, he is not sexually active now.

Body Parts General appearance Mental status -

Normal Findings Medium frame with upright posture Well groomed No odor Conscious and cooperative Use of simple words -

Actual Findings Medium frame with upright posture Well groomed No odor Conscious and cooperative Use of simple words -

Interpretation Normal findings

normal findings

Skull

-absence of nodules and masses - rounded -Proportionate to body size

- Proportional to body size -rounded -absence of mass and nodules - evenly distributed - thick and short hair - no lices and infection - asymmetrical - same as skin color - asymmetrical facial movement straight normal eye brows hair are normally distributed frequent blink response symmetric eyeballs pink conjunctiva reddish sclera

- normal finding

Hair

-evenly distributed -Thick hair -no infection

- normal findings

Face

-symmetric or slightly asymmetrical facial features -same as skin color

- abnormal findings

Eyes

When looking straight ahead, client can see objects periphery

normal findings

Body Parts Nose

Normal Findings -no discharge or flaring -Uniform in color -no tenderness and lesions -color same as facial skin -both patent

Actual Findings -no discharge or flaring -Uniform in color -no tenderness and lesions -color same as facial skin -both patent -symmetrical -aligned with the outer canthus of eye -mobile, firm, not tender -able to hear on both side -uniform pink in color -soft, moist smooth texture -32 adult teeth -smoothy, white shiny tooth enamel -pink gums -moist, firm texture -no retraction -light pink, smooth, soft palate -uvula is positioned in the midline of soft palate

Interpretation - normal findings

Ears

-symmetrical -aligned with the outer canthus of eye -mobile, firm, not tender -able to hear on both side

-normal findings

Lips

-uniform pink in color -soft, moist smooth texture

-normal findings

Teeth

-32 adult teeth -smoothy, white shiny tooth enamel

-normal findings

Gums

-pink gums -moist, firm texture -no retraction

-normal findings

Palates and uvula

-light pink, smooth, soft palate -uvula is positioned in the midline of soft palate

- normal findings

Body Parts Tongue

Normal Findings -tongue in central positioned

Actual Findings -tongue in central positioned

Interpretation - normal findings

Oropharynx and tonsils

-pink and smooth posterior wall -pink and smooth tonsils -no discharges in tonsils

-pink and smooth posterior wall -pink and smooth tonsils -no discharges in tonsils

- normal findings

Neck

-complete range of motion -no pain at any movement -uniform in color

-complete range of motion -no pain at any movement -uniform in color

- normal findings

Thorax

-color should be consistent with the color of the face -quiet, rhythmic and effortless respiration

-color should be consistent with the color of the face -quiet, rhythmic and effortless respiration

- normal findings

Chest

-full and symmetric chest expansion -bilateral symmetry of vocal fremitus

-full and symmetric chest expansion -bilateral symmetry of vocal fremitus

- normal findings

Heart

-RR: 12-20 -no shortness of breath -no chest pain or tightness

-RR: 12-20 -no shortness of breath -no chest pain or tightness

- normal findings

Body Parts Breast

Normal Findings -no pain and tenderness -symmetrical -no swelling

Actual Findings -no pain and tenderness -symmetrical -no swelling -no tenderness, limps or swelling -no rashes

Interpretation - normal findings

Axilla

-no tenderness, limps or swelling -no rashes

- normal findings

Abdomen

-skin is of normal racial tone which is brown -contour is flat -bowel sound is normal active and no bruits -no tenderness -liver is not palpable

-skin is of normal racial tone which is brown -contour is flat -bowel sound is normal active and no bruits -no tenderness -liver is not palpable

- normal findings

Upper extremities

-peripheral pulses are equal -lymph nodes are not palpable

-peripheral pulses are equal -lymph nodes are not palpable -no lesions -peripheral pulses are equal -lymph nodes are not palpable - numbness

- normal findings

Lower extremities

-no lesions -peripheral pulses are equal -lymph nodes are not palpable

- abnormal findings

Microscopic Examination Hemoglobin

Normal Findings Male: 140 180 g/l Female: 120 140 g/l Male: 0.42 0.54 Female: 0.37 0.48

Result 163.0 g/L

Interpretation Normal

Hematocrit

0.48

Normal

WBC

Male / Female: 5.0 10.0 x 10 9/L 50 60%

6.0 x 10 9/L

Normal

Segmenters

0.52

Normal

Lymphocytes

25 40%

0.41

Normal

Monocytes

3 9%

0.2

Eosinophil

1 3%

0.4

Stab

2 5%

None

None

Basophils

0 1%

1%

Normal

Microscopic Examination

Normal Findings

Result

Interpretation

Color

Straw amber

Yellow

Normal

Transparency

Clear

Slightly turbid

Normal

Reaction

Acidic or alkaline

Acidic

Normal

Specific gravity

1.005 1.025

1.025

Normal

Sugar

Negative

Negative

Normal

Protein

Negative

Negative

Normal

Microscopic Examination

Normal Findings

Result

Interpretation

Red Blood Cells

0 1hpf

None

None

Pus Cells

0 2hpf

1 2hpf

Normal

Squamous Ephit Cells

rare

Normal

Renal Ephit Cells

None

None

Amorphous Phosphates

Urates

None

None

Mucus Threads

many

Examination Fasting Blood Sugar

Normal Findings 3.85 5.80 mmol/L

Result

Interpretation

Blood Urea Nitrogen

2.50 6.43 mmol/L

Creatinine (male) (female) Blood Uric Acid (male) (female) Total cholesterol

79.6 132.6 umol/L 61.9 121.1 umol/L

0.201 0.413 mmol/L 0.142 0.336 mmol/L

3.63 6.21 mmol/L

5.24 mmol/L

Normal

Triglycerides

0.41 1.86 mmol/L

1.68 mmol/L

Normal

HDL

1.04 1.56 mmol/L

1.24 mmol/L

Normal

LDL

2.40 3.80 mmol/L

3.23 mmol/L

Normal

Test

Normal Value

Result

Interpret

Glucose / Sugar

3.59 5.95

5.07

Normal

Blood Urea Nitrogen

2.08 6.45

4.42

Normal

Creatinine

62.1 133.7

80.1

Normal

Uric Acid

237.9 511.0

432.6

Normal

DISCHARGE PLANNING
y y y y y y y y y y y y y y y y y y y

Medication: metoprolol 50mg 1tab BID Copidogrel 75mg. OD Exercise: Early ambulation to avoid further complication Treatment: continue medication Health Teaching: medication must be taken daily as prescribed o ensure control. Adhere to a low salt, low fat diet. Avoid excessive intake of alcohol, coffee, tea or cola. Always consult provider before interrupting therapy. OPD Check-up: follow up check up after 1 week. Diet: proper low salt, low fat diet. Sexuality: avoid having intercourse. Spirituality: just pray for guidance and safety.