- CASE FILE
Hypertension and symptoms related to severe hypertension, Orthostatic Tachycardia, and Impaired Kidney Function.
ABOUT THIS CASE FILE
I have been very feeling fatigued for about 2 years now, but just told myself it was medical student burn out. Around November 2018, I began feeling short of breath with minimal exertion, and thought that I was just out of shape due to my medical school rotations consuming all of my time. In March 2019, I became very short of breath after walking up one flight of stairs during morning rounds and decided I should go see my PCP regarding this concern on March 11. My PCP got a CBC and CXR which were within normal limits and I was told that it was probably just my stress and anxiety. On March 27, 2018 I woke up in the middle of the night to colicky RUQ abdominal pain and assumed I was just hungry. I grabbed a snack and went back to bed without the pain really having been resolved. That morning, I took my Internal Medicine Shelf Exam and went home to study for my Family Medicine Shelf Exam that I had the next morning. During my studying I began to have the same colicky RUQ pain but ignored it and it went away. Around 9PM that evening I began having severe bilateral flank pain that radiated to the groin area. Having had similar pain in the past, I tried to ignore the pain thinking that I was passing a kidney stone, but it eventually became so severe that I needed better pain management and went to the ED. In the ED, I was found to have a creatinine of 2.32 with no indications of kidney stones or kidney infections on imaging or labs. My CT did show bilateral diffuse hypoattenuations of both my kidneys, however. I was admitted for further workup. During my first admission my blood pressure was consistently in the 150s/100s during my time. I was told it was due to my pain and possibly anxiety. My creatinine maxed out at 2.35 on day one and after 4 days of Lactated Ringers at 150/hr it was still 1.9. My fluids were discontinued on day 4 due to fluid retention and my ability to tolerate P.O. intake completely fine. My creatinine only went down to 1.67 by the time I was discharged on Hospital Day 11. During my time there I received a renal US, full abdominal US, 2 abdominal CTs (one with and one without contrast), Echocardiogram (with bubble study), and had a plethora of labs done for different possible causes of my bilateral renal injuries (ANA, ANCA, etc.). I was seen by a nephrologist who told me that I was a zebra and that she had no idea what could be causing my issues. One week later, I was seen for my post discharge followup and was sent to the ED from the office because my BP was in 150s/110 and I had a severe headache, was seeing black spots everywhere, I was sweating, found it hard to breathe, and I looked pale. The ED did a migraine workup, including obtaining a CTH that was normal and did not obtain a cardiac workup because my BP dropped below HTN emergency/urgency cutoffs by the time I was seen in the ED (I am assuming). I was discharged from the ED with promethazine (for headache) and oxycodone (for flank pain). The NP who sent me to the ED called me and asked why I did not receive a cardiac workup when I was severely short of breath, seeing spots, having headaches, and having a high blood pressure and heart rate that was in the low 100s at rest. She told me to go back to the ED and I decided to go to another hospital. Upon arriving the the second ED, my BP was 176/117. I received a full cardiac workup, including a repeat EKG, echocardiogram with bubble study, BNP, etc. All "within normal limits." I was sent home but returned the next evening after an episode of hematospermia with four large blood clots and ejaculate that looked as if it was pure blood. The hospital admitted me the second time and I received more extensive workup, including GI (due to elevated AST/ALT with multiple liver hemangiomas on CT) and Cardiology. On holster monitoring, I was found to have a resting/supine heart rate in the 80s. When sitting up, my heart rate went into 120s, and while standing and walking around, my heart rate went into the 160s. I received a pheochromocytoma workup and more which all came back negative. I received a left-sided renal biopsy which showed "normal" signs of aging glomeruli and sclerosis which was negative for any immunofluorescent staining. My nephrologist told me that the biopsy showed that my previous incident did not scar my kidneys, however, on CT, MRI, and Ultrasound, my kidneys are consistent with pyelonephritis or "medical renal disease." As of right now, my creatinine is in the "high normal" range and I am on medications for symptom control (to lower my blood pressure and keep my heart rate from jumping high). I gained 30 pounds from fluids in the hospital and although I am not intravascularly fluid overloaded (no pitting edema, crackles on pulmonary exam, etc.), I have not been able to get rid of the fluid. I spent almost a month in the hospital and was unable to complete my final rotation of medical school on account of me fainting with a BP in the 150s/100s on my first day on morning rounds. I am therefore taking an extra year to complete my medical school education. The struggle of the entire situation and my current health status is exhausting. I am very fatigued every day, finding it very hard to wake up in the morning even with an ample amount of sleep. I can easily sleep all day, even if I have taken my ADD medication. I can't focus on anything. This event has taken over my life and I feel as if I am spiraling down into an abyss that I may never find my way out of.