A physical examination begins with the doctor greeting the patient and taking vital signs (radial pulse, brachial blood pressure, breathing rate, temperature) with the patient sitting. This should be followed by a general visual inspection, then examination of the structures of the head, including cranial nerves. The neck should be palpated for swollen glands or thyroid, then the torso should be examined, including auscultation for heart and lung sounds. After measurement of reflexes, distal pulses, and sensation acuity, the patient is asked to lie supine on the table. The breasts should be examined carefully (both female and male); the heart and lungs are re-ascultated in the new position. The abdomen should be ascultated and palpated to determine liver or spleen enlargement or tender areas. Next, the doctor will inspect the patient’s legs, particularly looking for swelling and normal pulses. Finally, pelvic/rectal examinations are completed according to the patient’s gender (Bickley & Szilagyi, 2012).

Blood pressure is obtained using a blood pressure cuff (sphygmomanometer) which is typically placed on the upper arm (brachial pulse). The clinician inflates the cuff by squeezing a small bulb attached to it. Once a sufficiently high pressure has been reached (well above the pressure that will counteract the blood pressure), the clinician lets the air out slowly while listening for the brachial pulse with a stethoscope. The pressure at which the heart beat is heard is the systolic blood pressure, and the pressure at which the systolic sound goes away is called the diastolic pressure. These two pressures correspond to the heart pumping blood out (systolic) and the heart resting (diastolic). The higher the obtained pressure is, the harder the heart is having to work in order to pump the blood to the rest of the body (Bickley & Szilagyi, 2012).. Mr. Smith’s blood pressure, 160/100, is high because systolic pressure should be less than 120, and diastolic should be less than 80. According to the American Heart Association, if 160/100 is the pressure Mr. Smith has consistently, he would be diagnosed with Stage 2 Hypertension (AHA, 2014).

Initially, the doctor requested blood testing for potassium (K+) level, hemoglobin and hematocrit, and platelet count. A blood sample was taken in order to measure these quantities. In the second round, an additional set of tests was obtained: K+, Hb, Hct, platelet count, HCO3, Urinary K+, blood glucose, serum aldosterone, 24 hour urinary aldosterone, renin, ACTH, and cortisol. Obtaining these values required further blood samples, a urinary sample, and 24-hour urinary collection. The doctor requested the ACTH (adrenocorticotropic hormone) test in order to determine the cause of persistent hypokalemia (low K+ levels). If ACTH was high (as she expected), this would explain the hypokalemia, but if it was low, the doctor would look for another cause (Pagana et al., 2014).

Mr. Smith was below reference values in the following measures. Reference values for K+ are 3.8-4.9 mmol/L (Mr. Smith’s was 2.6 mmol/L), for Hb 13.8-18.2 g/dL (Mr. Smith had 7.3 g/dL), Hct 45-52% (Mr. Smith 20.4%) and platelet count 150-400×109/L (Mr. Smith 20×109/L). The following values were high: HCO3, with reference values 22-26 mmol/L (Mr. Smith’s HCO3 was 38 mmol/L), blood glucose reference values 64.8-104.4 mg/dL (Mr. Smith’s glucose was extremely high at 460 mg/dL), ACTH reference 9-46 pg/ml (Mr. Smith 1082 pg/ml) and cortisol with reference values 0-25 microg/dL (Mr. Smith had 155.5 microg/dL). Urinary K+, urinary 24-hour aldosterone, and renin levels were within normal range (Pagana et al., 2014).

Mr. Smith’s doctor ordered an MRI (magnetic resonance imaging) and CT (computed tomography) as imaging procedures.MRI uses a magnetic field and radio frequency pulses, while CT uses X-rays. Both techniques create thin-slice pictures of internal organs which can be built up into a 3-dimensional image if desired, and both can be used with contrast agents. MRI is generally used to view soft-tissue areas such as organs, while CT is best for viewing injuries to bone (Heidenreich et al., 2014). In Mr. Smith’s case, both CT and MRI indicated that his prostate cancer had metastasized into the osseous (bone) tissue.

Mr. Smith’s diagnosis includes refractory hypokalemia. The term “refractory” refers to a symptom which does not respond to treatment, and “hypokalemia” means abnormally low levels of potassium in the blood. Mr. Smith’s condition is clearly serious since he appears to have Stage IV prostate cancer, given the fact of distant (bone) metastases (Carter et al., 2013). The MRI/CT scans were crucial to staging the cancer because without them the stage would be uncertain (although the disruption of blood cells, i.e. red blood cells and platelets, might have given a clue) (Heidenreich et al., 2014).

When a patient comes to the doctor’s office, the first thing the doctor does is to observe the patient’s symptoms (both directly and indirectly), then she forms a tentative hypothesis regarding the diagnosis. Often there are tests required to confirm the diagnosis. These may include blood tests, urine tests, or imaging such as MRI or CT. When the doctor receives the test results, she compares them to the results she expected according to her hypothesis. The results may support the diagnosis, in which case she proceeds with treatment (although treatment may have already started). If the results do not support the diagnosis, the doctor will create a new hypothesis and additional tests will be necessary (Carter et al., 2013).