Patient Scenario Information (copied from syllabus).
Mr. Smith is 60 years old. He was diagnosed with a prostate cancer five years ago. Over the past few days, Mr. Smith has been feeling weak and increasingly tired and has also been suffering from a headache that did not respond to over-the-counter medications. He scheduled an appointment with his physician.
His physician performed a physical examination and recommended a battery of laboratory tests and imaging procedures.
The table below shows Reference values in the right-hand column. These values reflect the normal range of values for patients without disease or illness. The center column reflects the resulting values for medical test results obtained for Mr. Smith.
Take note whether Mr. Smith’s values are within normal limits.
13.8 to 18.2 g/dL
After receiving Mr. Smith’s test results, his physician admits him to the hospital. Hospital staff treated him and discharged him.
The following week, Mr. Smith returns to his physician with the same complaint of weakness and a new complaint of shortness of breath. His blood pressure is 160/100 mmHg. MRI reveals metastasis of prostate cancer to osseous tissue. Abdominal CT shows obstruction of intestine due to nodular enlargement of adrenal glands.
Laboratory results from Mr. Smith’s second hospital admission and medical tests show following findings:
13.8 to 18.2 g/dL
70 mmol/L/24 hr
25-120 mmol/L/24 hr
24 hour Urinary Aldosterone
8.4 mcg/24 hr
2.3-21.0 mcg/24 hr
ACTH (Adrenocorticotropic Hormone)
CONCLUSION AND DIAGNOSIS
Laboratory findings, MRI and CT confirmed metastatic prostate adenocarcinoma, hypertension and refractory hypokalemia due to ectopic ACTH production. High levels of circulating cortisol caused continuous activation of mineralocorticoid receptors resulting in hypokalemia, metabolic alkalosis and hypertension.
After reading provided scenario, answer the following questions:
1. What are the components of physical examination? Describe each component. (See Module 1, Topic B, Part B.2 – found after week 8 in the Content tab) Please use the answers from this module only and not from another source- easy points here!
2. Mr. Smith’s blood pressure was 160/100 mmHg. How does a medical provider take or measure blood pressure? What do the top (numerator) and bottom (denominator) numbers mean in the biological sense? What is the significance the size of these two numbers? Is Mr. Smith’s blood pressure within normal range? Explain how you concluded whether Mr. Smith’s blood pressure is/is not within normal range.
3. Based on the data provided, what laboratory tests were performed and what samples were taken from the patient? Select one of the laboratory tests ordered for Mr. Smith and discuss why Mr. Smith’s physician might have ordered the test and the information she might have expected to obtain from that particular test.
4. Compare Mr. Smith’s values with reference values and indicate whether MR. Smith’s values are below, above, or within normal range (compare Mr. Smith’s values with the Reference values) for each laboratory tests in the table above from the second set of tests.
5. What imaging procedures did Mr. Smith undergo? Discuss the distinctions and similarities between the two different imaging approaches. What were the results of imaging procedures in Mr. Smith’s case?
6. Select one of the medical terms from the CONCLUSION and DIAGNOSIS section above and define what it means. Also, discuss, in your own words and based on what you can gather about Mr. Smith’s condition, how the laboratory or imaging tests helped with drawing a conclusion or making the diagnosis. In your own words, discuss how medical providers use the scientific method to come to work through the examination and diagnosis of a patient.
Mr Smith Scenario Sample Answer
A physical examination is medical process of diagnosis or examination used to evaluate the body parts and their functions through observation, feeling, tapping and listening. It also encompasses collecting information regarding a patient’s lifestyle and their medical history. There are four components of physical examination. These are inspection, palpitation, percussion and auscultation. The process generally involves the use of the hands, ears and the stethoscope to evaluate the body parts or organs.
Inspection: This is the inspection of the body for normal color, shape and consistency. The main areas a physician will pay attention to during inspection include the skin, face, eyes, neck, chest, abdomen, legs, muscles and joints (Messele, Osman & Abdurahman, 2005). During inspection of these parts the physician will look for bruises, veins, swelling, masses, cuts, lumps and changes in color.
Palpation:Palpitation is the process of examining a part of the body for abnormalities by feeling using hands. During palpitation an examiner will feel the chest wall to feel the heart, lymph nodes and the abdomen. Masses or lumps are what an examiner mainly checks for during palpitation.
Percussion: This examination method also uses the hands where the examiner taps areas of the body. The examiner listens to the sounds produced, which helps determine if there are fluids or masses formed inside the parts. These parts include the abdomen, back and chest wall, which tell if organs like the lungs or stomach, contain either fluids or masses where they are not supposed to be as they cause different sounds (Chemocare, 2015).
Auscultation: Auscultation is another procedure where a physician or nurse will listen to the heart, neck, lungs and abdomen to detect problems (Chemocare, 2015). This is done using a stethoscope, which amplifies sounds from these areas. The tests usually detect problems in the arteries in the organs; heart beat rate and sound changes, lung normal sound change. Such changes will indicate possibility of a condition.
Measuring blood pressure
This is a procedure that is used for measuring the pressure of the blood in the arteries. It is used for determining whether blood flowing is flowing the right way or not commonly done using sphygmomanometer. Blood pressure is usually recorded using two numbers – the systolic and the diastolic (Chemocare, 2015). The Systolic is the number at the top, which indicates the force of your blood in the arteries when the heart beats (contracts and) and the diastolic is the bottom number, which indicates blood force when the heart relaxes. At 120/80 mm Hg blood pressure, a person is considered as having the ideal blood pressure. Anything above this is called hypertension and may result to damage of other body organs and can cause stroke or heart failure (American Society of Hypertension, 2010). When the pressure is below 90/60 mm Hg the condition is known as low blood pressure, usually associated with feelings of dizziness and faintness.
Mr. Smith’s blood pressure is not within the normal range and requires medical attention to help lower it. Any reading between 120/80 mmHg to 139/89 is a sign of hypertension and is usually known as pre-hypertension. When it goes above that it becomes hypertension stage 1 (140/90 to 159/99 mmHg). With his pressure at 160/90 mmHg and above he is at hypertension stage 2 blood pressure and requires immediate medical help.
Based on the provided information, there were a number of tests that were performed on Mr. Smith. Among them was testing the level of potassium in his blood and urine; platelet count; hemoglobin test; testing the level of bicarbonate and blood glucose; cortisol and renin tests; urinary and serum aldosterone; and ACTH test.
Mr. Smith’s values
Mr. Smith’s values, from the tests performed, are out of range. His potassium levels seem to be too low, 2.6 mmol/L as compared to the normal range of 3.8-4.9 mmol/L. Mr. Smith’s Hct percentages are also considerably low at 20.4 when the normal Hct percentage range of 45-52% and his Hb test results, 73 g/dl, also seem to be low when compared to the normal rage of 13.8-18.2 g/dl. Mr. Smith’s platelet count is very low at 20×109/L instead of the normal 150-400×109/L. His HCO3 on the other hand seems to be too high at 38 mmol/l instead of falling within the normal range of 22-26 mmol/l. His blood glucose and ACTH tests also seem to be reasonably higher than they ought to be. However, Mr. Smith’s urinary tests are within the given normal ranges.
Imaging procedures performed
The imaging procedures performed on Mr. Smith included Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). MRI is a test that makes se of radio waves and magnetic fields to get images of the internal organs while a CT scan is a form of X-Ray that produces 3D pictures of a person’s internal organs. An MRI provides more info than a CT scan. The imaging procedures conducted showed that Mr. Smith had prostate cancer, refractory hypokalemia and hypertension.
Mineralocorticoid receptor (MLR) is the word that I chose from the case conclusion and diagnosis section. The MLR, also referred to as aldosterone receptor, is a protein usually programmed by the NR3C2 gene (Messele, Osman & Abdurahman, 2005). MLR acts as glucorticoids and aldosterone receptors and helps to depress potassium levels. In accordance to the information given by Mr. Smith, I deduce that he is suffering from potassium deficiency, a condition known as hypokalemia, which might be making him feel weak. Mr. Smith has a high blood pressure which when combined with Metabolic Alkalosis can result to persistent headaches, as seen in his case (American Society of Hypertension, 2010). The imaging procedures performed helped in determining how ectopic ACTH could have triggered Mr. Smith’s high blood pressure and hypokalemia. It also showed how cortisol resulted into his high blood pressure and Metabolic Alkalosis through keeping the MLRs active.
The scientific method that was employed in Mr. Smith’s case study was that both the doctor and the patient wondered what could be ailing Mr. Smith. The doctor carried out background investigation, which included finding out past diagnosis such as Mr. Smith being diagnosed with prostate cancer 5 years preceding his visit. This was then followed by construction of a hypothesis. Since qualified medical professional constructed the hypothesis, it was comprehensive and accurate. After constructing the hypothesis, the next step involved testing the hypothesis. This stage entailed a physical examination followed by 2 imaging procedures. This stage plays a major role in determining the root cause of Mr. Smith’s medical problems. The next stage involves pairing and analyzing the examination results with the patient’s complaints in order to reach a conclusive diagnosis. The last stage is where the medical professional communicates the test results and diagnosis with the patient.