Term 3 Sample Write-up #7

FCM Sample Write-Up #7
Term 3
Sample A

ID/CC: HR is a 77-year-old patient with a history of untreated BPH and HTN who presents with 2-3 months of progressive fatigue, leg swelling, shortness of breath, and decreased urinary output.

HPI:

HR was in his usual state of health until approximately 2-3 months ago when he noticed he was more fatigued than usual with activities of daily living such as going to the grocery store or working on his property. He noticed he was not urinating as frequently as usual, which he attributed to a “flare” of his prostate enlargement, something he was told he had in 2008 but has never been treated for. During these 2-3 months, the patient continued to drink a usual amount of fluids, but notes that most of the time he tried to urinate he could only get a tiny bit out (an inch of fluid if it was put into a standard sized glass).

About 1 month prior to admission, he noticed that his legs and abdomen were swelling. His stomach appeared much larger to him than usual, but he did not experience any suprapubic or abdominal pain. He weighed himself and realized he gained 30 pounds (up to 180 pounds) and his waist size grew 4 inches (up to 38). He began to use adult diapers to catch leaking of urine he was experiencing at that time. He states he bought an herbal supplement at a health foods store that stated it would “cure prostate problems” and was using that the last few weeks without improvement.

Two weeks prior to admission he began to experience some mild shortness of breath, which he described as the sensation of being unable to catch a full breath. Eventually, his fatigue is became too overwhelming to do any of his ADLs for himself and so he drove himself to the ER.

He says his blood pressure runs high, anywhere from the 150s to the 180s, although he does not check his pressure on a regular basis. The patient has health insurance and a PCP but did not present to medical care for the problems he was experiencing prior to his visit to HFH ER.

Of note, the patient denies fever, chills, chest pain, PND, orthopnea, use of any prescribed medications whatsoever including ACE inhibitors, ARBs, diuretics, and NSAIDs, or a personal or family history of heart or kidney disease.

Past Medical History:

• Medical Problems
  • HTN- not controlled, runs 150s-180s, unclear how often he checks at home
  • BPH- told he has a large prostate in 2008, has not been treated medically although he uses herbal supplements the last few weeks
• Past Surgical History
  • Tonsillectomy as a child

Medications:

• Herbal prostate supplements x2; found at a health foods grocery store
• Vitamin C

Allergies:

• No known drug allergies

Health Related Behaviors:

• Tobacco- never smoker
• Alcohol- previously drank 1 glass of red wine nightly, stopped 2-3 months ago unrelated to his current medical problems
• No other drug use

Sexual History:

• Not sexually active in the last 10 years. Female partners only.

Family History:

• No significant family history

Social History:

HR lives alone in Chewelah on 7 acres. He tends to several goats and chickens on the property. He was previously married and separated from his wife 10 years ago. He has two children who live in Longview, WA. He previously worked in the Portland/Vancouver metro area before retiring to Chewelah. He has a good friend who lives near him who plans to take care of him when he returns home if necessary.

Review of Systems:

• Constitutional: No fever, chills, night sweats.
• HEENT:
  • Eyes- No double vision, blurry vision, discharge or pain.
  • Ears- No pain, discharge, loss of hearing. Has experienced ringing in his ears since he was a child.
  • Nose- No rhinorrhea, epistaxis, or sinus pain.
  • Throat/Mouth- No bleeding, ulcers, or reported problems with dentition.
• Pulmonary: No wheezing, cough, hemoptysis. Some shortness of breath (see HPI).
• Cardiovascular: No chest pain, palpitations.
• Integument: No rashes or lesions of concern.
• Gastrointestinal: “hard stomach” (see HPI).
• Genitourinary/Gynecologic: N/A
• Endocrine: No polyuria.
• Musculoskeletal: See HPI.
• Hematologic: No lymphadenopathy.
• Neurologic: Some sensation change in his toes after having frostbite years ago.
• Psychiatric: Reports his mood is not depressed.
• Allergic/Immunological: N/A.

Physical Exam:

Gen: HR is in no apparent distress, answering questions appropriately.

• Vitals: HR 95, Respirations 16, BP 155/86 supine, 145/78 sitting, 120/77 standing, O2 100% on RA, Temp 37
• Skin: Normal nails, no rashes. No jaundice. Toes up to the metatarsal-phalangeal joints are red/purple in color, with toenails appearing yellow and thick.
• HEENT:
  • Head- Normocephalic, atraumatic. Face, scalp, skull without tenderness.
  • Eyes- Pupils equal, round, and reactive to light and accommodation. No conjunctival injection, scleral icterus. Optic disc not appreciated on fundoscopy, but vessels appear grossly intact and normal. Bilateral conjunctival pallor is present.
  • Ears- External ears normal and non-tender. Mastoid processes non-tender. Tympanic membrane pearly gray, visible light reflex, no erythema, discharge, or effusion.
  • Nose- External nose without lesions or asymmetry. No discharge. No sinus tenderness.
  • Mouth/Throat- Normal dentition for age, no ulcers, bleeding, or masses visualized. Uvula midline.
• Neck: No palpable cervical or supraclavicular lymph nodes. Trachea midline. Thyroid without masses.
• Chest/Lungs: Symmetric and normal lung excursion, resonant to percussion and clear to auscultation bilaterally. No spinal or CVA tenderness to percussion.
• Cardiovascular: Regular rate and rhythm. Normal S1 and S2 without gallops, rubs, or murmurs. No carotid bruits. Carotid, radial, and femoral pulses 2+ and symmetric. Pedal pulses not palpable due to edema. 2-3+ pitting edema of the lower limbs to the patella bilaterally.
• Abdomen: Normal active bowel tones, resonant to percussion in all four quadrants, no tenderness to light or deep palpation in all four quadrants. Liver and spleen non-palpable.
• Genital: Omitted.
• Neurologic:
  • Mental status: Alert. Speech is fluent and appropriate. Oriented to person, place, and time.
  • CN II: Tested- vision normal and pupillary reflex intact.
  • CN III, IV, and VI: Tested (extraocular eye movements) and intact.
  • CN VII: Tested (facial expressions) and intact.
  • CN IX and X: Tested (palatal rise to phonation) and intact.
  • CN XI: Tested (shrug shoulders/turn) and intact.
  • CN XII: Tested (protrude tongue) and intact.
  • Motor:
    • All major arm and leg muscle groups 5/5 strength except 4/5 strength in the triceps bilaterally.
  • Sensation: Intact and symmetrical sensation to light touch of the face, arms, and legs, with slightly diminished sensation in his toes bilaterally.
  • Reflexes: 2+ and symmetric bicep, tricep, brachioradialis, and patellar reflexes.
  • Cerebellum: finger to nose test and heel to shin test normal bilaterally.
  • Gait: not tested

Summary:

HR is a 77-year-old patient with a history of uncontrolled BPH and HTN who presents with a 2-3 month history of progressive fatigue, lower limb and abdominal swelling, decreased urinary output, and shortness of breath, with an exam notable for HTN while supine and sitting, bilateral conjunctival pallor, decreased arm and leg strength, and 2-3+ pitting edema of both legs to the knees.

Assessment/Plan:

1. AKI with fatigue, leg/abdominal swelling, decreased urinary output – The patient’s decreased urinary output and history of untreated prostate enlargement, with the associated leg and abdominal swelling make post-renal obstruction causing renal failure the most likely diagnosis.He does not have hallmarks of pre-renal failure, a result of decreased perfusion to the kidneys. He denies a history of heart disease, classic symptoms of heart failure, and denies a history of NSAID, smoking, and alcohol use or use of medications such as ACE inhibitors, ARBs, or diuretics that can cause pre-renal failure. There is also no major burns or hemorrhage leading to blood volume loss. He is not dehydrated and the symptoms have been going on for 2-3 months, which also go against pre-renal failure. Renal artery stenosis is one consideration that should be ruled out, although one might expect other vascular symptoms such from diseases such as CAD or carotid stenosis, and the patient lacks two major risks for vascular disease—diabetes and smoking history.There is a long list of medications that can cause intrinsic kidney failure, none of which the patient admits to taking. He started taking herbal supplements that may very well be nephrotoxic, but only in the last several weeks, long after his symptoms started. Other causes of intrinsic renal failure such as vasculitis or other auto-immune disorders are not as likely without supportive history of other more systemic symptoms or diagnosed autoimmune disorders. However, these intrinsic causes would need to be further pursued if he does not have pre-renal or post-renal failure.Liver failure causing decreased production of albumin could also mimic this presentation minus the oliguria, although he denies alcohol use, liver disease, and jaundice as well as any GI complaints, and he does not have signs of liver disease on exam.
   1. Bedside bladder scan with placement of Foley catheter if residual is high
   2. CMP- assess electrolyte balance, kidney function, liver function
      1. Important considerations- high K+/uremia/metabolic acidosis may require dialysis
      2. Restrict K+ in diet if K+ is high
   3. Renal ultrasound
      1. Assess for hydronephrosis
      2. Assess for renal artery stenosis
   4. Assess for anemia with CBC
   5. Urinalysis from collected urine to assess electrolyte balance and look for casts, pyuria, hematuria, proteinuria
   6. Digital rectal exam to assess size of prostate
2. Shortness of breath – likely due to volume overload in the setting of AKI, also considered possibility of CHF (HFrEF vs. HFpEF). He is afebrile, making pneumonia less likely (CXR could rule this out)
   1. EKG, chest x-ray, and BNP to asses for ischemia and heart failure and signs of hyperkalemia
   2. Monitor for improvement as renal failure improves
3. Conjunctival pallor, bilateral – concerning for anemia (iron deficiency vs. other underlying etiology)
   1. CBC with diff, blood smear
   2. Iron studies
4. BPH – likely causally related to #1, above.
   1. Consider trial of alpha-blocker such as tamsulosin 0.4 mg po QHS; would not consider surgery unless failed medication trial.
   2. Will need Urology follow up as outpatient
5. HTN – moderately elevated, likely chronic.
   1. Will hold ACE/ARBs for now. Will switch to another antihypertensive agent in the meantime – CCB such as amlodipine would be a reasonable choice (though could exacerbate LE Edema). HCTZ unlikely to be effective given likely GFR, would avoid ACEI/ARB in the setting of AKI.
6. Discharge planning – pending improvement in urine output and Cr, as above. Will need careful outpatient f/u with counseling re: med adherence.