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Med Surg Case Study #6

Presenting Complaint: Mr. Davis, a 45-year-old male, presents to the emergency department with complaints of fatigue, decreased urine output, swelling in his lower extremities, and a metallic taste in his mouth over the past week. He reports no improvement in his symptoms.


Patient Background: Mr. Davis is a 45-year-old construction worker with a history of hypertension and type 2 diabetes, which he has been managing with medication. He has no known drug allergies. He is a non-smoker and occasionally consumes alcohol.


Assessment: Upon examination, Mr. Davis appears tired and somewhat disoriented. His blood pressure is elevated at 160/95 mmHg, heart rate is 90 beats per minute, and respiratory rate is 18 breaths per minute. He has significant pedal edema and periorbital edema. Laboratory results show elevated serum creatinine and blood urea nitrogen (BUN) levels. Urinalysis reveals proteinuria and hematuria.


1. Based on Davis's history and assessment findings, what is the possible diagnosis for his condition?


2. What diagnostics might be used to confirm the diagnosis?


3. What treatments might be needed for Davis's condition?




See answers below





Med Surg Notebook




Answers

1. What are the possible diagnoses for Ms. Anderson's condition?

  • The possible diagnosis for Mr. Davis's condition is acute kidney injury, characterized by elevated serum creatinine and BUN levels, along with clinical manifestations such as decreased urine output, edema, and abnormal urinalysis results (proteinuria and hematuria).

2. What diagnostics might be used to confirm the diagnosis?

  • Diagnostic tests used to assess kidney function and identify the cause of acute kidney disease may include blood tests (e.g., renal function panel, electrolyte levels), imaging studies (e.g., renal ultrasound), and urinalysis to assess for specific markers and potential underlying causes. A kidney biopsy may also be considered in some cases.

3. What treatments might be needed for Ms. Anderson's condition?

  • The treatment for acute kidney disease would depend on its cause. Possible treatments may include addressing the underlying condition, such as managing hypertension and diabetes more effectively, discontinuing nephrotoxic medications, providing fluid and electrolyte management, and potentially initiating renal replacement therapy if kidney function does not improve.





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