Case # 4: Development of renal insufficiency in a middle-aged Hispanic female with a history of diabetes and hypertension

(Contributed by Nancy Neff, M.D., Assistant Professor, Department of Community Medicine, Baylor College of Medicine)

MEDICAL HISTORY

Mrs. C was a 42-year-old Latin American female with a 17-year history of diabetes and chronic anemia and a 4-month history of hypertension. Born and raised in Mexico, she had been in the United States for 25 years. She spoke English and had been gainfully employed. Her diabetes had not been well controlled in the past and compliance was felt to be a problem. She developed edema as well as high blood pressure and was treated with Vasotec and HCTZ. The edema resolved, but she was then noted to have a urinary tract infection (treated with Bactrim) and renal insufficiency with mild hyperkalemia. The Vasotec and HCTZ were discontinued and she was begun on Procardia. On follow-up her primary care physician noticed her potassium was now 6.2 and her renal insufficiency was worse. The BUN was 32, creatinine 2.7, with 4 + proteinuria on urinalysis. She was admitted to the hospital for renal evaluation.

Assignment:

Clinical Students: Based on the patient's history, discuss briefly the rationale for the management of the new onset edema and hypertension described in the history. State whether you agree or disagree with the therapeutic decisions. If you disagree, state what you would have done differently. What do you think the renal evaluation should have consisted of?
  • Review the details of the patient's sociocultural background provided in the history. On a scale of 1 (not at all acculturated) to 5 (highly acculturated), how would rate her level of acculturation? Suppose that the statement, "compliance was felt to be a problem" had been omitted from the history. Would your acculturation rating change?

    Pre-clinical Students:

    1. Suppose that you had to take this patient's medical history when she was admitted to the hospital for renal evaluation. What questions would you want to ask her?
    All Students: Review the results of the renal evalution.