Question

Mr. Smith is 60 years old. He was diagnosed with a prostate cancer five years ago. Over the past few days, Mr. Smith has been feeling weak and increasingly tired and has also been suffering from a headache that did not respond to over-the-counter medications. He scheduled an appointment with his physician.

His physician performed a physical examination and recommended a battery of laboratory tests and imaging procedures.

The table below shows Reference values in the right-hand column. These values reflect the normal range of values for patients without disease or illness. The center column reflects the resulting values for medical test results obtained for Mr. Smith.

Take note whether Mr. Smith’s values are within normal limits.

	Mr. Smith	Reference Values
K+	2.6 mmol/L	3.8-4.9mmol/L
Hb (Hemoglobin)	7.5 g/dL	13.8 to 18.2 g/dL
Hct (Hematocrit)	20.4%	45-52%
Platelet Count	49x109/L	150-400x109/L

After receiving Mr. Smith’s test results, his physician admits him to the hospital. Hospital staff treated him and discharged him.

The following week, Mr. Smith returns to his physician with the same complaint of weakness and a new complaint of shortness of breath. His blood pressure is 160/100 mmHg. MRI reveals metastasis of prostate cancer to osseous tissue. Abdominal CT shows obstruction of intestine due to nodular enlargement of adrenal glands.

Laboratory results from Mr. Smith’s second hospital admission and medical tests show following findings:

	Mr. Smith	Reference Values
K+	2.6 mmol/L	3.8-4.9mmol/L
Hb	7.3 g/dl	13.8 to 18.2 g/dL
Hct	20.4%	45-52%
Platelet Count	20x109/L	150-400x109/L
HCO3	38 mmol/l	22-26 mmol/L
Urinary K+	70 mmol/L/24 hr	25-120 mmol/L/24 hr
Blood Glucose	460 mg/dl	64.8-104.4 mg/dL
Serum Aldosterone	1 ng/dl
24 hour Urinary Aldosterone	8.4 mcg/24 hr	2.3-21.0 mcg/24 hr
Renin	2.1 ng/ml/hr	0.65-5.0 ng/ml/hr
ACTH (Adrenocorticotropic Hormone)	1082 pg/ml	9-46 pg/ml
Cortisol	155.5 microg/dL	0-25 microg/dL

CONCLUSION AND DIAGNOSIS

Laboratory findings, MRI and CT confirmed metastatic prostate adenocarcinoma, hypertension and refractory hypokalemia due to ectopic ACTH production. High levels of circulating cortisol caused continuous activation of mineralocorticoid receptors resulting in hypokalemia, metabolic alkalosis and hypertension.

After reading provided scenario, answer the following questions:

1.   What are the components of physical examination? Describe each component. (See Module 1, Commentary, Topic 8. Disease Categories, Part B. Steps in Diagnosis)

2.   Mr. Smith’s blood pressure was 160/100 mmHg. How does a medical provider take or measure blood pressure? What do the top (numerator) and bottom (denominator) numbers mean in the biological sense? What is the significance the size of these two numbers? Is Mr. Smith’s blood pressure within normal range? Explain how you concluded whether Mr. Smith’s blood pressure is/is not within normal range.

3.   Based on the data provided, what laboratory tests were performed and what samples were taken from the patient? Select one of the laboratory tests ordered for Mr. Smith and discuss why Mr. Smith’s physician might have ordered the test and the information she might have expected to obtain from that particular test.

4.   Compare Mr. Smith’s values with reference values and indicate whether MR. Smith’s values are below, above, or within normal range (compare Mr. Smith’s values with the Reference values) for each laboratory tests in the table above from the second set of tests.

5.   What imaging procedures did Mr. Smith undergo? Discuss the distinctions and similarities between the two different imaging approaches. What were the results of imaging procedures in Mr. Smith’s case?

6. Select one of the medical terms from the CONCLUSION and DIAGNOSIS section above and define what it means. Also, discuss, in your own words and based on what you can gather about Mr. Smith’s condition, how the laboratory or imaging tests helped with drawing a conclusion or making the diagnosis. In your own words, discuss how medical providers use the scientific method to come to work through the examination and diagnosis of a patient.

Answer 1

1. Components of physical examination: Regular overall routine blood test is one of the most important ways to keep track on the physical well-being.
K+: potassium blood test is used to diagnose conditions related to abnormal potassium levels and these conditions include kidney disease, high blood pressure and heart disease.
Complete blood count test is analysed to check for 10 diffrrent components, in which important components include red blood cell count, haemoglobin and hematocrit and abnormalities in this indicates iron defeciency, nutritional defeciencies, bone marrow issues, tissue inflamation, infection, heart conditions, cancer.

2. According to American Heart Association, blood pressure is in its normal level if it is below 120/80 mm/Hg. If the blood pressure ranges between 160/100 mm/Hg to 179/109 mm/Hg then it is considered to be in the stage 2 high blood pressure condition. The top number refers to the amount of pressure in the arteries during contraction of heart muscles and it is called as systolic pressure. The bottom number refers to the pressure of heart muscle between beats and it is called as diastolic pressure.

3. Based on the datas provided, patient was ordered to go for complete routine blood test and blood sample was collected to carry out the tests for different parameters. Various blood tests the patient undergone: complete blood count, basic metabolic pannel (checks for levels of certain compounds in the blood), complete metabolic pannel (includes measurement of additional proteins and substances related to liver function), lipid pannel (test for cholesterol - LDH, LDL), DHEA-Sulphate serum test (for kidney functioning), C-reactive protein test (inflammation indicative test). From the second set of laboratory tests, to look in detail for the complete functioning of the bdoy system.

4. Comparing both laboratory tests, blood platelet count has drastic change and haemoglobin content also found to be lower in the second test than the first test examined.

5. The patient has undergone two imaging types - MRI (Magnetic Ressonance Imaging) and abdominal CT (Computed Tomography) scan.
MRI- Is used in radiology to form pictures of the anatomy and the physiological processes of the body. They are frequently used to diagnose issues with joints, brain, wrists, ankles, breasts, heart, blood vessels.
CT Scan - Uses X-ray technology and advanced computer analysis to create detailed pictures of your body. It can help diagnose problems in the liver, spleen, colon, pancreas, kidneys and other internal organs. A CT scan is typically used for bone fractures, tumors, cancer monitoring and finding internal bleeding. Both MRIs and CT scans can view internal body structures. However, a CT scan is faster and can provide pictures of tissues, organs and skeletal structure. An MRI is highly adept at capturing images that help doctors determine if there are abnormal tissues within the body.

6. From the above examinations, doctor has concluded and diagonised with the results obtained from MRI scan because the MRI  scan clearly depicts the cancer which is clearly imaged. This MRI technique can be used to help better define possible areas of cancer in the prostate, as well as to get an idea of how quickly a cancer might grow. It can also help show if the cancer has grown outside the prostate or spread to other parts of the body.