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Case Analysis Group 1
Case Analysis Group 1
Angeles City
Case Analysis
Group 1
BSMT 3A
January 7, 2010
CASE 2
From a rural hospital in Barangay Ilang-Ilang, this 71-year old woman was
transferred to a tertiary hospital complaining of shortness of breath and showing
evidence of pulmonary edema. There was no history of chest pains, nausea,
vomiting or diaphoresis. Her admission diagnosis was Congestive Heart failure
(acute exacerbation), Myocardial Infarction (subendocardial), DM and HTN.
Medications included Lasix, morphine, nitroglycerin, and Procardia. Laboratory
tests were significant for increased CK, 544 U/L (21-215) with a CKMB of 29.2
ng/mL (0-4), which is a relative index of 54. During the first few days of her
hospital stay, blood glucose ranged from 201 to 365 mg/dL (70-110); creatinine
ranged from 1.9 to 3.7 mg/dL (0.6-1.0); and BUN ranged from 31 to 46 mg/dL (5-25).
Admission urinalysis was significant for: glucose 100 mg/dL; blood moderate;
protein >300 mg/dL (<90); WBCs 2-5/hpf; RBCs 10-20/hpf; epithelials/lpf few
squamous, few renal; casts/lpf 5-10 granular, 0-1 WBC. After aggressive
treatment of the she received intravenous nitroglycerin and insulin. The
discharge diagnosis was status postsubendocardial MI, triple-vessel cardiac
disease, CHF, renal insufficiency, HTN, and DM. She was scheduled to return to
the hospital eventually for a triple vessel coronary bypass. What renal condition
do the urinalysis data suggest? Explain. Do the analyses on blood correlate with
this? Explain. What is the pathophysiology behind the renal condition in the first
question? Explain.
Gender: Female
Age: 71
Symptoms:
Shortness of breath
Pulmonary edema
Diagnosis:
Medications:
Lasix – CHF
Morphine –pain killer
Nitroglycerin –vasodilator
Procardia –antiaginal, antihypertensive
Insulin –DM
Urinalysis Results:
Chemical:
Glucose: 100mg/dl
Blood (moderate)
Protein- >300 mg/dL (<90)
Microscopic:
RBC 10-20/hpf
WBC 2-5/hpfb
Epithelial. Cells (few)
Renal Cell (few)
Granular Cast (5-10/lpf)
Leukocyte Casts (0-1/lpf)
Patient Diagnosis:
Chronic Glomerulonephritis
Terminologies
What renal condition do the urinalysis data suggest? Explain. Do the analyses
on blood correlate with this? Explain. What is the pathophysiology behind the
renal condition in the first question? Explain.
Tests show protein, blood cells, and kidney cells in the urine, while
a high concentration of the body's waste products of metabolism
(such as urea and creatinine) may be found in the blood.
Attending Physician: Does your mother suffered from any chest pains?
Daughter: No.
AP: Nausea…vomiting?
Daughter: No, what she always complains about is her having shortness of breath
AP: From what we have of your mother’s previous record in Ilang-Ilang Rural hospital,
she’s been showing evidence of pulmonary edema. But we need series of tests to confirm
it and to know exactly the reason why your mother is here. Don’t worry iha, your mother
will be fine.
(exit….)
Scene 2: (this scene should portray a medtech asking the sample specimen needed for the
lab) Remember: Proper identification of the medtech and the patient should be evident.
Medtech: Goodmorning maam! I’m ________________, the medtech in charge for this
particular sample collection. I’m here to collect a urine sample from the patient. Are
you ____________________ (patient’s complete name w/ middle name)
Patient: yes, I am.
Daughter: They need your urine sample again.
Mother: But I don’t need to pee right now. It’s hard for me nowadays…
MT: Sorry for the inconvenience maam, but we have already a solution for that.
(showing a geriatric bag or “wee-wee” bag). For this you will pee as you like and it
would be just fine.
Daughter: would it be good for her?
MT: It would be very convenient. I’ll be back in time..(exits..)
All are types of immune mechanisms which contributes to glomerular injury except:
a. Deposition of circulating soluble antigen-antibody complexes
b. Formation of antibodies specific against the glomerular basement membrane
c. Streptococcal release of neuramidase, which alters IgG with binding of anti-IgG
to the glomerulus.
d. none of the above
Reduction in nephron mass from the initial injury reduces the GFR then leads to:
a. hypertrophy
b. hyperfiltration of the remaining nephrons
c. both a and b
d. none of the above
The most significant and the only one that can be found in a cast:
a. WBC
b. RBC
c. Renal epithelial
d. Squamous epithelial
Chronic glomerulonephritis
Damage to the glomeruli affects the kidney's ability to filter fluids and wastes properly.
This leads to blood and protein in the urine.
This condition may develop after survival of the acute phase of rapidly progressive
glomerulonephritis. In about one-quarter of people with chronic glomerulonephritis there
is no prior history of kidney disease, and the disorder first appears as chronic kidney
failure.
Glomerulonephritis is among the leading causes of chronic kidney failure and end stage
kidney disease. Causes include:
* Diabetic nephropathy/sclerosis
* Focal segmental glomerulosclerosis
* IgA nephropathy (Berger's disease)
* Lupus nephritis
* Membranous glomerulonephritis
* Mesangial proliferative disorder
* Nephritis associated with disorders such as amyloidosis, multiple myeloma, or
immune disorders, including AIDS
Symptoms:
This condition causes high blood pressure (hypertension) and chronic kidney failure.
Chronic kidney failure symptoms that gradually develop may include the following:
* Decreased alertness
o Drowsiness, somnolence, lethargy
o Confusion, delirium
o Coma
* Decreased sensation in the hands, feet, or other areas
* Decreased urine output
* Easy bruising or bleeding
* Fatigue
* Frequent hiccups
* General ill feeling (malaise)
* Generalized itching
* Headache
* Increased skin pigmentation -- skin may appear yellow or brown
* Muscle cramps
* Muscle twitching
* Nausea and vomiting
* Need to urinate at night
* Seizures
* Unintentional weight loss
Additional symptoms that may be associated with this disease:
Because symptoms develop gradually, the disorder may be discovered when there is an
abnormal urinalysis during a routine physical or during an examination for another,
unrelated disorder. It may be discovered as a cause of high blood pressure that is
difficult to control.
Laboratory tests may reveal anemia or show signs of reduced kidney functioning,
including azotemia. Later, signs of chronic kidney failure may be apparent, including
edema .
* Chest x-ray
* Kidney or abdominal CT scan
* Kidney or abdominal ultrasound
* IVP
* Urinalysis
A kidney biopsy may show one of the forms of chronic glomerulonephritis or scarring of
the glomeruli.
This disease may also alter the results of the following tests:
* Albumin
* Abdominal MRI
* Anti-glomerular basement membrane
* BUN
* Complement component 3
* Complement
* Creatinine clearance
* Renal scan
* Total protein
* Uric acid, urine
* Urine concentration test
* Urine creatinine
* Urine RBC
* Urine specific gravity
* Urine protein
Treatment:
Treatment varies depending on the cause of the disorder, and the type and severity of
symptoms. The primary treatment goal is control of symptoms. High blood pressure may
be difficult to control, and it is generally the most important aspect of treatment. Various
medications may be used to attempt to control high blood pressure.
Dietary restrictions on salt, fluids, protein, and other substances may be recommended
to help control of high blood pressure or kidney failure.
The outcome varies depending on the cause. Some types of glomerulonephritis may get
better on their own.
If nephrotic syndrome is present and can be controlled, other symptoms may be
controlled. If nephrotic syndrome is present and cannot be controlled, end-stage kidney
disease is likely.
* Nephrotic syndrome
* Acute nephritic syndrome
* Chronic renal failure
* End-stage renal disease
* Hypertension
* Malignant hypertension
* Fluid overload -- congestive heart failure, pulmonary edema
* Chronic or recurrent urinary tract infection
* Increased susceptibility to other infections