Case #1
The patient is a 41 year-old male who has a longstanding history of hypertension and diabetes and presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis. He denies any other medical illnesses.
On physical exam the patient is a well-developed, well-nourished male in moderate distress. Blood pressure 180/110, pulse 80, respirations 24 and he was afebrile. Body weight 76.5 kg. HEENT was remarkable for fundoscopic findings of A-V nicking and copper wire changes consistent with hypertensive injury. Cardiac exam had an S1, S2 and S4. The remainder of the exam was remarkable for 2+ lower extremity edema and superficial excoriations of his skin from scratching.
Laboratory Data
|
Chemistry |
Normal Values | Urinalysis | |
|
Sodium |
133 | 136-146 mmol/L | pH 6.0 Specific gravity 1.010 Protein 1+ Glucose negative Acetone negative Occult blood negative Bile negative Waxy casts
|
|
Potassium |
6.2 | 3.5-5.3 mmol/L | |
| Chloride | 100 | 98-108 mmol/L | |
| Total CO2 | 15 | 23-27 mmol/L | |
|
BUN |
170 | 7-22 mg/dl | |
|
Creatinine |
16.0 | 0.7-1.5 mg/dl | |
| Glucose | 108 | 70-110 mg/dl | |
| Calcium | 7.2 | 8.9-10.3 mg/dl | |
| Phosphorus | 10.5 | 2.6-6.4 mg/dl | |
| Alkaline Phosphatase | 306 | 30-110 IU/L | |
|
Parathyroid Hormone |
895 | 10-65 pg/ml | |
|
Hemoglobin |
8.6 | 14-17 gm/dl | |
| Hematocrit | 27.4 | 40-54 % | |
|
Mean cell volume |
88 | 85-95 FL |
24-hour urine protein and creatinine - volume 850 ml, protein
600 mg/dl and creatinine 180 mg/dl
Renal ultrasound- Right kidney 9 x 6.0 cm,
Left kidney 9.2 x 5.8 cm
Both kidneys illustrate hyperechogenicity and
no hydronephrosis.
Case #1 Questions
1. "presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis." what does the symptoms suggest to you? Answer
2. What are the fundus changes in a hypertensive? Answer
3. What are the fundus changes of a diabetic? Answer
4. What does S4 signify? What cardiac findings will you expect to find in a hypertensive? Answer
5. What are the possibilities for his 2+ lower extremity edema? Answer
6. What is the significance of the finding " superficial excoriations of his skin from scratching." ? Answer
7. Why was a renal ultrasound ordered? What information can you gather from renal ultrasound studies? Answer
8 .How does the results of the renal ultrasound influence your thinking on the diagnosis? What is the normal size of the kidney? Is his kidney size normal? What does small or large kidney signify? Answer
9. What is the significance of the report "Both kidneys illustrate hyperechogenicity" How does evaluation of echogencity help in the diagnosis? Answer
10. What evidence in renal ultrasound, will suggest obstruction? Answer
11. Is the cause of this patient’s renal failure acute or chronic? How did you arrive at that conclusion? Answer
12. What is the calculated GFR? Answer
13. What would be the calculated GFR in this case, if the patient was female? Answer
14. What is the 24 hour urine protein excretion in this patient? Answer
15. Is this 24 hour urine collection adequate? How did you arrive at that conclusion? Answer
16. How is a 24 hour urine to be collected and when is it appropriate to order this test? Answer
17. What is the measured GFR in this patient? Answer
18. Why is the parathyroid hormone elevated? Answer
19. What is the most likely cause of this patient’s anemia? Answer
20. Should this patient be started on dialysis? What are the indications for dialysis? Answer
21.What is the most likely diagnosis for his renal disease? How did you arrive at that conclusion? Answer
22. What are the most likely histological findings on renal biopsy in this patient? Answer
23. Could his renal failure be due to hypertension? What evidence you will need to implicate hypertension as the cause for his renal failure? Answer
24. If you were to place this patient on a 2 gram sodium diet how many milliequivalents of sodium would this diet contain? Answer
25. How many grams of sodium chloride would this be? Answer