100 Cases in Clinical Medicine

Renal

CASE 9: TIREDNESS

History

An 85-year-old woman is investigated by her general practitioner (GP) for increasing tired-
ness which has developed over the past 6 months. She has lost her appetite and feels con-
stantly nauseated. She has lost about 8 kg in weight over the past 6 months. For the last
4 weeks she has also complained of generalized itching and cramps. She has been hyper-
tensive for 20 years and has been on antihypertensive medication for that time. She has
had two cerebrovascular accidents which have limited her mobility. She is an African-
Caribbean, having emigrated to the UK in the 1960s. She lives alone but uses a ‘meals on
wheels’ service and goes to a day hospital twice a week. She has two daughters.

Examination

Her conjunctivae are pale. Her pulse is 88/min regular, blood pressure 190/110 mmHg;
mild pitting oedema of her ankles is present. Otherwise, examination of her cardiovascu-
lar and respiratory systems is normal. Neurological examination shows a left upper motor
neurone facial palsy with mild weakness and increased reflexes in the left arm and leg.
She is able to walk with a stick. Funduscopy shows arteriovenous nipping and increased
tortuosity of the arteries.

Normal

Haemoglobin 7.2 g/dL 11.7–15.7 g/dL

Mean corpuscular volume (MCV) 84 fL 80–99 fL

White cell count 6.3% 109 /L 3.5–11.0% 109 /L

Platelets 294 % 109 /L 150–440% 109 /L

Sodium 136 mmol/L 135–145 mmol/L

Potassium 4.8 mmol/L 3.5–5.0 mmol/L

Urea 46.2 mmol/L 2.5–6.7 mmol/L

Creatinine 769 &mol/L 70–120&mol/L

Glucose 4.1 mmol/L 4.0–6.0 mmol/L

Albumin 37 g/L 35–50 g/L

Calcium 1.94 mmol/L 2.12–2.65 mmol/L

Phosphate 3.4 mmol/L 0.8–1.45 mmol/L

Bilirubin 15 mmol/L 3–17 mmol/L

Alanine transaminase 23 IU/L 5–35 IU/L

Alkaline phosphatase 423 IU/L 30–300 IU/L

Urinalysis:'protein;'blood

Blood film: normochromic, normocytic anaemia

INVESTIGATIONS

Questions

• What is the diagnosis?


• How would you investigate and manage this patient?