SAINT MARY’S UNIVERSITY

BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES

SCHOOL OF HEALTH AND NATURAL SCIENCES

INDIVIDUAL CASE ANALYSIS

Presented to
The Faculty of the School of Health and Natural Sciences
Saint Mary’s University
Bayombong, Nueva Vizcaya

In Partial Fulfillment of the Requirements of

NCM 112 Related Learning Experience

Submitted to:
Sir. Peter-Tom Callang
Clinical Instructor

Submitted by:
Marisabel Joy E. Udde-e
BSN 3F

September 2023

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

TABLE OF CONTENTS
I. PERSONAL DATA

II. PRESENT HISTORY OF ILLNESS

III. PAST HISTORY OF ILLNESS

IV. BRIEF DESCRIPTION

V. ANATOMY AND PHYSIOLOGY

VI. PATHOPHYSIOLOGY

VII. LABORATORY RESULT AND DIAGNOSTIC STUDIES

VIII. PHYSICAL ASSESSMENT

IX. DRUG ANALYSIS

X. COURSE IN THE WARD

XI. NURSING CARE PLAN

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

I. PERSONAL DATA
Name Mr. Ceasar B. Macababbad
Age 82 years old
Address P2, Don Domingo Maddela
Birthday MOctober 20, 1941
Sex Male
Blood Type Type O
Nationality Filipino
Civil Status Married
Religion Roman Catholic
Educational College Graduate In BSC
Attainment
Language Ilocano, Tagalog,
Primary Health Care RHU
Source of information RHU
Presenting Complain Frequent urination, constipation, and
hunger.
Attending Physician Dr. Agustin

SIGNIFICANT OTHER’S
Name Mrs. Rosita T. Macababbad
Sex Female
Age 82 years old
Birthday October 5, 1941
Address P2, Don Domingo Maddela
Religion Roman Catholic
Civil Status Married
Relationship Husband

II. HISTORY OF PRESENT ILLNESS

a. Chief Complaint
Mr. Macababbad went to the RHU for a follow-up examination for his type 2
diabetes mellitus as well as because he was experiencing frequent urination and
constipation,. He also mentioned during the conversation that he sometimes feels
extreme hunger. As a result of his blurry vision, he mentioned that he wears
spectacles.

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

b. Signs and Symptoms

Symptoms of Diabetes Mellitus present in patient include frequent urination, blurry
vision as well as hunger and constipation.

III. HISTORY OF PAST ILLNESS

Medical History
The patient claimed that he was diagnosed with diabetes at the age of 77.

a. Familial History
According to Mr. Macababbad, neither his maternal nor his paternal sides have a
known history of diabetes mellitus.

b. Environmental History
The house is constructed of concrete and wood. It appears to be an ordinary
residence. It is primarily built of concrete. Most of visitors are greeted at the
guest area. It has enough beds for them, as well as a sala and a kitchen where they
all eat. Inside their home, they have a faucet. The roof has been properly fixed. They
cook with a gas tank. They have a dog as well. Outside is their own tiny canteen.
They get along well with their neighbor.

c. Cultural History
He ensures that he and his family go to mass each Sunday. He has no cultural beliefs.

d. Social History
Mr. Macababbad is not employed. He spends his time watching television, playing
phone games, and swapping stories with his neighbors, and he has an eats a lot and
drinks a lot of water. His lifestyle has become sedentary, with no exercise other than
fast strolling and going to the market to buy food. He does not smoke and does not
consume alcoholic beverages. He also stated that he always buy cooked food at the
restaurant.

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

IV. BRIEF DESCRIPTION

a. Definition
A disorder in the body's ability to control and utilize sugar (glucose) as fuel is type 2
diabetes. This chronic (long-term) disorder causes the bloodstream to circulate with
an excessive amount of sugar. Over time, cardiovascular, neurological, and immune
system issues might result from excessive blood sugar levels. There are basically
two interconnected issues at play in type 2 diabetes. The hormone that controls the
flow of sugar into your cells, insulin, is not produced by your pancreas in sufficient
amounts, which causes your cells to react poorly to insulin and absorb less sugar.

b. Etiology
 Resistance of Insulin
 Genetic Predisposition
 Obesity

c. Predisposing factors
Factors that may increase your risk of type 2 diabetes include:

Weight. Being overweight or obese is a main risk.

Fat distribution. Storing fat mainly in your abdomen - rather than your hips and
thighs - indicates a greater risk. Your risk of type 2 diabetes rises if you're a man
with a waist circumference above 40 inches (101.6 centimeters) or a woman with a
measurement above 35 inches (88.9 centimeters).

Inactivity. The less active you are, the greater your risk.
Physical activity helps control your weight, uses up glucose as energy and makes
your cells more sensitive to insulin.

Family history. The risk of type 2 diabetes increases if your parent or sibling has
type 2 diabetes.

Race and ethnicity. Although it's unclear why, people of certain races and ethnicity
- including Black, Hispanic, Native American and Asian people, and Pacific Islanders
- are more likely to develop type 2 diabetes than white people are.

Blood lipid levels. An increased risk is associated with low levels of high-density
lipoprotein (HDL) cholesterol — the "good" cholesterol and high levels of
triglycerides.

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BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

Age. The risk of type 2 diabetes increases as you get older, especially after age 45.

d. Signs and Symptoms

Signs and symptoms of type II DM often develop slowly. You can live with type II DM
for years and not know it. When signs and symptoms are present, they include:

 Increased thirst
 Frequent urination
 Increased hunger
 Unintended weight loss
 Fatigue
 Blurred vision
 Slow-healing sores
 Frequent infections
 Numbness or tingling in hands or feet
 Areas of darkened skin, usually in the armpits & neck

e. Epediomology
 In 2014, more than 422 million of a global population have Type II DM.
 1.6 million people died because of diabetes.
 Prevalence of diabetes among adults has increased to 8.5% and among
children – up to 2.8%.
 Diabetes leads to blindness, heart attacks, and strokes.
 People from low- or middle-income families are under a threat.
 According to the investigations of the World Health Organization (2017), the
number of people with diabetes has considerably increased during the last
decade. For example, at the end of the 1900s, only 108 million people with
diabetes were recorded, and at the beginning of the 2000s, approximately 422
million people have this disease globally. Besides, about 1.6 million deaths are
caused by diabetes. Regarding Type II diabetes patients, 8.5% of them are
adults, and 2.8% of them are children or adolescents (Reinehr, 2013; World
Health Organization, 2017). Diabetes is a serious disease that may be
characterized by different complications, the most dangerous of which are
blindness, heart attacks, and strokes. The World Health Organization (2017)
states that people from middle- and low-income families are exposed to having
diabetes more frequently than rich people.

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

a) Diagnostic Procedure
i. Define Purpose

Type 2 diabetes is diagnosed by doctors based on the results of blood tests

that assess blood sugar levels. These tests are frequently performed as part
of a yearly physical assessment. If you have prediabetes or risk factors for
type 2 diabetes, several blood tests may be conducted more regularly. Other
tests are performed to detect metabolic syndrome symptoms.

ii. How is it done

A1C Test

The A1C test measures your average blood sugar level over the past 2 or 3
months. An A1C below 5.7% is normal, between 5.7 and 6.4% indicates you
have prediabetes, and 6.5% or higher indicates you have diabetes.

Fasting Blood Sugar Test

This measures your blood sugar after an overnight fast (not eating). A fasting
blood sugar level of 99 mg/dL or lower is normal, 100 to 125 mg/dL
indicates you have prediabetes, and 126 mg/dL or higher indicates you have
diabetes.

Glucose Tolerance Test

This measures your blood sugar before and after you drink a liquid that
contains glucose. You’ll fast (not eat) overnight before the test and have your
blood drawn to determine your fasting blood sugar level. Then you’ll drink
the liquid and have your blood sugar level checked 1 hour, 2 hours, and
possibly 3 hours afterward. At 2 hours, a blood sugar level of 140 mg/dL or
lower is considered normal, 140 to 199 mg/dL indicates you have
prediabetes, and 200 mg/dL or higher indicates you have diabetes.

Random Blood Sugar Test

This measures your blood sugar at the time you’re tested. You can take this
test at any time and don’t need to fast (not eat) first. A blood sugar level of
200 mg/dL or higher indicates you have diabetes.

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

iii. Nursing Considerations before, during, and after

Before During after

1. Identify the patient by 1. Swab alcohol pad to the 1. Apply an adhesive
asking the patient to state chosen puncture site. Use bandage once the bleeding
his/her name. Also check sterile/clean gauze to dry it on the puncture site has
the client’s identification thoroughly. Piecing the stopped.
band. ( confirm patient’s skin with a wet skin
identity using two patient (alcohol) allows the 2. Remove gloves and
identifiers, based on the chemical to pass through record the resulting
hospital protocol) the outer layer of the skin glucose level from the
thus, causing the digital display for
2. Explain the procedure to procedure more painful glucometer or from the
the patient or parents (if and uncomfortable. color of reagent strip to the
patient is a child) to gain standardized chart.
cooperation. 2. Don’t squeeze the
puncture site to prevent 3. Obtain and record
diluting the sample with baseline vital signs.
fluids from tissues.
4. Practice strict asepsis.

b) Medical Management
Diabetes treatment's major goal is to normalize insulin activity and blood
glucose levels in order to reduce the development of vascular neuropathic
repercussions.

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

V. ANATOMY AND PHYSIOLOGY

The endocrine system is made up of

glands that produce and secrete hormones.
These hormones regulate the body's growth,
metabolism (the physical and chemical
processes of the body), and sexual
development and function. The hormones are
released into the bloodstream and may affect
one or several organs throughout the body.

Hormones are chemical messengers

created by the body. They transfer information
from one set of cells to another to coordinate
the functions of different parts of the body.
The major glands of the endocrine
system are the hypothalamus, pituitary, thyroid,
parathyroids, adrenals, pineal body, and the
reproductive organs (ovaries and testes). The
pancreas is also a part of this system; it has a
role in hormone production as well as in digestion.
The endocrine system is regulated by feedback in much the same way that a
thermostat regulates the temperature in a room. For the hormones that are regulated by
the pituitary gland, a signal is sent from the hypothalamus to the pituitary gland in the form
of a "releasing hormone," which stimulates the pituitary to secrete a "stimulating hormone"
into the circulation. The stimulating hormone then signals the target gland to secrete its
hormone. As the level of this hormone rises in the circulation, the hypothalamus and the
pituitary gland shut down secretion of the releasing hormone and the stimulating hormone,
which in turn slows the secretion by the target gland. This system results in stable blood
concentrations of the hormones that are regulated by the pituitary gland.
Hormone Pituitary Stimulating Hypothalamic Releasing
Hormone Hormone

 Thyroid Thyroid-stimulating Thyrotropin-releasing

hormones T4, T3 hormone (TSH) hormone (TRH)
 Cortisol Adrenocorticotropin Corticotropin-releasing factor
hormone (ACTH) (CRF)
 Estrogen or Follicle-stimulating Luteinizing hormone-releasing
testosterone hormone (FSH), luteinizing hormone (LHRH) or
hormone (LH) gonadotropin-releasing
hormone (GnRH)
 Insulin like Growth hormone Growth hormone-releasing
growth factor-I hormone (GHRH)

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

(IGF-I)

THE PANCREAS
The pancreas is a pinkish
white glandular organ found in
vertebrates near the stomach and
small intestine. The pancreas is the
second largest gland that is
connected to the digestive tract,
after the liver.
The pancreas is one of the
few organs that have both an
exocrine and an endocrine function.
Exocrine glands are glands that
secrete their products into ducts
(duct glands). Endocrine glands are
glands that secrete their product
directly into the blood rather than
through a duct. The pancreas'
exocrine function involves the
secretion of bicarbonate and
digestive enzymes into the small
intestine. Its endocrine function involves the regulation of blood sugar levels by secreting
the hormones insulin, glucagon, and somatostatin directly into the blood. The endocrine
portion of this organ consists of about 1 million islets of Langerhans, amounting to only 1-3
percent of the organ weight. The majorities of cells are exocrine and secrete one to three
liters of digestive fluid per day.
The pancreas is an important organ for digestion and the control of circulating
levels of glucose. This organ is an excellent example of an intricate, well-tuned organ that
functions in harmony with other parts of the body, providing a service to the body while
receiving the nutrients and removal of wastes necessary for its survival. For example, in
terms of its function in the digestive system, it
is one of several parts of the body that work
together, involving cooperative giving and
receiving, including the stomach, intestines,
liver, pancreas, heart, brain, and so forth.

Anatomy
In human beings, the pancreas is a 6-10
inch elongated organ weighing 65 to 160

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BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

grams and lying in the abdominal cavity. It lies posterior to the stomach, anterior to the
kidneys, and empties into the duodenum portion of the small intestine.
The human pancreas can be divided into five regions: (1) the head, which touches
the duodenum, (2) the body, which lies at the level of second lumbar vertebrae of the spine,
(3) the tail, which extends towards the spleen, (4) the uncinate process, and (5) the
pancreatic notch, which is formed at the bend of the head and 1: Head of pancreas
body. 2: Uncinate process of pancreas
3: Pancreatic notch
Blood Supply 4: Body of pancreas
5: Anterior surface of pancreas
The pancreas is supplied arterially by the pancreaticoduodenal 6: Inferior surface of pancreas
arteries: 7: Superior margin of pancreas
8: Anterior margin of pancreas
 the superior mesenteric artery feeds the inferior 9: Inferior margin of pancreas
10: Omental tuber
pancreaticoduodenal arteries 11: Tail of pancreas
• the gastroduodenal artery feeds the superior 12: Duodenum
pancreaticoduodenal artery

Nerve Supply
The pancreas receives neural innervation from the vagus (cranial X). This is part of the
autonomic parasympathetic supply. The role of the vagus is to stimulate secretion of the
pancreatic digestive juices.
Autonomic sympathetic nerves to the pancreas derive from the celiac ganglionic plexus, the
superior mesenteric plexus, and the hepatic plexus. These plexuses lie outside the pancreas
and send postganglionic fibers into the pancreatic cells. These sympathetic nerves inhibit
the production of digestive enzymes (Berne et al. 1996).
The innervation of the pancreas is comprised of both an intrinsic component that consists
of many intrapancreatic ganglia and an extrinsic component made of neurons lying outside
the digestive tract and belonging to the sympathetic and parasympathetic systems. Many
different neurotransmitters have been found within the pancreas including acetylcholine,
epinephrine, norepinephrine, serotonin, nitric oxide, and others (Salvioli et al. 2002).

Microscopic Anatomy
When the pancreas is sliced, stained, and then viewed with a microscope, it is easy to
distinguish many different types of cells that correspond to different pancreatic functions.
The microscopic appearance of the pancreas shows a series of islands (the Islets of
Langerhans) consisting of small cells packed closely together, surrounded by much larger
and less dense acinar cells. The islands have an endocrine function and the surrounding
cells have an exocrine function.
Appearance Region Function
 centralized islands endocrine pancreas secretes hormones that
(islets of regulate blood glucose

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

Langerhans) levels

 surrounding acinar exocrine pancreas produces enzymes and

cells bicarbonate

Endocrine Function

There are four main types of cells in the islets of Langerhans. They all look similar when
using standard staining techniques, but when special stains are used they can be classified

Name of cells Product % of islet cells Representative function

beta cells Insulin and Amylin 50-80% lower blood sugar
alpha cells Glucagon 15-20% raise blood sugar
delta cells Somatostatin 3-10% inhibit endocrine pancreas
gamma cells Pancreatic 1% inhibit exocrine pancreas
polypeptide
into four different types:

The islets are a compact collection of endocrine cells arranged in clusters and cords that
are crisscrossed by a dense network of capillaries. The capillaries are lined by layers of
endocrine cells in direct contact with them by either cytoplasmic processes or by direct
apposition. The cells release their hormones, without ducts, directly into the capillaries.

HORMONES PRODUCED BY THE PANCREAS

Insulin is a polypeptide containing two chains of amino acids joined together by two
disulfide bridges, and contains a total of 51 amino acids.
* helps to transport glucose into skeletal muscle and liver.
* is produced when blood sugar exceeds 50 mg/deciliter.
* has an average production of 1.0 to 2.5 mg/day.
* stimulates skeletal muscle and liver to convert glucose to a storage form called
glycogen.
* stimulates fat cells to synthesize fat.
* acts on the hypothalamus to reduce appetite.

Amylin is another polypeptide secreted by the beta cells. It is slightly smaller than insulin
with 37 amino acids. It works to supplement the actions of insulin.
* inhibits the secretion of glucagon.
* lowers the level of glucose in the blood.
* slows the emptying of the stomach into the intestine.

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BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

* sends a signal of satiety to the brain.

Glucagon is a polypeptide containing 29 amino acids.

* is released into the blood in response to a blood glucose level falling below 80
mg/deciliter
* acts primarily on the liver to stimulate glucose production by breaking down
glycogen and converting protein and fat into glucose
* secretion is inhibited by amylin (Bowen 2002).

Somatostatin
Purpose: Regulate the production and excretion of other endocrine tumors
Action: Slows down production of insulin, glucagon, gastrin, and other endocrine tumors
Secreted in response to: High levels of other endocrine hormones
Secretion inhibited by: Low levels of other endocrine hormones
Disease due to deficient action: Poorly defined
Disease due to excess action: Diabetes, gallstones, and dietary fat intolerance
Tumor called: Somatostatinoma

The endocrine function of the pancreas is to produce important hormones including insulin,
glucagon, and somatostatin and export them to the blood supply on demand.

Pancreatic polypeptide is secreted by the gamma cells and consists of 36 amino acids. It is
produced in response to chewing and swallowing food. It probably acts to reduce appetite
(Taylor et al. 1982).

Insulin
Insulin is a hormone that has profound effects on metabolism. Insulin causes cells in the
liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the
liver and muscle, and stopping use of fat as an energy source. When insulin is absent (or
low), glucose is not taken up by body cells, and the body begins to use fat as an energy
source, for example, by transfer of lipids from adipose tissue to the liver for mobilization as
an energy source. As its level is a central metabolic control mechanism, its status is also
used as a control signal to other body systems (such as amino acid uptake by body cells). In
addition, it has several other anabolic effects throughout the body.

When control of insulin levels fails, diabetes mellitus will result. Consequently insulin is
used medically to treat some forms of diabetes mellitus. Patients with Type 1 diabetes
mellitus depend on external insulin (most commonly injected subcutaneously) for their
survival because the hormone is no longer produced internally. Patients with Type 2
diabetes mellitus are insulin resistant, and because of such resistance, may suffer from a
relative insulin deficiency. Some patients with Type 2 diabetes may eventually require
insulin if other medications fail to control blood glucose levels adequately, though this is
somewhat uncommon.

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

Insulin also influences other body functions, such as vascular compliance and cognition.
Once insulin enters the human brain, it enhances learning and memory and in particular
benefits verbal memory.

Insulin is a peptide hormone composed of 51 amino acids and has a molecular weight of
5808 Da. It is produced in the islets of Langerhans in the pancreas. The name comes from
the Latin insula for "island". Insulin's structure varies slightly between species of animal.
Insulin from animal sources differs somewhat in 'strength' (in carbohydrate metabolism
control effects) in humans because of those variations. Porcine (pig) insulin is especially
close to the human version.

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

VI. PATHOPHYSIOLOGY

Modifiable Factors Non-Modifiable

 Diet Factors
 Sedentary  Age
Lifestyle  Gender
 Ethnicity

Dysfunction of the Decreased sensitivity

beta cells in the of the cells to insulin
pancreas

Production of Glucose is unable to

impaired insulin enter the cells

Desensitization of Glucose remains in

the liver and the blood stream
extremities to the
levels of blood
glucose

Continued release of
glucose by the liver

Hyperglycemia

Diabetes Mellitus
Type 2

Glucose Glucose Glucose intake Blood

Concentration Concentration of the cell viscosity
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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

Glucose in Osmotic Production of Blood

urine pressure in ATP pressure in
the blood the arterioles
Glucose
reabsorption Energy for
in the renal H2O move normal Bursting of
tubules from the cells cellular arterioles
towards the functions
Osmotic
blood
pressure
Formation of
Polyphagia scar tissue
Dehydration
H2O
reabsorption
Arteriosclerosis

Stimulation of
Urine output Nutrients can’t
osmoreceptors
get into the
retina Hardening of
Thirst the Glumerulus
Polyuria
Retinopathy
Polydispia
Glomerulosclerosis

Blurring of
vision Nepropathy

Renal related
complications

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

VII. LABORATORY RESULT AND DIAGNOSTIC RESULT

HEMATOLOGY (SEPTEMBER 14, 2023)

TEST RESULT NORMAL INTERPRETATION IMPLICATION

VALUES
Hemoglobin 139 g/L 135-180 g/L Normal Normal
Hematocrit 42 vol % 40-50 vol % Normal Normal
WBC count 7.6 x 10 5-10 x 10^ Normal Normal
9/L
RBC count 4.57 4.5-5.9 x Normal Normal

10^12/L

Differential Count
Lymphocytes 0.27 0.20-0.40 Normal Normal
Neutrophils 0.63 0.40-0.70 Normal Normal
Monocytes 0.06 0.00-0.06 Normal Normal
Eosinophils 0.04 0.00-0.07 Normal Normal
Basophils 0.00 0.00-0.01 Normal Normal
Bands/stabs
Immature
cells
Platelet count 235 x 10/L 150-450 X Normal Normal
10^9/L
NRBC
RBC Indices
MCV 92.0 fl 82.0-95.0fl Normal Normal
MCH 30.5 pg 27.0-31.0 pg Normal Normal
MCHC 331 g/L 320-360 g/L Normal Normal
RDW 12.5 % 11.6-14.6 % Normal Normal

FASTING BLOOD SUGAR

TEST RESULT NORMAL INTERPRETATION IMPLICATION

VALUES
Fasting Blood 8.2 mmol/L 4.18 - 5.6 Extremely high Hyperglycemia
Sugar
Glycosylated 6.7 % (49) 4.5 - 6.5 (26- Poorly controlled Prediabetes
Hemoglobin mmol/mol 48) diabetes
(HA1c)

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

URINALYSIS REPORT (SEPTEMBER 15, 2023)

PHYSICAL ANALYSIS MICROSCOPIC ANALYSIS

RESULT
Color Light yellow Epitheleal Cells /hpf
Transparency Clear Pus Cells /hpf
CHEMICAL ANALYSIS Red Blood Cells /hpf
ROUTINE Mucus Threads /hpf
Glucose Bacteria 1 /hpf
Protein Amorphous Urates
pH Amorphous
Phosphates
Specific gravity Uric Acid Crystals
SPECIAL
Glucose 4+ Course Granular
Casts
Protein Negative Fine Granular Casts /hpf
pH 6.5 Hyaline Casts
Specific Gravity 1.006 Pus Casts
Blood Negative Waxy Casts
Bilirubin Negative Others
Uroblinogen Normal
Ketone Negative
Nitrate Negative
Leukocytes Negative
Ascorbic Acid Negative

VIII. PHYSICAL ASSESSMENT AND ITS PHATOPHYSIOLOGICAL BASIS

General Appearance
Increased thirst and increased water consumption. Although his appetite has increased, his
weight at home has remained stable for some time. He disputes any signs of fatigue, fever,
chills, or night sweats.
Vital Signs:
BP 160/100
T 36.7
RR 20

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

SPo 96
PR 74
BODY PARTS TECHNIQUES FINDINGS INTERPRETATION
A. Skin Inspection -dry -due to old age
-light brown, -physiologic
wrinkled skin
-no rash,
pruritus, or
lesions.
B. Head Inspection -symmetrical -physiologic
-round -physiologic
Palpation -no tenderness, -normal
no masses

C. Hair Inspection -color white and -due to aging

black process
-scalp is no -normal
dandruff or
lesion

D. Eyes Inspection -anicteric sclera -normal

-symmetrical -normal
-has blurry vision -possibly due to DM
E. Pupil Inspection -equal round, -normal
brisk, reactive to
light
accommodation

F. Ears Inspection -earlobes are -normal

bean shape

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

-no lesions
-good hearing
ability
-no discharge or
foul smelling
discharge

G. Nose Inspection -shown no sign of -normal

DOB
-no masses, no
Palpation -normal
tenderness
-normal
-no olfactory
problems. N
-no nasal -normal
discharges noted.
H. Mouth

1. Lips Inspection -symmetrical, no -normal

ulceration
-dry with
- normal
symmetrical
contour

2. Tongue -tongue is moist -normal

-moves freely, -normal
non tender.

-no inflammation

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

3. Gums noted -normal

-no lesions - normal
I. Neck Inspection -symmetrical -normal
Palpation -no masses and -normal
lesions
J. Chest Inspection -no lesions -normal
present

K. Back Inspection -wrinkled skin -due to old age

Palpation
L. Abdomen Inspection -symmetrical -normal
M. Musculoskeletal Inspection -no joint or
muscle pain, no
sores or lesions
on feet.
N. Neurological Inspection -patient’s -normal
memory is intact.
-patient is
- normal
conscious and
has coherent,
spontaneous
speaking ability.
- normal
-patient is
oriented to
persons and
place.
-is responsive to - normal
both verbal and
non verbal
stimuli. - normal

-no paralysis was

noted in any of
patient’s body

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

parts. - normal
-patient was very
cooperative and
responsive
during the entire
assessment.
O. Psychiatric Inspection -no mood swings, - normal
depression, or
anxiety.
P. Genitourinary Inspection -increased - due to DM
urinary
frequency.
Q. Gastrointestinal Inspection -no abdominal
pain, nausea,
vomiting,
diarrhea.
-experiences
constipation

22
 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

IX.

23
 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

X. COURSE IN THE WARD

Date/
Purpose Doctor’s Order Diagnosis
Time
June 2, Request for Empagliflozin and DM II - Poorly controlled
2023 blood chem Linagliptin
(Glyxambi) 10mg
tab #90 (1
tab/day)

Rosuvastatin 10 .
mg tab (1 tab/day)

Date/
Purpose Doctor’s Order Diagnosis
Time
July10, Request for Empagliflozin and
2023 prescription Linagliptin
(Glyxambi) 10mg
tab #90 (1
tab/day)
Rosuvastatin 10 .
mg tab (1 tab/day)

Date/
Purpose Doctor’s Order Diagnosis
Time
September Request for Empagliflozin and
11, 2023 prescription Linagliptin
(Glyxambi) 10mg
tab #90 (1
tab/day)
Rosuvastatin 10 .
mg tab (1 tab/day)

24