Intern Report Case Presentation 3.7

Case Presentation by Dr. Cameron Kyle-Sidell

CHIEF COMPLAINT(S): “My mother keeps throwing up”

HISTORY OF PRESENT ILLNESS: This is an 84-year-old woman who was brought in by her daughter and granddaughter.   They report that she’s been throwing up constantly for 3 days, approx 10 times per day.  Unable to tolerate food or water.  Reports having some lightheadedness when she walks.  No fevers, cough, rashes, or sick contacts.  No abdominal pain.  No recent trauma.  She did fall several weeks ago hurting her elbow and her left, but came to the emergency room and got a CT of the head which showed no bleed.  Patient medical history includes only hypertension treated with lisinopril.  Previous cesarean section.

VITAL SIGNS: Systolic blood pressure 105, heart rate 71, oral temperature 35.1.  Pulse oximetry is 98% on room air.

PE: No pertinent findings

Course in the ED:

CBC, electrolytes, lipase, and ALP ordered.  IV established and patient received 1 L NS.  Abd X-ray ordered.  First thing to come back were the electrolytes.  Patient’s creatinine is 6.4. Per CIS, patient’s baseline creatinine was 1.3 on November 28, 2010, two months previous.  BUN is 108. All other labs WNL.  Patient currently awaiting abdominal x-ray.

1.  Regardless of the type, what is the final common pathway leading to all ARF?

  1. Reduced renal blood flow
  2. Decreased urine output
  3. Rising BUN and creatinine
  4. Increased urine output

2.  Prerenal Failure is characterized by all except:

  1. BUN/Cr ratio greater than 10:1
  2. Decreased specific gravity
  3. Urine sodium concentration less than 20 mEq/dl
  4. FENa less than 1%

3.  Our patient’s extremely elevated creatinine level of 6.4 tells us that she is experiencing:

  1. Prerenal azotemia only
  2. Intrinsic azotemia only
  3. Prerenal and intrinsic azotemia
  4. Impossible to tell

AND THE BONUS MILLION DOLLAR QUESTION:

After treatment, the patient’s creatinine…?:

  1. who cares, we lost the patient
  2. remained super high, like, because, the patient is on dialysis
  3. came down to, like, 2-something
  4. returned to baseline

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