Analyze the ABG and determine the acid–base disturbance.

Order Instructions
Directions
All students should complete Part 1, choose two (2) cases of your preference. All students should complete Part 2. Note: All case studies are provided as a learning tool for students who wish to have them.

Part 1 – Choose 2 of the 5 cases
The following activity includes several case presentations of edema. Make a diagnosis for each case, remembering the following questions:

Is the edema acute/sudden or chronic (e.g., duration, progression)?
Is it unilateral or bilateral? Is the edema generalized or localized?
Is it pitting or nonpitting?
Is it dependent?
In addition to edema, what other characteristics are associated with the edema (e.g., redness, pain)?
What is the pertinent past or coexisting medical history? What medications is the patient taking?
You may want to refer to chapter 3 and chapter 4 to help determine the diagnosis.

Case 1

45-year-old Mrs. Rodriguez is complaining of intermittent mild bilateral feet/ankle swelling for the past 2 months, but it is worse on her right leg. She denies leg pain, but she does describe her legs as feeling heavy at times and reports standing for long periods worsens the swelling. She notes her veins are getting larger in her legs. For the past 8 months, she has been experiencing intermittent numbness in her feet and reports her left knee has been achy. She is a server at a busy restaurant and sometimes works 10-hour days. She denies any fever, warmth, erythema, or trauma.

Past medical history: obesity (BMI 31); type 2 diabetes mellitus.
Medications: metformin.
Physical examination: vital signs are within normal limits; exam is unremarkable except for bilateral tortuous veins in both lower extremities, which are worse on the right leg, and decreased sensation in both feet.
Note: Assume history and examination is within normal limits if not listed.
Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Case 2

68-year-old Mr. Quincy is complaining of left leg swelling for the past 2 weeks. The swelling started while he was on a cruise. The swelling is intermittent and below the knee to his foot. He describes a cramplike pain in his left calf. Lately, both legs have been cramping while walking, but it resolves when he sits. He denies any fever, warmth, erythema, or trauma.

Past medical history: iliofemoral deep vein thrombosis of his left leg after he had left hip replacement for osteoarthritis 9 months ago; treated with rivaroxaban for 6 months; stable angina; obesity (BMI 31); dyslipidemia.
Social history: quit smoking 4 years ago but resumed one-fourth pack per day 1 year ago.
Medications: simvastatin; aspirin; metoprolol.
Note: Assume history and examination is within normal limits if not listed.
Physical examination: vital signs are within normal limits; right leg is within normal limits except hairless, shiny skin; left leg has 1+ pitting edema in the pretibial area and foot; mild pain with left calf compression and one small tortuous vein on the medial aspect of his calf; left leg is also hairless and shiny. A venous duplex Doppler ultrasound of his left leg was done and reveals no deep vein thrombosis.

Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Case 3

85-year-old Mrs. Delaney has bilateral ankle and foot swelling for the past 3 weeks; she states her feet hurt and her shoes feel tight and describes this swelling as the first occurrence; she denies fever, erythema, warmth, or trauma.

Past medical history: aortic valve replacement; hypertension; dyslipidemia; osteoporosis.
Medications: amlodipine; benazepril; atorvastatin; alendronate sodium; aspirin.
Physical examination: vital signs within normal limits; exam unremarkable except for grade 1 systolic ejection murmur at the left sternal border, second intercostal space with no radiation, and mild (< 1+) pitting edema bilateral ankles and feet.
Note: Assume history and examination is within normal limits if not listed.
Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Case 4

78-year-old Mr. Smith is complaining of increased swelling in his lower legs for the past 3 weeks. He states it worsens when his legs are hanging down and gets a bit better when he elevates them. The swelling started about a week after he left the hospital for an episode of pneumonia. He states his legs occasionally swell, especially when he eats too much salt, and the last time it happened was about 8 months ago. He reports taking a water pill for a while but not lately. He noted that he feels like he has put on a few pounds this week and feels a bit more tired and short of breath. He has had to sleep propped up with two pillows. He denies leg pain, fever, warmth, or trauma.

Past medical history: anterior wall myocardial infarction 2 years ago; hypertension; heart failure with reduced ejection fraction; dyslipidemia.
Social history: 1 pack a day smoker for 30 years—quit 2 years ago.
Medications: sacubitril/valsartan; metoprolol; rosuvastatin; aspirin (which he forgets to take).
Physical examination: vital signs — temperature 98.5°F; pulse 70 beats per minute, respirations 22 per minute; blood pressure 150/80 mmHg; pulse oximeter 96%; weight increase of 5 pounds in 1 month; cardiovascular exam remarkable for an S3 gallop; lungs with bibasilar fine inspiratory crackles; bilateral lower extremities pretibial to feet with 2 + pitting edema; and mild pain when depressing skin.
Note: Assume history and examination is within normal limits if not listed.
Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Case 5

40-year-old Mr. Jason is complaining of right leg swelling, pain, erythema, and warmth for the past 2 days. The swelling started after he accidentally cut the front of his leg with a pocketknife while fishing.

Past medical history: hypertension.
Medications: amlodipine.
Social history: drinks four to five beers on the weekends and has smoked one or two cigarettes a day for the last 15 years (he states he is trying to quit).
Physical examination: temperature 100°F; pulse 88 beats per minute; respirations 18 per minute; blood pressure 140/92 mmHg; examination unremarkable except for edematous anterior right leg with open linear wound approximately 1-inch long; wound with scant purulent drainage; and area is warm and tender with blanching erythema that extends 3 inches around the wound.
Note: Assume history and examination is within normal limits if not listed.
Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Part 2: Students are to complete Part 2
A 70-year-old woman was recently treated for pneumonia with antibiotics. After 1 week on antibiotics, she started developing severe diarrhea of 6–7 loose, watery stools per day. The diarrhea has been present for 3 days. She also has a decreased appetite, feels nauseous, and has not been drinking a lot of fluids. She feels very weak and dizzy. She lives alone, so she called 911 and was brought to the emergency department. She is diagnosed with diarrhea, presumptive Clostridium difficile.

Patient medical history: Clostridium difficile 2 years prior.
Physical examination: temperature 99.0°F; pulse 100 beats per minute; respirations 24 per minute; and blood pressure 90/50 mmHg, which dropped to 70/40 mmHg when seated. Examination unremarkable except for dry mucous membranes and generalized mild abdominal tenderness with palpation.
Laboratory findings reveal:
Chemistry panel: sodium 135 mEq/L; potassium 3.4 mEq/L; chloride 100 mmol/L; HCO3- 12 mEq/L; blood urea nitrogen 40 mg/dL.
Creatinine: 1.2 mg/dL.
ABG: pH 7.22, PaO2 85 mmHg, PaCO2 20 mmHg, HCO3- 12 mEq/L.
Activity

Analyze the ABG and determine the acid–base disturbance.
Calculate the compensation response and determine if it is appropriate.
This item is optional. Calculate and interpret the anion gap.
Discuss the diagnosis.
Develop a treatment plan.

Another Case

Directions
Students should complete one (1) case (your choice) from Part 1, complete all of Part 2, complete one (1) case (your choice) from Part 3 and complete Part 4. Note: All case studies are provided as a learning tool for students who wish to have them.

Part 1: Pick one of the three (3) cases
Review the urinary infectious cases and determine the most likely cause, including pathogen and mode of transmission. Discuss data that supports your decision and treatment strategies.

Case 1

A 50-year-old woman presented complaining of burning sensation when urinating and feeling like she has to go every hour for the last day. She denies fever and suprapubic or back pain.

Past medical history: dyslipidemia and hypertension.
Medications: atorvastatin.
Allergies: sulfa.
Physical examination: temperature 98.5°F; pulse 80 beats per minute; respirations 18 per minute; blood pressure 110/66 mmHg; examination unremarkable; no suprapubic or costovertebral angle tenderness; urine dipstick reveals moderate leukocytes and positive nitrites, with all other values within normal limits.
What is the most likely diagnosis and pathogen causing this disorder and mode of transmission? Discuss data that support your decision.
What diagnostic test, if any, should be done?
What are diagnostic test findings would support your diagnosis?
Develop a treatment plan for this patient.
Case 2
A 65-year-old woman with no urinary system complaints had a routine urinalysis with the following results:

What is the most likely diagnosis and pathogen causing this disorder and mode of transmission? Discuss data that support your decision.
What diagnostic test, if any, should be done? Develop a treatment plan for this patient.
Case 3
A 45-year-old woman is complaining of urgency and dysuria for the past 2 days. Yesterday, she started getting chills, feels she is getting a fever, and her back hurts.

Past medical history: UTI 1 year ago.
Medications: none.
Allergies: no known drug allergy (NKDA).
Physical examination: temperature 100°F, pulse 86 beats per minute; respirations 18 per minute; blood pressure 110/70 mmHg; positive costovertebral angle and suprapubic tenderness, otherwise unremarkable; urine dipstick reveals positive leukocytes but negative for nitrites and blood.
What is the most likely diagnosis and pathogen causing this disorder and mode of transmission?
Discuss data that support your decision.
What diagnostic test, if any, should be done? What diagnostic test findings would support your diagnosis?
Develop a treatment plan for this patient.
Part 2: Complete all

Review the following case and urinalysis report.

A 46-year-old woman is asymptomatic and has a routine urinalysis as part of her annual physical. The urinalysis with microscopy report is as follows:

Describe the urinalysis findings and determine possible reasons for the findings and follow-up, if necessary.

Part 3: Pick one of the three (3) cases

Hematuria is common and can be due to benign conditions (e.g., strenuous exercise) or serious disorders (e.g., renal cell carcinoma). Review these cases and determine the most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies.

Case 1

A 50-year-old White man is complaining of left-sided flank pain that started about 3 hours ago. He describes the pain as sharp and intermittent. He notes that his urine is a bit darker, but he denies seeing blood. The pain started after he finished mowing a client’s lawn (he is a gardener). He denies dysuria, urgency, or fever.

Past medical history: gout.
Medications: allopurinol 100 mg orally every day.
Allergies: no known drug allergies (NKDA).
Social history: denies smoking, alcohol use, or drug misuse.
Physical examination: temperature 98.5°F; pulse 96 beats per minute; respirations 20 per minute; blood pressure 138/88 mmHg.
General: anxious, holding left side, and moving around; otherwise, examination is unremarkable.
Urinalysis: positive for blood with 15 RBCs per HPF; remainder unremarkable.
Discuss most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies.
Case 2

An 8-year-old Black girl is complaining of burning when urinating for the past day. She reports wetting herself at school because she was unable to hold it until she was able to get to the bathroom. When she toileted, she voided only small amounts. She denies fever, back, or suprapubic pain. The child is accompanied by her mother.

No past medical history or medications.
Allergies: penicillin (hives).
Vaccines: up to date.
Physical examination: vital signs and examination are within normal limits.
Urine dipstick: positive for leukocytes, nitrites, and blood.
Discuss most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies.
Case 3

A 68-year-old White man is concerned because he thinks he is peeing blood. He noticed it about 1 month ago, and he thought it was related to sex as he noticed it right after intercourse. However, he has had two other episodes within the past two weeks not related to sexual intercourse. He denies fever, dysuria, frequency, abdominal, back, or pelvic pain. He states he used to have a weak stream and have to urinate at night, but these symptoms have improved since starting finasteride (5α-reductase inhibitor).

Past medical history: BPH.
Medications: finasteride.
Allergies: no known drug allergy (NKDA).
Social history: has smoked 1 pack of cigarettes per day for the past 40 years; drinks two to three beers on the weekends.
Physical examination: body mass index 32; vital signs and examination are within normal limits.
Urinalysis with microscopic evaluation: positive for blood with 40 RBCs/HPF; no casts or dysmorphic cells noted.
Discuss most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies.
Part 4: Complete

A 13-year-old boy presented to the clinic complaining of a sore throat that persisted for 2 days. After those 2 days, he developed fever, nausea, and malaise. A throat culture revealed the presence of group A beta-hemolytic streptococci, and the child was started on antibiotic therapy. The child’s symptoms gradually improved, but approximately 2 weeks later, he returned to the clinic because the fever, nausea, and malaise returned. He became tachypneic and short of breath. The mother noted that his eyes were puffy, his ankles were swollen, and his urine was dark and cloudy.

On examination, the child’s blood pressure was 148/100 mmHg; his pulse 122 beats per minute; and his respirations were 35 per minute. Orbital and ankle edema were present. Crackles were auscultated bilaterally. No heart murmurs were found. Slight tenderness to percussion over the flank areas was noted.

A chest X-ray showed evidence of congestion and edema in the lungs. The patient’s hematocrit was 37%, and his WBC count was 11,200/mm3. Blood urea nitrogen was 48 mg/dL (normal is less than 20 mg/dL). Urinalysis results showed that the patient’s protein was 2+ (24-hour excretion was 0.8 g), specific gravity was 1.012, and there were moderate amounts of RBCs and WBCs in the urine. Serum albumin was 4.1 g/dL (normal is 3.5–4.5).

Which evidence supports the conclusion that this patient has a kidney disease?
Which clinical pattern of kidney disease does this patient have? Explain the symptoms.
Which morphologic changes would you expect in the kidney?
What is the prognosis?
What are the possible short- and long-term complications of this disease?
Is it necessary to hospitalize the patient?
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