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You are an FY1 working in the renal department. Anna is a 71 year old lady who has come in for dialysis. Your consultant has asked you to review her. Please take a history, focussing on any symptoms she is currently experiencing as well as her ideas, concerns and expectations. You will then be asked to discuss the case with the examiner.

You are a 71 year old woman called Anna.

HPC: Your main problem is that you have been feeling more and more tired over the last couple of months. You’re awake for most of the night. You’re finding that you’re exhausted by the late morning and need to take naps in the afternoon. You’re having difficulty concentrating when you read or watch TV, which you think is related to the fatigue.

You try to stay as active as you can, but you get worn out easily when you’re out and about. Over the last 4-6 weeks you’ve noticed that your breathing has got worse – you have to take a break to catch your breath when you’re climbing the stairs, which you never used to. You get breathless lying down in bed too, so have been sleeping propped up on pillows. Walking and climbing stairs is made even more difficult by the fact that you are achey all over, and your feet and lower legs have started swelling up. This has also been going on for around 4-6 weeks. The aching feels like it’s in your bones and is worst in your arms and legs.

You think that your lack of appetite isn’t helping all this. You have to force yourself to eat and can only manage a few mouthfuls at a time. You feel quite nauseous a lot of the time but have not vomited.

If asked specifically: You do not have any muscle weakness or paralysis. You are not itchy. You don’t think that you are passing any more or less urine than usual.

You were diagnosed with chronic kidney disease 6 years ago and started dialysis 18 months ago. You come for dialysis 3 times a week. Your CKD was picked up because of your diabetes, as you get regular checks of your kidney function.

ICE: You think that you’re feeling rotten because your kidneys are getting worse, and you’re worried that this means you’re going to die soon without a transplant. You feel bad about the strain that your illness is putting on your husband, because he’s a few years older than you but still drives you to all of your appointments and dialysis sessions. All the staff in the dialysis centre are lovely, but coming here is a huge burden. You really don’t know what to expect because you’re waiting for a donor, and are getting increasingly distressed about the uncertainty.

PMH: You have had type 1 diabetes since you were 14. A few years ago you had to have your eyes treated with lasers because of your diabetes. You were diagnosed with hypertension 10 years ago. You had a hysterectomy when you were 49.

DH: Your diabetes is managed with an insulin pump. You are on lots of different medications for your blood pressure and kidneys, but they come in a dosette box, so you lose track of exactly what they are. You also take aspirin and a statin, plus vitamin D, calcium and iron supplements.

SH: You are a retired primary school teacher. You volunteer once a week in a charity shop, but you’re worried that you’ll have to give it up because of your fatigue. You live with your husband, and have three grown-up children who live locally. You smoked about 10 cigarettes a day when you were younger, but quit when you had your first child. You used to enjoy the odd glass of wine, but stopped drinking when your kidneys got bad.

The student should take a history focussing on the main symptoms of chronic kidney disease which include: • Nausea, weight loss and poor appetite • Peripheral oedema • Fatigue • Shortness of breath • Sleep disturbance • Bone pain/muscle pain and cramps

The student should also examine the patient – there is no specific “renal system” examination, so a general physical examination would be appropriate, guided by the symptoms the patients describes.

Ask the student to summarise and present their findings and differentials, along with initial management steps. A competent candidates answer may be along the lines of:

“As Anna is on dialysis and has a history of CKD and diabetes, my first differential would be end stage renal disease based on the symptoms she describes. These symptoms could also be indicative of malignancy, in particular the fatigue, weight loss and nausea, so this would also be an important differential and one not to be missed.”

Given that this patient’s diagnosis is clearly end-stage renal disease, the focus of the discussion should be on the complications and management of this condition. For example:

• What hormonal and electrolyte abnormalities occur as a result of end stage renal disease? What are the clinical features of these? • What clinical signs would you look for on examination? • What are some causes of chronic kidney disease? • What dietary advice is given to people with end stage renal disease? • Describe the different types of dialysis. • What are some complications that can occur during dialysis? • Can you tell me about how donor kidneys are sourced? • What medications may a recipient of a donor kidney require? What are the implications of this?

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