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
Sodium
133
136-146 mmol/L
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
Urinalysis
pH 6.0
Specific gravity 1.010
Protein 1+
Glucose negative
Acetone negative
Occult blood negative
Bile negative
Waxy casts
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 No. 2
Case #2
The patient is a 54 year-old male with a history of coronary artery disease who was admitted to the hospital for
increasing lower extremity edema, abdominal swelling and shortness of breath. The patient had noted an ~30 pound
weight gain over the past month and during the past week has had three pillow orthopnea.
On physical exam the patient is a well-developed, well nourished male in moderate respiratory distress. Blood
pressure 140/80, pulse 95, respirations 28 and labored. Body weight 101 kg. HEENT was unremarkable. Cardiac
exam had an S1, S2 and S3 without S4 or murmur. Pulmonary exam was remarkable for bilateral rales 2/3rd up both
lung fields. Abdomen was enlarged with a positive fluid wave. Lower extremities were remarkable for 3+ pitting
edema.
Laboratory Data
June
Sodium
130
July 1
July 2
July 3
Normal Values
133
134
133
136-140 mmol/L
Potassium
4.9
5.7
5.8
6.0
3.5-5.3 mmol/l
Chloride
100
90
91
93
98-108 mmol/L
Total CO2
22
20
17
15
23-27 mmol/L
20
87
94
101
7-22 mg/dl
0.9
3.0
3.5
3.7
0.7-1.5 mg/dl
BUN
Creatinine
Renal ultrasound- Right kidney 10 x 5.5, Left kidney 10.5 x 6.0. Both kidneys demonstrate normal echogenicity and
are without masses or cysts. There is no hydronephrosis.
Urine analytes- (July 2nd) sodium 10 mmol/L
creatinine 130 mg/dl
Case No. 3
Case : A young mam sustained multiple injuries in a motorcycle accident .
He received blood transfusion and underwent , 24 h after admission he
had only passed 500 ml of urine . he was clinically dehydrated and his
blood pressure was 90/50 mmHg.
Investigations :
Serum : potassium= 5.6 mmol/L
Urea
= 21.0 mmol/L
Creatinine = 140 umol/L
Urine : Sodium = 5 mmo/L
Urea =
480 mmol/L
Case No.4
C.M. is a 27-year-old woman with type 1 diabetes diagnosed at age 14 when she presented with
diabetic ketoacidosis. Her initial insulin treatment was complicated by poor glycemic control,
frequent hypoglycemia, and weight gain.
Two years ago, she developed hypertension, which was treated with hydrochlorthiazide, 25 mg
daily. At that time, she was noted to have nonproliferative diabetic retinopathy. Blood urea
nitrogen (BUN) was 23 mg/dl, creatinine was 0.9 mg/dl, and dipstick urinalysis was negative for
protein.
She now presents with accelerated hypertension (172/108 mmHg) and pitting edema of the legs
to the level of the knees. Urinalysis reveals 3+ protein and 2+ blood. Urine microscopic analysis
reveals hyalin and red blood cell casts. BUN is 37 mg/dl; creatinine is 1.5 mg/dl; and 24-h urine
reveals 9.7 g of protein. Creatinine clearance is 58 ml/min. Total cholesterol is 279 mg/dl.
From the Presented Cases , Choose one and answer the following questions :
1.
2.
3.
4.
Comment on the laboratory data / values presented?
What is the present / existing condition of the patient . Justify your answer.
What other test you may recommend to confirm the diagnosis.
How are other test recommended helpful to confirm the diagnosis.
