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Case 1 45-year-old Mrs. Rodriguez is complaining of intermittent mild bilateral feet/ankle swelling for the past 2 months, but it is worse on her right leg. She denies leg pain, but she does describe her legs as feeling heavy at times and reports standing for long periods worsens the swelling. She notes her veins are getting larger in her legs. For the past 8 months, she has been experiencing intermittent numbness in her feet and reports her left knee has been achy. She is a server at a busy restaurant and sometimes works 10-hour days. She denies any fever, warmth, erythema, or trauma. Past medical history: obesity (BMI 31); type 2 diabetes mellitus. Medications: metformin. Physical examination: vital signs are within normal limits; exam is unremarkable except for bilateral tortuous veins in both lower extremities, which are worse on the right leg, and decreased sensation in both feet. Note: Assume history and examination is within normal limits if not listed. Activity 1.Identify the probable diagnosis and what data support your decision. 2.Describe the pathogenesis for the diagnosis. 3.What data are inconsistent with your diagnosis? 4.What diagnostic tests would you order, if any, and how would you treat this patient? Case 2 68-year-old Mr. Quincy is complaining of left leg swelling for the past 2 weeks. The swelling started while he was on a cruise. The swelling is intermittent and below the knee to his foot. He describes a cramplike pain in his left calf. Lately, both legs have been cramping while walking, but it resolves when he sits. He denies any fever, warmth, erythema, or trauma. Past medical history: iliofemoral deep vein thrombosis of his left leg after he had left hip replacement for osteoarthritis 9 months ago; treated with rivaroxaban for 6 months; stable angina; obesity (BMI 31); dyslipidemia. Social history: quit smoking 4 years ago but resumed one-fourth pack per day 1 year ago. Medications: simvastatin; aspirin; metoprolol. Note: Assume history and examination is within normal limits if not listed. Physical examination: vital signs are within normal limits; right leg is within normal limits except hairless, shiny skin; left leg has 1+ pitting edema in the pretibial area and foot; mild pain with left calf compression and one small tortuous vein on the medial aspect of his calf; left leg is also hairless and shiny. A venous duplex Doppler ultrasound of his left leg was done and reveals no deep vein thrombosis. Activity 1.Identify the probable diagnosis and what data support your decision. 2.Describe the pathogenesis for the diagnosis. 3.What data are inconsistent with your diagnosis? 4.What diagnostic tests would you order, if any, and how would you treat this patient? Part 2: Students are to complete Part 2 A 70-year-old woman was recently treated for pneumonia with antibiotics. After 1 week on antibiotics, she started developing severe diarrhea of 6–7 loose, watery stools per day. The diarrhea has been present for 3 days. She also has a decreased appetite, feels nauseous, and has not been drinking a lot of fluids. She feels very weak and dizzy. She lives alone, so she called 911 and was brought to the emergency department. She is diagnosed with diarrhea, presumptive Clostridium difficile. Patient medical history: Clostridium difficile 2 years prior. Physical examination: temperature 99.0°F; pulse 100 beats per minute; respirations 24 per minute; and blood pressure 90/50 mmHg, which dropped to 70/40 mmHg when seated. Examination unremarkable except for dry mucous membranes and generalized mild abdominal tenderness with palpation. Laboratory findings reveal: Chemistry panel: sodium 135 mEq/L; potassium 3.4 mEq/L; chloride 100 mmol/L; HCO3- 12 mEq/L; blood urea nitrogen 40 mg/dL. Creatinine: 1.2 mg/dL. ABG: pH 7.22, PaO2 85 mmHg, PaCO2 20 mmHg, HCO3- 12 mEq/L. Activity 1.Analyze the ABG and determine the acid–base disturbance. 2.Calculate the compensation response and determine if it is appropriate. 3.This item is optional. Calculate and interpret the anion gap. 4.Discuss the diagnosis. 5.Develop a treatment plan. Part 3 A 50-year-old woman presented complaining of burning sensation when urinating and feeling like she has to go every hour for the last day. She denies fever and suprapubic or back pain. Past medical history: dyslipidemia and hypertension. Medications: atorvastatin. Allergies: sulfa. Physical examination: temperature 98.5°F; pulse 80 beats per minute; respirations 18 per minute; blood pressure 110/66 mmHg; examination unremarkable; no suprapubic or costovertebral angle tenderness; urine dipstick reveals moderate leukocytes and positive nitrites, with all other values within normal limits. 1.What is the most likely diagnosis and pathogen causing this disorder and mode of transmission? Discuss data that support your decision. 2.What diagnostic test, if any, should be done? 3.What are diagnostic test findings would support your diagnosis? 4.Develop a treatment plan for this patient. An 8-year-old Black girl is complaining of burning when urinating for the past day. She reports wetting herself at school because she was unable to hold it until she was able to get to the bathroom. When she toileted, she voided only small amounts. She denies fever, back, or suprapubic pain. The child is accompanied by her mother. No past medical history or medications. Allergies: penicillin (hives). Vaccines: up to date. Physical examination: vital signs and examination are within normal limits. Urine dipstick: positive for leukocytes, nitrites, and blood. 1.Discuss most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies. Part 4: Complete A 13-year-old boy presented to the clinic complaining of a sore throat that persisted for 2 days. After those 2 days, he developed fever, nausea, and malaise. A throat culture revealed the presence of group A beta-hemolytic streptococci, and the child was started on antibiotic therapy. The child’s symptoms gradually improved, but approximately 2 weeks later, he returned to the clinic because the fever, nausea, and malaise returned. He became tachypneic and short of breath. The mother noted that his eyes were puffy, his ankles were swollen, and his urine was dark and cloudy. On examination, the child’s blood pressure was 148/100 mmHg; his pulse 122 beats per minute; and his respirations were 35 per minute. Orbital and ankle edema were present. Crackles were auscultated bilaterally. No heart murmurs were found. Slight tenderness to percussion over the flank areas was noted. A chest X-ray showed evidence of congestion and edema in the lungs. The patient’s hematocrit was 37%, and his WBC count was 11,200/mm3. Blood urea nitrogen was 48 mg/dL (normal is less than 20 mg/dL). Urinalysis results showed that the patient’s protein was 2+ (24-hour excretion was 0.8 g), specific gravity was 1.012, and there were moderate amounts of RBCs and WBCs in the urine. Serum albumin was 4.1 g/dL (normal is 3.5–4.5). 1.Which evidence supports the conclusion that this patient has a kidney disease? 2.Which clinical pattern of kidney disease does this patient have? Explain the symptoms. 3.Which morphologic changes would you expect in the kidney? 4.What is the prognosis? 5.What are the possible short- and long-term complications of this disease? 6.Is it necessary to hospitalize the patient?
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