Scenario 1a: 58-Year-Old Female Admitted For Workup

Scenario 1a 58 Year Old Female Is Admitted For A Work Up For A Complai

A 58-year-old female is admitted for a workup concerning her complaints of neck and low back pain. During her admission process, it is noted that she has a history of renal transplantation six years prior. Recent laboratory findings reveal an elevated serum calcium level at 13.9 mg/dL, with normal range being 8.5 to 10.2 mg/dL. Her complete blood count (CBC) shows a hematocrit of 33%, and hemoglobin of 11.1 g/dL, which are below the normal ranges for adult females (hematocrit: 37-47%; hemoglobin: 12-16 g/dL). The combination of her symptoms and laboratory results suggests an underlying pathology that warrants further investigation.

Paper For Above instruction

The clinical presentation of a 58-year-old woman with neck and low back pain, coupled with abnormal laboratory findings, points towards a complex underlying condition. Her history of renal transplantation adds another layer to her diagnostic considerations, necessitating a comprehensive assessment and management approach.

Firstly, the elevated serum calcium level, a condition known as hypercalcemia, is significant and warrants immediate attention. Normal serum calcium ranges between 8.5 and 10.2 mg/dL; levels above this can cause a variety of symptoms, including musculoskeletal pain, neurocognitive disturbances, and gastrointestinal issues (Kumar & DiGiuseppe, 2019). In her case, hypercalcemia likely contributes to her musculoskeletal pain, especially considering her complaint of neck and back discomfort. The etiology of hypercalcemia in this patient could be multifactorial.

One probable cause is secondary hyperparathyroidism, a common complication in patients with chronic kidney disease and those who have undergone renal transplantation. Parathyroid hormone (PTH) levels should be measured to confirm this hypothesis; elevated PTH can lead to increased calcium levels through bone resorption. Moreover, immunosuppressive medications such as calcineurin inhibitors, which she might be taking for her transplant, can influence calcium and PTH levels (Chung et al., 2018).

Additionally, her anemia, indicated by low hemoglobin (11.1 g/dL) and hematocrit (33%), could be related to several factors. Chronic kidney disease and transplant status predispose to anemia due to inadequate erythropoietin production, iron deficiency, or effects of medications such as immunosuppressants. Anemia can also contribute to musculoskeletal discomfort and fatigue (Kell, 2020).

Other assessments that would be helpful include measuring her serum PTH, vitamin D levels, renal function tests (such as serum creatinine and estimated glomerular filtration rate), and iron studies. Bone density assessment may also be indicated, considering the potential for renal osteodystrophy, which can cause bone pain and fractures. Imaging studies such as X-rays or MRI of the spine can evaluate structural abnormalities or osteoporotic changes contributing to her pain (Moe et al., 2019).

Management of her hypercalcemia involves addressing the underlying cause. For secondary hyperparathyroidism, treatments may include phosphate binders, vitamin D analogs (such as calcitriol), and possibly parathyroidectomy in refractory cases. Ensuring adequate hydration and avoiding medications that exacerbate hypercalcemia are initial steps (KDOQI guidelines). In terms of anemia, erythropoiesis-stimulating agents and iron supplementation may be considered to improve her hemoglobin levels.

In addition to pharmacologic therapy, addressing her pain through physical therapy, pain management strategies, and ergonomic adjustments should be part of her comprehensive care plan. Managing her electrolyte disturbances carefully, monitoring her renal function, and coordinating her care with nephrology are crucial due to her transplant history.

In conclusion, her presentation suggests that her musculoskeletal pain may be driven by secondary hyperparathyroidism and renal osteodystrophy, compounded by anemia related to her transplant status. A multidisciplinary approach involving nephrology, endocrinology, and pain management specialists is essential to optimize her outcomes.

References

• Chung, C. P., et al. (2018). Immunosuppressive therapy and mineral metabolism in renal transplant recipients. Nephrology Dialysis Transplantation, 33(9), 1524-1531.
• Kell, P. (2020). Anemia management in chronic kidney disease. Clinical Journal of the American Society of Nephrology, 15(1), 1-10.
• Kumar, S., & DiGiuseppe, J. A. (2019). Hypercalcemia: Pathophysiology, diagnosis, and management. American Family Physician, 99(8), 473-480.
• Moe, S., et al. (2019). Bone disorders in chronic kidney disease. Nature Reviews Nephrology, 15(12), 672-685.
• National Kidney Foundation. (2017). KDOQI Clinical Practice Guideline for Bone Metabolism and Disease in Chronic Kidney Disease. American Journal of Kidney Diseases, 69(5), S1–S112.
• Chung, C. P., et al. (2018). Immunosuppressive therapy and mineral metabolism in renal transplant recipients. Nephrology Dialysis Transplantation, 33(9), 1524-1531.
• Kelly, K. J., et al. (2017). Management of secondary hyperparathyroidism. Seminars in Nephrology, 37(4), 343-350.
• Ketteler, M., et al. (2020). Treatment of secondary hyperparathyroidism in CKD. Kidney International Reports, 5(2), 189-199.
• Liu, S., et al. (2019). Bone health in kidney transplant recipients. Current Osteoporosis Reports, 17(5), 182-189.
• National Kidney Foundation. (2020). Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Kidney Disease–Mineral and Bone Disorder (CKD-MBD). Kidney International Supplements, 7(1), 1-59.