Case 14: Introduction

History of Present Illness (HPI)

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A 91 year-old man with a past medical history of dementia, congestive heart failure, hypertension, and chronic kidney disease stage V presents to your nephrology clinic with his daughter. She recently moved him into a local nursing home and they are here to establish care.

The patient is oriented only to self. He reports that he feels very tired, but he denies any other complaints. His current medications include carvedilol, donepezil, simvastatin, and aspirin.

The patient’s daughter tells you that his health has been declining over the past few months. He has had multiple hospitalizations, and each time he returns to home weaker than before. She tells you that now, he is in a nursing home. She also says, “The doctors told me to look out for signs that his kidneys could be getting even worse, but I’m not really sure what those are.”

Which of the following are signs or symptoms of severe kidney failure, or uremia (more than one may be correct)?
Increased appetite
More often, patients will experience a decrease in appetite. If uremia is severe, patients may also experience a metallic or bad taste in their mouth particularly with food.
Nausea
Nausea is very common in uremia, and can often be associated with retching or vomiting.
Pruritis (itching)
Itching is commonly associated with uremia, and is thought to be due to the buildup of toxins.
Altered sensation of taste
A sometimes subtle sign of uremia is a change in how food tastes, or a sour or metallic taste. Patients may describe a decrease in appetite that is related to this altered sensation of taste.
Muscle paralysis
Paralysis is not a finding commonly seen with uremia. However, patients can experience twitching of the muscles.
Chest pain
Chest pain is a concerning symptom that can be seen with development of uremic pericarditis.
Fatigue
Though fatigue may be multifactorial in patients with chronic illness, worsening of fatigue should raise suspicion for uremia.

You take some time to explain the symptoms of uremia.

Click here to perform the physical exam and assess this patient for other signs!