Nice cases in internal medicine

[arifhussainarif]

1st case

A 64-year-old female with a 10 year history of insulin-treated diabetes attends surgery for a diabetic annual review. She has a long history of migraine which is controlled by medication. She has no previous known history of hypertension but blood pressure recording is elevated at 165/90 mmHg. Microalbuminuria screen is negative and U+Es show:

Urea 11.7 mmol/l (3-8)
serum creatinine 110 micromol/ L (50-100)

Repeat blood pressure recording shows a similar reading and you decide to initiate valsartan.

The patient returns 2 weeks later for a routine check which shows a blood pressure on treatment of 142/85 mmHg. However, a repeat blood test shows:

Urea 14.8 mmol/l
Serum creatinine 124 micromol/L

The patient informs you that she feels well.

Which of the following is the most appropriate management strategy?


(Please select an option)


 Referral to a nephrologist to investigate for renal artery stenosis 
 
1.Discontinue valsartan and closely monitor renal function 

 2.Continue valsartan and closely monitor renal function 

3. Discontinue the valsartan and switch to a calcium channel blocker 

4. Continue valsartan at a reduced dose and closely monitor renal function 

[drfaten]

i think first we should search fr renal artery stenosis.
2.Continue valsartan and closely monitor renal function 

[asmaaquraan]

salam
i hope that you welcome me to share you resolving the case ,my name is asmaa monther alquraan from Tafilah-Jordan , iam a 4th year medical student in Jordan University of Science and Technology live in irbed tell i finish my study inshallah .

will i guess the appropriate is to Continue valsartan at a reduced dose and closely monitor renal function ; in order to controle the blood pressure and to avoid over dose if she is entering a stage of renal failure .  but i wonder what medication she take for her migrain ?
i hope to correct me if there is a mistake .
thanx

[arifhussainarif]

answer to case 1


3.Continue valsartan and closely monitor renal function

In patients with diabetes and hypertension, rises in creatinine are common following the introduction of effective blood pressure lowering medication. This is particularly common in the presence of pre-existing renal impairment, in this case probably due to hypertensive renal disease associated with impaired renal autoregulation. Thus, modest rises in serum creatinine (in the order of 10-20%) are common particularly following the introduction of ACE inhibitors / ARB as these drugs pharmacologically reduce intra-glomerular pressure which in turn may reduce GFR. This small reduction in GFR is often temporary and has no adverse clinical consequences. Indeed, the fall in intra-glomerular pressure is beneficial in terms of long-term renal protection. In this patient, there is a less than 15% increase in creatinine and so the valsartan should be continued with continued monitoring. If creatinine progressively rises (>25%), then the medication should be stopped and further investigation to evaluate for renal artery stenosis considered.

[arifhussainarif]

Case 2

A 28-year-old male who has had type 1 diabetes since childhood attends for his annual diabetes review. He has recently had laser treatment of proliferative diabetic retinopathy.

His current treatment includes insulin and an ACE inhibitor. A recent HbA1c is 8.2% and a lipid profile shows cholesterol 4.2mmol/L and HDL 1.8 mmol/l. Renal function is normal but two recent urine samples have suggested microalbuminuria. There are no signs of peripheral neuropathy. He is a non-smoker and has no family history of premature cardiovascular disease.

What is the desirable blood pressure goal in this patient according to UK guidelines (NICE and BHS)?


(Please select an option)


 1.BP 140/85 mmHg 
 2.BP 145/80 mmHg 
 3.BP 125/75 mmHg 
 4.BP 130/80 mmHg 
 5.BP 135/85 mmHg 

[drfaten]

4.BP 130/80 mmHg 

[Mohd ALkhateeb]

3-125/75mmHg

[Dr. Manal]

4- 130/80

[jasrizal md]

I am a new comer joint this association. i appreciate and proud with it....i have read some cases  and some others ...very good
thanks
jasrizal md

[Mazen Hasan]

You are welcome jasrizal md...
Go ahead and post your cases
Thank you for joining us..

[arifhussainarif]

An 17 yr-old male nursing student presented with justa 2-day history of headache, feverand sore throat. On examination he was noted to have cervical lymphadenopathy.Hus heart rate was 80 beats /min and BP was 170/100mmHG. There was soft systolic murmer at the left lower sternal edge, which did not radiate. All other examination was normal.
investigations are shown.

HB                          13.6 g/dl
WCC                       12.0*10*9/l
Plateletes                 180*10*9/l
Na                           136mmol/l
K                             4.8mmol/l
Urea                         7.3
Creatinine                 143 micromol/l
Blood culture             NO growth
Throat swan culture    No Growth
Urinalysis                   10-20 rbc ++
                               granular casts,
                               no growth



ANA dsDNA binding   negetive


What diagnosis would you consider most likely ?

a. Post-streptococcal glomeronephriti.
b. Bergers nephritis.
c. Infective endocarditis.
c.Henoch-Scholein  Purpura
e Focal semental  glomerulonephritis

[drfaten]

really i will
a- HTN,Edema ,frank hematuria and ◦Left ventricular dysfunction with or without hypertension or pericardial effusion may be present during the acute congestive
b-IgA nephritis (also known as Berger's disease and synpharyngitic glomerulonephritis) is a form of glomerulonephritis (inflammation of the glomeruli of the kidney). It presents with hematuria and generally resolves spontaneously, but a proportion of patients develops chronic renal failure. IgA is the antibody which accumulates in the kidney and probably plays a central role in the disease.

Signs and symptoms

The classic presentation (in 40-50% of the cases) is frank hematuria which starts one or more days after an upper respiratory tract infection (sore throat). Flank pain can occur. The hematuria resolves after a few days. These episodes occur on an irregular basis, and in most patients, this eventually stops (although it can take many years).

A smaller proportion (20-30%) has microscopic hematuria and proteinuria (less than 2 gram of protein per 24 hours). These patients can have mild symptoms and are only picked up if a doctor decides to take a urine sample.

Very rarely (5% each), the presenting history is:

Nephrotic syndrome (excessive protein loss in the urine)
Acute renal failure (generally a complication of the hematuria)
Chronic renal failure (no previous symptoms, presents with anemia, hypertension and other symptoms of renal failure)
IgA-nephritis can occur in the context of liver failure, coeliac disease, rheumatoid arthritis, Reiter's disease, ankylosing spondylitis and HIV. Occasionally, there are simultaneous symptoms of Henoch-Schönlein purpura

e- FSGS may be primary or secondary to reflux nephropathy, Alport syndrome, heroin abuse or HIV. FSGS presents as a nephrotic syndrome with varying degrees of impaired renal function (seen as a rising serum creatinine, hypertension). As the name suggests, only certain foci of glomeruli within the kidney are affected, and then only a segment of an individual glomerulus. The pathological lesion is sclerosis (fibrosis) within the glomerulus and hyalinisation of the feeding arterioles, but no increase in the number of cells (hence non-proliferative). The hyaline is an amorphous material, pink, homogeneous, resulting from combination of plasma proteins, increased mesangial matrix and collagen. Staining for antibodies and complement is essentially negative. Steroids are often tried but not shown to be effective. 50% of people with FSGS continue to have progressive deterioration of kidney function, ending in renal failure.

[drfaten]

i will choose a after searching fr all of that

[arifhussainarif]

You were very right 130/80 in last case. others users who wrote 130/80 were right as very vigilant htn control is required.

[arifhussainarif]

I do not think many people participate in answering these questions