Renal & Urinary System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M42_F1.jpg"}},{"insert":"\n\n"},{"insert":"The bright winter sun shines through the windows of your office as you prepare to see your first patient of the afternoon.\r\n \r\nYou smile to yourself thinking of the warm spring and summer days to come.\n\nBefore the consultation proper, you review a referral letter from your colleague, Dr. Hopkins, who works in the endocrinology department.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M42_F2.jpg"}},{"insert":"\n\n"},{"insert":"As per the letter, 60-year-old Mr. Geller has had type-2 diabetes mellitus for 20 years now, complicated by mild nonproliferative diabetic retinopathy. \r\n \r\nHis medical history is significant for a left-sided ischemic stroke six years ago, without long-term complications.\n\nHe is currently on metformin 2000 mg\/day, gliclazide 80 mg\/day, aspirin 100 mg\/day, and atorvastatin 40 mg\/day. \r\n\r\nAside from some mild experimentation in his youth, he has not smoked. He does not consume alcohol now, and even earlier, only drank socially.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M42_F3.jpg"}},{"insert":"\n\n"},{"insert":"Dr. Hopkins requests that you evaluate Mr. Geller in the light of the following recent abnormal laboratory values:\r\n \r\nCreatinine: 2.24 mg\/dL (0.7-1.3)\r\nHemoglobin: 10.2 g\/dL (14-17.5)\r\nAlbumin: 2.8 g\/dL (3.5-5.5)\r\nUrinalysis: 2+ proteinuria\n\nTwo years ago, his annual lab values were within normal limits, except for microalbuminuria. He was supposed to have repeat labwork last year but was non-compliant.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M42_F4.jpg"}},{"insert":"\n\n"},{"insert":"As you enter the room, you encounter a jovial Mr. Geller who greets you with a handshake and a smile. \u0022Good afternoon, Doctor,\u0022 he states.\r\n \r\n\u0022Good afternoon to you Mr. Geller! How are you feeling today?\u0022 you ask.\n\n\u0022I am feeling fine, Doctor! This beautiful weather is a wonderful change from the rain we\u0027ve been having,\u0022 your patient remarks.\r\n \r\n\u0022I\u0027m enjoying the sunshine as well today, Mr. Geller. I\u0027ve reviewed your referral letter, and Dr. Hopkins has asked me to evaluate you for some very serious issues,\u0022 you say, as you get down to business.\n"}]}


{"ops":[{"insert":"\u0022Mr. Geller, your lab work shows that you are anemic and that your kidneys are not functioning as well as they should. We need to do some further tests\u0022 you explain.\r\n \r\n\u0022That is what Dr. Hopkins has already told me. I feel okay though and have been urinating fine,\u0022 your patient states.\n\nPatients often confuse urinary output with renal function, so you take a moment to educate Mr. Gellar on the differences.\r\n \r\n\u0022The kidneys are responsible for the excretion of many other elements besides water. Most of the time these abnormalities are only found on routine laboratory tests.\u0022, you say and continue,\r\n \r\n\u0022Although you may be feeling just fine, your kidneys may not be properly removing these waste substances from your body. This could have serious long-term effects on your health.\u0022\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M42_F6.jpg"}},{"insert":"\n\n"},{"insert":"Your words seem to have gotten Mr. Geller\u0027s attention, so you proceed with the consultation. \r\n\r\nOn examination, his vitals are: BP 150\/90 mmHg, pulse 73 bpm, temperature 36.8 \u2103, and oxygen saturation 99% (on room air).\n\nMr. Geller appears pale and has slight edema in both lower extremities. Ophthalmoscopy confirms the presence of mild nonproliferative diabetic retinopathy.\r\n \r\nThe remainder of the examination is unremarkable.\n"}]}


{"ops":[{"insert":"\u0022Mr. Geller, we need to perform several further tests to determine the best course of treatment,\u0022 you explain. \r\n \r\nAs you turn to your computer to enter the necessary requisitions, you notice that he seems uneasy.\n\n\u0022Do you have any questions, Mr. Geller?\u0022 you ask.\r\n \r\n\u0022Yes, Doctor. My endocrinologist told me to stop taking my tablets, and switch to insulin instead.\u0022\r\n \r\n\u0022Do you think that this is really necessary? It seems very inconvenient\u0022, he adds.\n"}]}