This 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 fundoscopicfindings of A-V nicking and copper wire changes consistent withhypertensive injury. Cardiac exam had an S1, S2 and S4. The remainder ofthe exam was remarkable for 2+ lower extremity edema and superficialexcoriations of his skin from scratching.

 

24-hour urine protein and creatinine - volume 850 ml, protein 600 mg/dl andcreatinine 180 mg/dlRenal ultrasound- Right kidney 9 x 6.0 cm, Left kidney 9.2 x 5.8 cmBoth kidneys illustrate hyperechogenicity and no hydronephrosis.
Objectives
The aim of this case is to understand the pathophysiology of chronic renal  failure and to understand the investigations of chronic renal failure.
Questions
1. What does the symptoms of pruritis, lethargy, lower extremity edema,  nausea and emesis suggest to you ?
2. What are the fundus changes of a diabetic?
3. What does S4 signify? What cardiac findings will you expect to find in a  hypertensive?
4. What are the possibilities for his 2+ lower extremity edema?
5. What is the significance of the finding “superficial excoriations of his skin  from scratching.”?
6. Why was a renal ultrasound ordered? What information can you gather  from renal ultrasound studies?
7. How does the results of the renal ultrasound influence your thinking on  the diagnosis? What is the normal size of the kidney? Is his kidney size normal? What does small or large kidney signify?
8. What evidence in renal ultrasound, will suggest obstruction?
9. Is the cause of this patients renal failure acute or chronic? How did you  arrive at that conclusion?
10. Is this 24 hour urine collection adequate? How did you arrive at that  conclusion?
11. How is a 24 hour urine to be collected and when is it appropriate to order  this test?

12. Why is the parathyroid hormone elevated?
13. What is the most likely cause of this patient’s anemia?
14. Should this patient be started on dialysis? What are the indications for  dialysis?
15.What is the most likely diagnosis for his renal disease? How did you  arrive at that conclusion?
16. What are the most likely histological findings on renal biopsy in this  patient?

Chemistry Sodium Potassium Chloride Total CO BUN Creatinine Glucose Calcium Phosphorus Alkaline Phosphatase Parathyroid Hormone Hemoglobin Hematocrit Mean cell volume Laboratory Investigations Results 133 6.2 100 15 170 16.0 108 7.2 10.5 306 895 8.6 27.4 88 Normal Values 136-146 mmol/L 3.5-5.3 mmol/L 98-108 mmol/L 23-27 mmol/L 7-22 mg/dl 0.7-1.5 mg/dl 70-110 mg/dl 8.9-10.3 mg/dl 2.6-6.4 mg/dl 30-110 IU/L 10-65 pg/ml 14-17 gm/dl 40-54% 85-95 FL Urinalysis pH 6.0 Specific gravity 1.010 Protein +1 Glucose negative Acetone negative Occult blood negative Bile negative Waxy casts Chemistry Sodium Potassium Chloride Total CO BUN Creatinine Glucose Calcium Phosphorus Alkaline Phosphatase Parathyroid Hormone Hemoglobin Hematocrit Mean cell volume Laboratory Investigations Results 133 6.2 100 15 170 16.0 108 7.2 10.5 306 895 8.6 27.4 88 Normal Values 136-146 mmol/L 3.5-5.3 mmol/L 98-108 mmol/L 23-27 mmol/L 7-22 mg/dl 0.7-1.5 mg/dl 70-110 mg/dl 8.9-10.3 mg/dl 2.6-6.4 mg/dl 30-110 IU/L 10-65 pg/ml 14-17 gm/dl 40-54% 85-95 FL Urinalysis pH 6.0 Specific gravity 1.010 Protein +1 Glucose negative Acetone negative Occult blood negative Bile negative Waxy casts