In-Depth Knowledge of a Discipline or Content Area
Geriatric Case Study
Situation
An 83-year-old female presented to the outpatient clinic, having developed tiredness over the past four months, increasing in character, with loss of appetite and constant nausea. Consequently, she has also lost almost 6 kg in weight over the said period. Moreover, she has had itching all over her body and cramps for five weeks. She is a known hypertensive patient diagnosed ten years before admission and has been on antihypertensive medication with reported compliance.
Background
An 83-year-old patient who is a known hypertensive and still on antihypertensive medication presents with new complaints of increasing tiredness, anorexia, and nausea. The patient also reports having had a prior history of a cerebrovascular accident, which consequently affected her ability to move around. She is a Caucasian female who lives with her two daughters at their home in North Carolina. Other than hypertension and stroke, she has no other significant medical and surgical history, and she reports having been healthy for most of her lifetime. Her husband succumbed to colorectal cancer in 2009.
Assessment
On general examination, the patient is in a fairly good condition. However, she has pale conjunctivae. She is not in any form of pain. Her vital signs are as follows: temperature 37.2 degrees Celsius, blood pressure of 184/106 mmHg, respiratory rate of 22 breaths per minute with nasal flaring, and oxygen saturation of 97% on room air. Her pulse rate is 82 beats per minute and regular. Examination of the respiratory and cardiovascular systems yields no significant abnormal findings. The abdomen is also normal on inspection, superficial and deep palpation; it is not tender, and there are no masses felt on palpation. The bowel sounds are present and normal. The abdomen is moving rapidly and symmetrically with respiration. Upon neurological examination, there is a right upper motor neuron palsy of the facial nerve. The right arm and leg are both hyper-reflexive and have a mild weakness, rendering the patient unable to walk without support. A funduscopy done on the patient reveals that the arteries have increased tortuosity. There is also arteriovenous nipping.
Several other investigations are done on the patient. A complete blood count reveals a decreased hemoglobin level but with normal white cell count with differential. Kidney function tests show increased urea and creatinine levels. Urine analysis demonstrates the presence of blood and protein in the urine. A peripheral blood film indicates normochromic normocytic anemia.
Differentials with pertinent positives and negatives
This patient’s symptoms, i.e., nausea, anorexia, weight loss, increasing tiredness (fatigue), itching (pruritus), and cramps, are characteristic and typical of end-stage renal failure. It is, however, not easy to tell whether the suspected renal failure is acute or chronic. Both acute and chronic renal failure present with elevated urea and creatinine levels, making it hard to distinguish between the two conditions.
Recommendation
It is essential to do a renal ultrasound on this patient to tell the kidneys’ size accurately and identify obvious or underlying causes for renal failure. Long-standing renal failure is demonstrated with kidneys that are reduced in size and echogenic. The patient may have likely developed hypertensive renal failure.
Follow-up
Renal ultrasound as a key imaging investigation should be done, and the radiographic findings should be followed up. Kidneys that are asymmetrically-sized or symmetrically decreased in size will guide proper diagnosis and effective management.