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 all renal tumors. Renal cell carcinoma is more common in men than women with about 60% of cases occurring in men and about 40% in women. Most cases of renal cell carcinoma occur in adults between 50 to 70 years of age. It is a type of kidney tumor characterized by the development of finger-like projections in at least some of the tumor. Coronary heart disease is the leading cause of death in the United States affecting more than 13 million Americans. Coronary artery disease is a condition in which the coronary artery, the blood vessel supplying oxygenated blood to the heart, becomes clogged with plaque build-up.Without adequate blood flow from the coronary arteries, the heart becomes starved of oxygen and vital nutrients it needs to work properly.

Hypertensive cardiovascular disease also known as hypertensive heart disease occurs due to the complication of hypertension or high blood pressure. In this condition the workload of the heart is increased manifold and with time this causes the heart muscles to thicken. The heart continues pumping blood against this increased pressure and over a period of time the left ventricle of the heart enlarges 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 , Cebu who was admitted for a scheduled operation last March 1, 2011. The patient was admitted on March 1, 2011 at Perpetual Succour Hospital accompanied by his family. He was ambulatory with vital signs of 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.

The group has chosen this case because they found it interesting to deal with a case on renal disease and they found it as a good avenue for learning more about the renal system. Some members of the group were able to assist the patient in his scheduled operation and he was under the group s care in his short stay in the medical intensive care unit. Though the group wasn t anticipating for the case to be diagnosed as carcinoma, still, they consider it as an opportunity to learn in advance 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, urinary system, integumentary system and cardiovascular system; Determine the current health status of the patient through thorough physical assessment, laboratory examinations and as well as diagnostic procedures of which the patient has undergone; Properly trace the pathogenesis of the disease processes starting from the precipitating and predisposing etiologic factors that cause the disease of the patient; Relate concepts and theories with the actual data gathered from the patient;

 Develop an effective and efficient nursing care plan pre-, inta-, and post-operatively, including the primary caregiver s participation that could help the patient in recovering fast, enhance the well-being of the patient and prevent post-operative complications; Rationalize all medical, surgical and nursing actions applied to the patient; Evaluate on the effectiveness of the interventions including the medical and nursing care managements rendered to the patient; Develop an effective and efficient discharge planning instructions for the primary caregiver to practice directly towards enhancement of the patient s health and sense of well-being.

SCOPE AND LIMITATIONS

This clinical paper contains information related to the care and condition of the patient. This paper also includes review of systems (pre-,intra-, and post-operatively), laboratory results with their corresponding interpretations, background of the normal anatomy and physiology of the affected part, the pathophysiology of the disease, and different surgical, medical, pharmacologic and nursing managements rendered to the patient and from the moment the patient is wheeled in to the Operating Room until the time he was wheeled out to the Surgical Intensive Care Unit, to the Medical Intensive 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 in Perpetual Succour Hospital, which includes 6 days of clinical duty in the operating Room and Medical Intensive Care Unit by the group. The group was only able to be in contact with the patient for 1 day, after which, the patient was already transferred in the ward. We only get to visit our patient after our clinical duty in our respective areas. In the process of making this clinical paper, the group encountered some limitations which are the following: Limited available resources, such as accessible internet stations.

PATIENT S 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 Electric Cooperative, 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 sa akong 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 signs of 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 was admitted due to urinary calculi in one of the hospitals in Bohol. It lasted for one week but he couldn t remember the exact date and location of the said hospitalization. He also forgot the name of his attending physician that time. The patient stated that the illness was resolved.

His second hospitalization was on November 6, 2010 due to Coronary artery disease at Perpetual Soccour Hospital and he had undergone Coronary Artery Bypass Graft. It started last October 2010, when the patient was washing his car and doing his activities of daily living, he experienced dyspnea, excessive perspiration and numbness of the upper extremities. According to him, the pain originated from the back radiating to his chest. He called his family doctor and narrated the said event. His doctor advised him to take Imdur tablet and have himself admitted at Perpetual Soccour Hospital. The patient rated the pain as 9 in a pain scale of 10 with 0 as the lowest and 10 as the highest. The patient underwent Coronary Angiogram and found out that he has Coronary Artery Disease. He underwent Coronary Artery Bypass Graft on November 6, 2010.

His third hospitalization was last 2010. Last 2008, patient experienced painless hematuria. There were no specific interventions done and he found relief from drinking more fluids. He wasndt able to consult a physician. On September 2010, prior to admission, the patientds condition started as an onset of left flank pain associated with hematuria with the pain rated as 10 in a pain scale of 0 as no pain and 10 as the most painful. There was no fever noted. He had ultrasound done which showed renal masses. CT scan was done with the same finding. Patient was advised for 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 tab OD * patient stated that he compliantly take these medication Recent Travel: No recent travel outside Cebu City

FAMILY HISTORY

Interpretation: Patient s grandmother in his mother side died of a kidney problem and his grandfather died of an unknown cause while his grandparents in his father side has a chronic illness of hypertension. Patient s mother was hypertensive and his father died of an accident. Patient may inherit his illness such as renal papillary carcinoma and hypertension from his parents and grandparents. Also, his younger brother died of a kidney problem.

FUNCTIONAL HEALTH PATTERN

LIFESTYLE Personal Habits Does not engage in any vices or use recreational drugs. 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 only during weekends, the patient cooks for the family. He loves cooking humba, adobo,lechong paksiw and the like. Rarely eats vegetables and fish. He usually drinks soda every after meal. The patient takes his breakfast with 1 cup of coffee every day. After his CABG, he minimized eating meat and preferred to eat vegetables and fish and drinks milk instead of coffee. Patientds weight decreased from 97 kgs before his heart surgery to 81 kgs in the present. He has large body built.

Sleep and Rest Pattern: Sleeps well 8 to 9 hours at night and has good sleeping habits. Does not have difficulty getting sleep. Able to get adequate rest and sometimes falls asleep while watching television. Activity and Exercise: Work does not require vigorous physical activity. Does walking as his way of exercise during vacant periods. After the operation on his heart, the patient had underwent rehab in Perpetual Succour Hospital for about 2 weeks.

Typical day: Arises at 5 am. Eats his breakfast before going to work. They have housekeepers doing 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 stays at home to take a rest and as advised by his physician.

Recreation, Pets and Hobbies: Enjoys teaching and singing religious songs in their own parish every Sunday. Likes to watch news and sports during leisure time and loves taking care of his grandchildren. Has 21 cats as pets and are well taken care of.

SOCIAL PATTERN Roles 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 Roman Catholic and an active choir member in their parish. Goes to mass together with his family every Sunday and usually they sponsor the mass. No specific cultural influence that affects patient's health care.

Occupational Health Pattern: Works as a general manager in an electric cooperative and states that 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 is near to their perspective parish church and school. It has a far distance to the market and place 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 son was a smoker.Drives his own car in going to work 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 responds appropriately with appropriate affect and facial expression. Patterns of healthcare financing: Has PhilHealth as 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 (8:10am11:41) POST- OPERATIVE PHASE March 4 ,2011 (10:00pm-6:00am)

General Survey

Awake and oriented Sedated and to time, place, unconscious person and event

Awake, irritable, restless and oriented to time, place, person, and event

Informed consent for the procedure was duly signed by the patient Pre-operative medications given by the nurse on duty In a supine position In a right lateral position

In a semi-fowler s position

LABORATORY EXAMINATION
Pre-Operative Laboratory Results Urinalysis Definition and purpose Urinalysis 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.

Table 2: Macroscopic
Component Results February 02, 2011 @ 8:46 AM Amber Cloudy Negative ++ 6.0 1.020 Negative Negative Negative Negative ++ +++ Results February 17, 2011 11:45:59 AM Amber Cloudy Negative +2 6.0 1.015 Negative Negative Negative Negative ++ +++ Normal Characteristic Amber Yellow Significance

Color Appearance Glucose Protein pH Specific Gravity Bilirubin Urobilinogen Urine Ketone Nitrite Leukocytes Blood

Normal Abnormal Normal Abnormal Normal Normal Normal Normal Normal Normal Abnormal Abnormal

Clear/transparent Negative Negative 4.0-8.0 1.003-1.030 Negative Negative Negative Negative Negative Negative

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 an increased permeability thus resulting in the escape of large molecules.

CHAPTER III: LITERATURE REVIEW ANATOMY AND PHYSIOLOGY

Figure 6: The cell and its structure