CASE STUDY 4 Due W November 30, 2016 Directions: Please read the following scena

Question

CASE STUDY 4 Due W November 30, 2016

Directions:

Please read the following scenarios and answer the questions that accompany each. Use complete sentences when answering your questions. You will likely need to use your textbook, the class BB site, additional web sites, and your own analytical skills to answers these questions in full. Likewise, information found in resources other than your brain, should also not be copied word for word, but should be rephrased in your own word. Word for word copying in either case will count as plagiarism and no points will then be given for the assignment.

Please TYPE out your answers on a separate sheet of paper.

Case 1: 9 pts

Mr. B., a 35-year-old white male, was diagnosed with insulin-dependent diabetes mellitus (IDDM) at the age of 21. He has had significant renal impairment for about 5 years and has been on a hemodialysis program for about 1 year.

Past History:

Mr. B. has been on insulin since 21 years of age. He has never been treated for ketosis or diabetic coma. His current insulin regimen is Ultra Lente, 6 units every morning and 6 units every evening, with a sliding scale of regular insulin with each meal. He has been admitted to the hospital for evaluation of his renal function and work-up for kidney transplant.

Current Status:

      Mr. B. states that he has gained 15 pounds over the last 3 weeks and has noted edema in both legs, which has not been significantly improved by dialysis. Blood pressure has also been elevated, measuring about 170/110. He has noted symptoms of occasional blurred vision and increasing nosebleeds. Current medications include insulin, as above, and minoxidil, 10 mg every morning and 2.5 mg every night. He has no known allergies.
     His vital signs are as follows: blood pressure 190/104, heart rate 104, respirations 16, temperature 97.6° F. He has jugular venous distention without carotid bruits. Heart rhythm is regular with Il/VI systolic ejection murmur at the left sternal border, no rubs noted. He has 3+ pitting edema to his knees bilaterally. Lungs are clear to auscultation and percussion bilaterally. Respiratory excursion is symmetrical and adequate bilaterally. White blood cell count is 9600; hematocrit 31.3 ml, hemoglobin 11 g, mean corpuscular volume 88.3 um3, platelets 59,000/mm3. prothrombin time (PT) 9.9 sec., partial prothrombin time (PTT) 31 sec., potassium 5.2 rnEq/L, sodium 134 mEq/L, glucose 228 mg/dl, blood urea nitrogen 88 mg/dl, creatinine 8.1 mg/dl, albumin 3.1 g/dl, total protein 5.5 g/dl, phosphorus 7.4 mg/dl, cholesterol 441 mg/dl, LDH 1159 units, calcium 8.9 mEq/L, pH 7.32, Po2 68 mm Hg, PCO2 32 mm Hg, oxygen saturation 94%, bicarbonate 17 mEq/L. The urinalysis showed specific gravity of 1.009, protein 3+, blood 1+, white blood cells 5 to 6, and a few bacteria. Electrocardiogram showed a normal sinus rhythm, and chest roentgenogram indicated no acute cardiac or pulmonary pathology.

1.Does Mr. B have an acid/base imbalance? If so, which one and is it compensated or uncompensated? Why has he developed this?

2.What might be contributing to Mr. B’s hypertension?

3.What is creatinine? Why is the measurement of creatinine clearance used to estimate glomerular filtration rate (GFR)?

4.Why is the patient anemic?

5.What is uremia? What are the symptoms of uremia?

6.What is azotemia? Has azotemia occurred in this patient? Support your answer.

Case #2: Case History – 6 pts

A 26-year-old woman is in the clinic today for evaluation of weight gain and fatigue. She is 5 feet 6 inches and weighs 175 pounds. Prior to her pregnancy, she weighed 130 pounds and her maximum weight during pregnancy was 155 pounds. She is now 18 months postpartum and continuing to gain weight despite no change in diet or activity. She reports that the fatigue is getting worse even though her daughter is sleeping reliably through the night and the patient feels she is getting plenty of rest. She takes no other medications and has no significant medical history. Her vital signs today are HR 68, BP 108/60, RR 10, temperature 97° F. The nurse practitioner orders a CBC, TSH, and T4.

1.What sources of fatigue is the nurse practitioner evaluating with the CBC, T4, and TSH?

2.What other history or clinical findings would be indicative of hypothyroidism?

3.The patient’s laboratory values show an elevated TSH and a low T4. What does this mean?

4.After starting the patient on thyroid hormone replacement, the nurse practitioner asks the patient to return in 8 weeks to check her TSH level. What is the purpose of this test? What should be done if the test result is abnormal?

Explanation / Answer

CASE # 1

3. Creatinine is a waste product from the normal breakdown of muscle tissue. As creatinine is produced, it's filtered through the kidneysand excreted in urine. Doctors measure the blood creatininelevel as a test of kidney function. The kidneys' ability to handle creatinine is called the creatinine clearance rate, which helps to estimate the glomerular filtration rate (GFR) -- the rate of blood flow through the kidneys.

4. The patient is anemic because of undergoing dialysis and increasing nosebleeds

5. Uremia (uremic syndrome) is a serious complication of chronic kidney disease and acute kidney injury (which used to be known as acute renal failure). It occurs when urea and other waste products build up in the body because the kidneys are unable to eliminate them. These substances can become poisonous (toxic) to the body if they reach high levels.

Uremic syndrome may affect any part of the body and can cause-

6. Diagnosing azotemia is usually done with a simple blood or urine test. The doctor will test the blood for markers of kidney function, including blood creatinine and blood urea nitrogen (BUN). These are both substances that the kidney filters out. If there are high levels of either or both of these substances in the blood, it indicates that the kidneys are not working well.

Azotemia has occurred in this patient because the blood results show blood urea nitrogen- 88 mg/dl, creatinine -8.1 mg/dl

CASE # 2

1. Fatigue can be due to various reasons and therefore the Nurse Practitioner want to confirm by testing CBC, T4, and TSH. Nurse practitoner may suggest a complete blood count if you're experiencing weakness, fatigue, fever, inflammation, bruising or bleeding. T4 and TSH is done to diagnosed if the patient is suffering from hypothyroidysm which may be the cause of the fatigue.

2. Other history or clinical findings would be indicative of hypothyroidism include

3. The patient’s laboratory values show an elevated TSH and a low T4 it indicates that the patient is suffering from hypothyroidysm

4. Standard treatment for hypothyroidism involves daily use of the synthetic thyroid hormone levothyroxine (Levothroid, Synthroid, others). This oral medication restores adequate hormone levels, reversing the signs and symptoms of hypothyroidism.

One to two weeks after starting treatment, you'll notice that you're feeling less fatigued. The medication also gradually lowers cholesterol levels elevated by the disease and may reverse any weight gain. Treatment with levothyroxine is usually lifelong, but because the dosage you need may change, your doctor is likely to check your TSH level every year.

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