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Kornhauser Health Sciences Library

Aaron Turner: The Case

Problem Based Learning guide for 2nd Year medical students.

 

The Case

 

HPI:

Mr. Aaron Turner is a 53-year-old male who presents with fatigue, nausea and vomiting, and leg swelling over the last week. He says the symptoms developed gradually, and now he really can’t eat very much without vomiting.  He “just feels terrible” and feels like he has a “sour stomach”.  He feels nauseated all the time, whether he eats or not.  He denies having any pain.

He has not vomited blood and has not noticed any blood in his urine or bowel movements.  He reports he hasn’t been peeing as much as normal.  He hasn’t had any abdominal pain or diarrhea, and no one else in his house or at work has been sick that he knows of. His low back has started hurting again after re-starting weight lifting a few weeks ago, so he has been taking some extra doses of naproxen.

PMH:

Chronic back pain

Hypertension

Medications:

Naproxen 500 mg po q 12 hours and prn

Lisinopril 20 mg po daily

Hydrochlorothiazide 50 mg po daily

Allergies: None

Family History: Heart disease in his father; mother had breast cancer

Social History:

He works as a machinist at the Kentucky Truck Plant. No alcohol, tobacco or illicit drug use. He has started an exercise routine and is exercising by lifting weights at the gym a few days each week. 

Physical Exam

Vitals
Test Result
T 98.1
HR 72
BP 175/100
SpO2 94%
Weight 245 lbs (up 18 lbs compared to 3 months ago)
BMI 30
  • Gen: Ill appearing but not distressed.
  • HEENT: + JVD to angle of jaw at 60 degrees elevation. Mucus membranes moist and pink.
  • CV: S3 heard at lower sternal border, rhythm regular. Pulses strong all 4 extremities.
  • Pulm: Rales bilaterally at the lung bases.
  • Abd: No bruits, no organomegaly appreciated. Bladder not palpable. Bowel sounds present. No pain with palpation. Rectal exam shows normal tone, normal prostate and brown stool.
  • Ext: 2+ pitting edema to knees bilaterally.
  • MSK: No muscle tenderness with palpation.
  • Back: No costovertebral angle tenderness with percussion.
  • Skin: No lesions noted.

His primary care physician orders a basic metabolic panel and says she will call the patient with the results in a day or two.

These test results return in the evening, and the on-call physician is notified of the following results:

Lab Results 9/9 @ 1445
Test Value
Sodium 146 mEq/L
Potassium 6.7 mEq/L
Chloride 118 mEq/L
Bicarbonate 16 mEq/L
BUN 85 mEq/L
Creatinine 5.1 mg/dL
Glucose 78

The on-call physician checks the patient's electronic health record.

Comparison of Lab Results from 7/9 and 9/9
Test 9/9 @ 1445 7/9 @ 1400
Sodium 146 145
Potassium 6.7 4.1
Chloride 118 119
Bicarbonate 16 15
BUN 85 30
Creatinine 5.1 2.1
Glucose 78 90

She calls the patient and tells him to go straight to the ER. The patient asks if he can just be seen in the morning, but the physician is not comfortable waiting due to the elevation of his potassium and insists he go to the ER immediately. She then phones ahead to the ER to tell the ER physician that the patient is coming in and the reason for referral as well as to report his baseline labs several months prior.

The ER physician sees Mr. Turner after he has been triaged and repeats the physical exam, with no notable changes from the examination performed by the primary care physician earlier in the day.

He orders several additional laboratory tests, an EKG and imaging. The EKG comes back first:

ekg

3 sets of Lab Test Results
Test 9/9 @ 2130 9/9 @ 1445 7/9 @ 1400
WBC 11,000    
Hgb 9.1    
Hct 27.3    
Platelets 331000    
MCV 83    
RDW 14.1    
Sodium 146 146 145
Potassium 7.1 6.7 4.1
Chloride 116 118 119
Bicarbonate 14 16 15
BUN 90 85 30
Creatinine 5.0 5.1 2.1
Glucose 89 78 90
ESR 8    
CRP 3    
C3 66    
C4 20    
BNP 530    
Troponin I 0.061    
CK Normal    
Myoglobin Normal    
Urinalysis      
Specific gravity 1.015    
pH 6.3    
color yellow    
Protein 3+    
Occult blood negative    
Nitrate

negative

   
Leukocyte esterase negative    
RBC 0    
WBC 0, occasional granular casts seen    
Urine creatinine 100 mg/dL    
Urine urea 700 mg/dL    
Urine sodium 100 mg/dL    
Urine microscopy Renal tubular cells and renal tubular cell casts    

 

x-ray

The ER physician places the following orders IV calcium gluconate 6.8 mmol and IV insulin and dextrose, and places the patient on telemetry.

An ultrasound of his kidneys and bladder is ordered. The US demonstrates normal-sized kidneys without hydronephrosis and, as the patient can void without difficulty, a bladder post-void residual is measured and found to be low.

The ER physician then calls the internal medicine hospitalist team for admission.

Date: 9/10 @ 0200

The hospitalist team admits him to the floor, places him back on telemetry and holds all of his home medications.

Intravenous nifedipine, isosorbide dinitrate, and hydralazine are started for blood pressure control.

During the night, Mr. Turner develops dyspnea and his oxygen saturations drop to 88%. He is placed on oxygen and nephrology and cardiology are consulted. They recommend adding IV furosemide, which is started.

8 hours after the initiation of treatment in the ER, his potassium is 6.0, his BUN and creatinine are 37 and 3.1, respectively and his EKG changes are trending towards normal.

Dates: 9/10 and 9/11

His telemetry continues to be normal.

His input/output is monitored and he has a net negative fluid balance of 2 liters per day.

His intravenous medications are converted to PO.

His follow up chest x-ray is shown below:

Chest X-Ray Turner PBL Follow up

Selected labs are shown below:

Lab Results 9/11 @ 1400
Lab Result
Sodium 140
Potassium 4.8
Chloride 100
Bicarbonate 25
BUN 31
Creatinine 2.9
Glucose 85

Date: 9/12

A 2D echocardiogram shows ventricular hypertrophy and dilation with a decreased ejection fraction and impaired diastolic function.

The cardiologist tells Mr. Turner that he has a form of heart failure most likely due to his longstanding hypertension.

The nephrologist tells him that he appears to have underlying kidney disease from hypertension and that he got sick because he had a worsening of his kidney function due to multiple factors.

He is advised to receive vaccinations before leaving the hospital and told he will need regular monitoring by his kidney doctor and cardiologist every 3 months for the foreseeable future.

He is discharged on oral nifedipine, hydralazine, isosorbide dinitrate, and furosemide with follow-up in one week with cardiology and nephrology.  He is also made an appointment to see a nutritionist and follow up with his primary care physician regarding his desire to resume exercising, lose weight and alternative ways of managing his back pain in the future.

Clinical Librarian

Vida Vaughn

Vida Vaughn

Clinical Librarian / Assistant Director

Kornhauser Health Sciences Library

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