Health Simulation Activity
Creatinine - vitamin C
Questioning is the basis of all learning.
Overview
Information to create a role play, problem solving, simulation for learners to participate in a health activity as a medical intern. The information is presented as: narrative with background information and dialog between a Practicing Physician, intern, and patient.
Situation is a cancer patient who receives alternative treatment along with chemotherapy and its negative effects on their kidneys.
Hints and answers for the questions are provided below the narrative so the narrative may be printed and read as a read aloud with discussion or provided to groups of learners to create a role play presentation to apply and review body functions.
Anatomy and body function concepts include:
- Vitamin C history of its discovery
- Vitamins
- Kidneys function, bladder, urine
- Metabolism, proteins, amino acids, urea, ammonia
Role play
Setup
An oncologist consults with a nephrologists, kidney doctor about a cancer patient who has a standard blood test, with results showing a high creatinine level of 6.8 milligrams per deciliter. Where a normal range is considered between .5 milligrams per deciliter and 1.1 milligrams per deciliter.
- How is creatinine formed? (background)
- What might cause high levels of creatinine? (background)
The oncologist, nephrologists and intern (you) consult with the patient.
Doctor O, Good morning ... This is Dr. N and intern I who I have asked to meet with you to consider what might be causing your high levels of creatinine and how to proceed to get it down.
Doctor N, The results suggest there might be something affecting your kidneys so how have you been feeling lately?
Patient, Okay, but I have been rather tired and sluggish not feeling like doing much.
Doctor N, What have you eaten lately?
Patient, ... Cereal in the morning, a sandwich and cookie for lunch and a salad for dinner.
Doctor N, What fluids have you had?
Patient, Tea in the morning and my water bottle with water during the day. Oh and a cola with dinner.
Doctor N, turns to the intern and asks, What are you considering?" (Meaning: What might cause high levels of creatinine? Hints & suggestions - 1)
The intern knew this question would be coming and began reflecting on what they know about kidney function and observing the patient.
Intern:
Doctor N, What treatment can we safely begin immediately? (Hints & suggestions - 2)
Intern
Doctor N, What more information should we get? (Hints & suggestions - 3 & 4)
Intern
****
Results: Creatinine levels continue to increase and ultra sound shows nothing visually abnormal.
****
Doctor N, All the new information yields nothing to suggest a problem, what next?
Doctor N, What more information should we get? (Hints & suggestions - 5)
Intern
*****
Doctor N, ...
Patient, ...
After an exhaustive review the patient mentions a visit to another Dr. who prescribe weekly injections.
Doctor N, Ask? (Hints & suggestions - 6)
Doctor N, What kind of injections?
Patient, Vitamin C
Doctor N, Ask? (Hints & suggestions - 7)
Patient - 100 grams vitamin C.
Doctor N, turns to the intern and asks, How might vitamins C affect the kidneys and creatinine levels? (Hints & suggestions - 8)
Intern,
Doctor N, How might we treat .... ? (Hints & suggestions - 9)
Intern,
Future? (Hints & suggestions - 10, 11, & 12)
Hints and suggestions
- What might cause high levels of creatinine?
- Nauseous from chemotherapy drugs or other drugs can cause dehydration,
- Vomiting, or other illnesses (diabetes, high blood pressure, allergies ...
- Medicine prescribed, self medication, drug use.
- An obstruction or tumor in the kidney.
- If the condition is caused by dehydration, a saline drip.
- More tests: double check the creatinine levels.
- Ultra sound to check for an obstruction or tumor.
- Reinterview the patient and see what might have been missed.
- What kinds of injections are they?
- What is the dose of each injection?
- Vitamin c is ascorbic acid. It is needed to make connective tissue, heal wounds, and synthesize neurotransmitters,and an antioxidant. Our body doesn't make it so we need to get it from our diet. However, the amount being injected weekly is equivalent to a bottle of Vitamin C pills all at once or 100,000 milligrams per week. With the hope to kill cancer and improve her energy levels, but it is turning into oxalate, (a sharp edged crystals, that accumulates in the kidney tubules and blocks them. Clogging the tubules and causing the kidneys to die.
- Start dialysis and hope they kidneys will heal themselves.
- With dialysis the patient is able to be discharged.
- However, their kidney didn't heal and dialysis was required three times a week to stay healthy.
- Future transplant depending on cancer prognosis.
Background information
Creatinine forms from protein metabolism.
Nephritis is the inflammation of the nephrons, which in the worst case can cause kidney failure requiring dialysis.
Background for metabolism
- Metabolism supplies energy for muscular contraction.
- Creatinine is a byproduct of creatine. The amino acid creatine is a natural part of all muscles, and is processed to store energy for muscular contraction. The process by which it's metabolized creates creatinine, which is then found in muscles and blood. From where it flows to the kidney where it is removed, excreted, and collected as part of urine.
- People who are healthy, have no problem filtering creatinine out of the bloodstream by the kidneys.
Background about protein
- Protein is essential for growth.
- Eating food with protein is the sole source of the ten essential amino acids, and the primary source of nitrogen, necessary for the synthesis of other amino acids.
- Protein is digested and broken down to amino acids, primarily in the liver, which are absorbed into the circulation and taken to cells throughout the body, and quickly become combined by peptide linkages.
Background energy, metabolism, protein, amino acids
- Humans get energy from carbohydrates (simple and complex sugars), fats, and proteins through the process of metabolism.
- Metabolism includes the breakdown of substances (catabolism), the formation of new products (synthesis or anabolism), or the transferring of energy from one substance to another.
- Protein metabolism occurs primarily in the liver and, to a lesser extent, in the kidney.
- Metabolism (catabolism - break down also deamination) of proteins and amino acids removes an amino group (-NH2) from an amino acid and converts it to ammonia, which is ultimately converted to urea and excreted. Additionally deamination can be for plasma protein synthesis, and when amino acids are changed from one to another.
- Nitrogenous wastes contain ammonia and include, urea, uric acid, creatinine and ammonia, which is a colorless crystalline compound.
- Creatinine, also an NPN waste product, is produced from the breakdown of creatine (in muscles) and phosphocreatine. It can serve as an indicator of renal function. Creatine is synthesized in the liver, pancreas, and kidneys from the transamination (the transfer of an amine group from one amino acid to another to synthesis nonessential amino acids) of the amino acids arginine, glycine, and methionine.
- Ammonia is a waste product the liver can remove. Or it can be added to other chemicals to form an amino acid called glutamine, or form a chemical compound called urea.
- Your bloodstream moves urea to your kidneys, where it's eliminated in your urine.
- The plasma level of amino acids is tightly controlled and maintained near a constant level. Once the cellular limit of protein storage is met, excess amino acids are broken down and used for energy or stored as fat or glycogen.
- The liver is the primary site that breaks down amino acids into simpler ones and release energy, except branch-chained amino acid break down, which occurs in the muscle cells.
- The urea cycle, in which the toxic compound ammonia is converted to urea, occurs solely in the liver. The synthesis of plasma proteins, albumin, fibrinogen, and globulin also occur in the liver.
Background kidneys
- Kidneys filter your blood. About half a cup every minute. Nephrons are the structures in the kidney that do this. They have two parts: glomerulus, which filter the blood and tubules, tubes for the blood and other usable materials to flow back into the bloodstream.
- Removes waste material and excess fluid, and excretes it as urine.
- More about kidneys.
Source
Adapted from Discover Magazine. Overloaded by Nathaniel Scharping. Discover, March/April 2024.
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