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Case Study 4: A&P 2 5 points 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. 1. “Presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis”: what do these symptoms suggest to you? 2. What does “HEENT was remarkable for funduscopic findings of A-V nicking and copper wire changes consistent with hypertensive injury” mean? (Hint: how would you explain this in layman’s terms?) 3. What does S4 signify? What cardiac findings will you expect to find in a hypertensive? 4. What are the possibilities for his 2+ lower extremity edema? 5. What is the significance of the finding “superficial excoriations of his skin from scratching.”? 6. Why was a renal ultrasound ordered? What information can you gather from renal ultrasound studies? 7. After reviewing his renal ultrasound, is his kidney size normal? What is the normal size of a kidney? What does small or large kidney signify? 8. What is the significance of the report “Both kidneys illustrate hyperechogenicity”? What does this mean, and how does evaluation of echogencity help in the diagnosis? 9. What evidence in renal ultrasound, will suggest obstruction? 10. Is the cause of this patient’s renal failure acute or chronic? How did you arrive at that conclusion? 11. Is his 24 hour urine collection adequate? 12. 18. Why is the parathyroid hormone elevated? 13. What is the most likely cause of this patient’s anemia? 14. What is the most likely diagnosis for his renal disease? How did you arrive at that conclusion?
SCIENCE
HEALTH SCIENCE
NURSING

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