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A Case Presentation on



Coronary Artery Disease,

Hypertensive Cardiovascular

Disease and Renal Cell Papillary Carcinoma with Prominent

Tubular Architecture with Left

Radical Nephrectomy.



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.



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.



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.



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;



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.



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.



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.



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%



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



HEALTH HISTORY

CHIEF COMPLAINT

Contemplated surgery

Nagpaadmit ko kay schedule nako ug opera saakong kidney as verbalized by the patient.



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.



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.



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.



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.



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



FAMILY HISTORY



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.



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.



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.



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.



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.



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.



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.



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.



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.



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.



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



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.



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



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.



CHAPTER III: LITERATURE REVIEW

ANATOMY AND PHYSIOLOGY

Figure 6: The cell and its structure

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