26 Sep CASE STUDY 3A 52-year-old woman presented to the c
CASE STUDY 3A 52-year-old woman presented to the clinic for ongoing fatigue and weight loss during the last 6 weeks. She thinks she’s loss at least “10 pounds”. For the past week and a half she’s noted some progressing ‘muscle cramping’ tetany, as well as ‘tingling’ sensation around her mouth and lower extremities. She’s also noted some intermittent colicky abdominal pain. On your exam, you noted a positive Chvostek’s sign. PMH: 20-year history of Crohn’s disease. She also tells you that she is a practicing vegan. Evaluation and Management of Renal and Genitourinary Tract DisordersEvaluating for genitourinary (GU) disease and formulating its differential diagnoses can be challenging for practitioners. It takes prudence for the practitioner to determine the actual problem as the GU signs and symptoms can be nonspecific or absent until the problem becomes serious. Nonetheless, a keen assessment of the patient’s history, close observation of the ongoing manifestations and laboratory values interpretation serves as useful tools in formulating the explicit diagnosis. My main post will be discussing about the scenario in case study 3. I will be presenting my primary diagnosis, 3 differential diagnoses. My assessment description played in the diagnosis as well as potential treatments of the patient’s problem Patient’s history to obtain Additional query on manifestations is crucial in order to identify the cause of the problem. As electrolytes play a major role in conducting nerve impulses and contracting muscles, the patient complaining of muscle cramps and tingling sensation may possibly mean that there is an ongoing electrolyte imbalance. As electrolyte imbalance can also lead to abnormal electrical impulses of the heart symptoms for cardiac arrhythmias such as palpitations, chest fluttering and pain, lightheadedness and fainting should be critically assessed.The origin of the problem can be multifactorial and further inquiring information from the patient is crucial. The patient seemed to be particular in her diet as she reports practicing vegan diet. Vegetarian diet particularly vegan, is a healthy practice in preventing chronic diseases, however continues adoption should be further explored as there is no known benefit of long adherence to it (Cosgrove and Johnston, 2017). Vegan diet had proved to be effective in the reduction of cholesterol and increase in dietary fiber according to the study of Cosgrove and Johnston (2017), however, acid-base imbalance is a potential concern which can be damaging to the kidney if used long-term. As such asking the patient the length of time she has been practicing vegan diet is helpful in determining whether it provides her benefit or just adding risks to her health. It may also be helpful to ask if she is taking any diet supplements or herbs, or even practicing binge -eating as these may be a potential cause of her metabolic imbalances. Reviewing the patient’s medications is also an essential factor to obtain. The patient reporting 10 pounds of weight loss within six weeks is concerning. Although, it is clear that the patient is attempting to maintain a healthy lifestyle, the practitioner should determine the reasons for such practice. Is the patient hypertensive and has been taking antihypertensives or diuretics to manage her blood pressure? Is the patient taking diabetic drugs to maintain her blood sugar on normal range? Asking about the patient’s past medical and familial history should be further explored. The presence of genetic disorder such Gitelann syndrome or Bartter syndrome is also relevant in order to differentiate the patient’s problem from other conditions. Inquiring about family history of thyroid disorder can direct the provider to link her problems with thyroid hormones affecting renal development and physiology. As there is an interplay between thyroid and kidney disorder, investigating past medical history or family history of chronic kidney disease and thyroid dysfunction is essential, as thyroid and kidney may co-exist with common etiologic factors. Thyroid disease is important to investigate as hypothyroidism is associated with reduced gromerular filtration rate (GFR), contrasting hyperthyroidism with increased GFR thereby increasing renin – angiotensin – aldosterone activation (Basu and Mohapatra, 2012). Obtaining information if the patient has a history of alcoholism is also a relevant aspect to consider if the electrolyte imbalance is caused by chronic alcohol intake. Diagnostic Exam In defining the cause of hypomagnesemia the fractional excretion of magnesium is determined by measuring the fractional excretion of magnesium (Assadi, 2010), with formula specified belowFEmg = (urine magnesium × serum creatinine)/[0.7 (serum magnesium × urine creatinine)] × 100. The result is being interpreted as : Laboratory tests such as serum and urine chemistry values, kidney panel, parathyroid hormone and blood and urine osmolality are helpful parameters to differentiate diagnoses. Electrocardiogram is also a crucial tool to determine the likelihood of dysrhythmia/ arrhythmia caused by electrolyte imbalance Primary DiagnosisManifestations of hypomagnesemia and hypocalcemia can most likely symptomatic for patients with kidney failure. In a disease colon, fluid and electrolyte absorption is impaired resulting in acute kidney failure. For a patient with long-term history of crohn’s disease it is likely that the patient is manifesting malabsorption syndrome, hence having unfavorable effects on kidney function due electrolyte deficiency and fluid depletion. Because of the constant abnormal functioning of the gastrointestinal tract, the clinician should anticipate recurrence of acute kidney failure, impairing the normal regulation of electrolytes. Unfortunately, hypomagnesemia and hypocalcemia are common disorders encountered in Crohn’s disease and a result from recurrent kidney injury (Demir, Ercan, Karakas, Ulas and Buyukhatipoglu (2014). The kidney is the major regulator of total body magnesium as 95% of fitered magnesium is reabsorbed by the nephron, 15 % to 25% in the proximal tubule, and 5%-10 % in the distal convoluted tubule Symptoms of hypomagnesemia occurs when the level is less than 1.8%. Hypocalcemia often occurs with hypomagnesemia with the deficient magnesium suppressing the secretion of parathyroid hormone (PTH). Magnesium is necessary for PTH function. As such, a hypocalcemia presents with low magnesium level. A decrease in parathyroid hormone secretion from hypomagnesemia can manifest signs of hypocalcemia such as muscle weakness, chevostek and trousseau sign, tetany, generalized seizure, or even personality change (Grossman and Porth, 2014) (Assadi, 2010). Cardiovascular manifestation according to Grossman and Porth (2014) includes ECG changes causing QRS complex to widen, peaked T waves, PR interval prolongation, T wave inversion, appearance of U waves, and in worse cases, could be ventricularl dysrythmias which could be life-threatening. (Grossman and Porth, 2014) Secondary Diagnoses Treatment OptionsThe patient’s presenting manifestations of muscle cramping, including the presence of signs of tetany indicates hypocalcemic crisis requiring the patient for inpatient admission. Buttaro, Trybulski, Polgar Bailey & Sandberg-Cook (2017) indicated treatment of 1-2 ampules of calcium gluconate mixed in a 50-100 D5W to run for 10-20 minutes, followed by a maintenance of 10 ampules of calcium gluconate in a 1L D5W to run at 50ml/hr. The patient serum ph, and electrolyte values should be closely monitored, and the patient should be connected to a cardiac monitor. For presence of laryngospasm, the patient should be intubated immediately.Vitamin D can be given for chronic hypocalcemia to help absorb calcium in the GIT. If there is a problem in GI absorption, higher doses of calcium can be administered (Buttaro et al., 2017)Calcitriol 0.2 to 0.5 ug/day supplementing with 500 to 1000 mg of elemental calcium can also be given two to three times a day. Calcium should be used with caution for patient using thiazide diuretics with sodium restriction in hypoparathyroidism decrease calcium excretion, thus lowering Vit. D and Calcium supplement is imperative.For the management of severe hypomagnesemia (<1.2mg/dL), the patient should intravenously receive 3g to 4 g (24mEq to 32 mEq) of magnesium sulfate to run for 12 to 24 hours. The provider should ensure not to run the magnesium sulfate IV rapidly as majority of the repletion will be excreted in the urine. Dosing for patients with renal insufficiency should receive 25-50% of the initial dose given to patients with normal kidney function (Buttaro, et al., 2017). It is critical to monitor patients with any degree of renal failure to prevent excessively repleting magnesium.Henceforth, it is paramount to consult the endocrinologist and nephrologist to further investigate the patient’s condition as well as exploring the patient’s treatment plans. SummaryThe challenge of managing a patient with electrolyte imbalance accompanied by chronic comorbidities can be safely managed with keen analysis of the patient’s condition. Early detection and treatment of electrolyte imbalance can prevent further complications that can be detrimental to patient’s health. Critical thinking includes questioning, analyzing, synthesizing and accurately interpreting evidences would help generate a plausible and worthwhile diagnosis and formulate a treatment plan safely and effectively. References Assadi, F. (2010). Hypomagnesemia: An evidence-based approach to clinical cases. Iranian Journal of Kidney Diseases, 4(1), 13–19. Retrieved from https://eds-b-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=5&sid=45dd77cf-fbb6-409d-922c-c160532a1626%40pdc-v-sessmgr01Basu, G. and Mohapatra, A. (2012) Interactions between thyroid disorders and kidne Disease. Indian Journal of Endocrinology & Metabolism 16(2), p204-213. Retrieved from https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=2&sid=5bb562db-6cdb-458a-Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: ElsevierCosgrove, K. and Johnston, C. (2017). Examining the impact of adherence to a vegan diet on acid-base balance in healthy adults. Plant Foods Human Nutrition 72(2017) 308-313. Retrieved from https://edsaebscohostcom.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=2&sid=fd962f61-be86-4ab9-973a-da617e47e4b8%40sessionmgr4006Demir, M.H., Ercan, Z., Karakas E.Y., Ulas, T. and Buyukhatipoglu, H (2014). Chronic kidney disease: Recurrent acute kidney failure in a aatient with crohn’s Disease. North American Journal of Medical Sciences 6(12), p.648-649. Retrieved from https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=3&sid=8927bdbb-c8ae-4174-ac97-83c3f893255a%40sessionmgr4010Grossman, S. and Porth, S.C. (2014). Porth’s Pathophysiology. (9th ed.) Philadelphia, PA Lippincott, Williams and WilkinsHuether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.Stark, C., Nylund, C.M., Gorman, G.H., and Lechner, B.L. (2016) Primary renal magnesium wasting: an unusual clinical picture of exercise‐induced symptoms. Physiologic Reports 4(8): e12773. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848726/
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