Course 8, question 64
Case 14
Kas 8-14E: Patient on regular dialysis treatment with dyspnea
MUDr. Martin Havrda
Male, 65 years, retired.
Reason for examination: hypertension, dyspnea.
Family history: Father passed away at 70 due to lung cancer. Mother passed away at 84 following a
stroke. Sister is healthy.
Habits: He´s been smoking since the age of 18, 25-30 cigarettes per day. Alcohole – 1 beer daily for
the diner.
Past diseases: Common child diseases. At 21 he had severe motocycle accident with rupture of the
spleen and left kidney, both were removed, he was in coma for several weeks. At 40 he had peptic
ulcer. At 64 he was diagnosed to have cancer of the right kidney localized near to the hilus. It was
necessary to remove the kidney and he begun regular hemodialysis treatment. He goes to dialysis 3x
weekly for 4 hours (Monday, Wednesday, Friday).
Current complaints: He had his last dialysis on Friday in the morning. After the dialysis his body weight
was 81,0 kg and his blood pressure was 150/90 mmHg. In the same evening he went to the restaurant
with his friends and drank 2 glasses of beer. He did the same on Saturday. He ate and drank normally.
On Sunday he did not feel well, he had a headache and mild nausea, he had only soup for dinner and
went to the bed. He woke up in the middle of the night, he could not breathe. His breathing was better
in a sitting position than in a recumbent position. He called for emergency and he was brought to the
hospital.
He has a headache and blurred vision. His breathing is very difficult.
Examination: BP 240/130 mmHg PR 110 bpm BT 36,2°C body weight 87,0 kg.
Dyspnea at rest, orthopnea, anxiety and excitation. Pale, uremic skin. White sclera, pale coniunctiva.
Throat without irritation. Jugular veins filling up to the angle of mandibula. Thyroid gland not palpable.
Percussion of the chest clear, dull at the base of both lungs. Vesicular breathing reduced bilaterally
above the base of the lung, inspiratory unaccentuated rales over the lung base. Heart sounds regular,
systolic murmur above the aortic ostium spreading into both carotids. Abdomen soft. Liver 3cm below
the costal margin, tender. Symmetrical ankle edema, muscles of the calf soft, non tender.
Laboratory assessment: Blood count: WBC 13,5 Hgb 82 Htc 22,7 Plt 300. Serum: Na 140 mmol/l K 5,4
mmol/l urea 30,0 mmol/l creatinine 840 umol/l Ca 1,90 mmol/l P 3,1 mmol/l, parathormone level high,
Fe 5,2 umol/l VKFe 45,2 umol/l.
ECG: Sinus tachycardia 110/min, signs of hypertrophy and load of the left ventricle.
Questions:
1) Why the patient is dyspneic? Make all possible explanations based on described signs and
symptoms.
2) What is the likely cause of hypertension in this patient? Was the control of his hypertension
adequate till now?
3) What is the reason and consequence of renal anemia?
4) What treatment do you recommend just now for the patient? What treatment would you
recommend for the long-term? Is it possible to prevent reocurrence of the same complication?
Patophysiology: Explain the calcium-phosphate metabolism of this patient and consequences.
Pathology: Tumors of the kidney.