Acute Renal Failure

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ACUTE RENAL FAILURE

PATIENT CASE

HPI

Mr. J.R. is a 73-year-old man, who was admitted to the hospital with clinical manifestations of gastroenteritis and possible renal failure. The patient's chief complaints are fever, nausea with vomiting and diarrhea for 48 hours, weakness, dizziness, and a bothersome metallic taste in the mouth. The patient is pale and sweaty.

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ACUTE RENAL FAILURE

PATIENT CASE

HPI

He had been well until two days ago, when he began to experience severe nausea several hours after eating two burritos for supper. The burritos had been ordered from a local fast-food restaurant. The nausea persisted and he vomited twice with some relief. As the evening progressed, he continued to feel "very bad" and took some Pepto-Bismol to help settle his stomach. Soon thereafter, he began to feel achy and warm. His temperature at the time was 100.5°F. He has continued to experience nausea, vomiting, and a fever. He has not been able to tolerate any solid foods or liquids. Since yesterday, he has had 5-6 watery bowel movements. He has not noticed any blood in the stools. His wife brought him to the ER because he was becoming weak and dizzy when he tried to stand up. His wife denies any recent travel, use of antibiotics, laxatives, or excessive caffeine, or that her husband has an eating disorder.

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ACUTE RENAL FAILURE

PMH

HTN X 14 years

Post-AMI x 10 years

Heart failure X 8 years

No known renal disease or DM

Osteoarthritis X 5 years

DVT at age 61, treated with anticoagulants for 1 year

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ACUTE RENAL FAILURE

FH

Father died at age 50 from AMI

Mother has type 2 DM

Has two brothers, both living, with no known medical problems

Has two sons without medical problems

SH

Retired pharmacy professor who is living at home with his wife of 34 years

Denies use of alcohol, tobacco, and illicit drugs

Has 2 cups of coffee maximum daily

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ACUTE RENAL FAILURE

ROS

Was not performed as patient is acutely ill

Meds

Digoxin 0.125 mg po QD

Furosemide 40 mg po QD

Enalapril 20 mg po QD (recently added to furosemide to manage HTN)

OTC acetaminophen 500 mg po PRN

ALL

Sulfa drugs (anaphylaxis)

Molds (watery eyes and sneezing)

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ACUTE RENAL FAILURE

Physical Examination and laboratory Tests

General

The patient is a pale, diaphoretic, elderly Asian male in acute distress. The patient's eyes appear sunken with dark circles around them.

Arterial Blood Gas Results

See Patient Case Table 30.1

Patient Case Table 30.1 Arterial Blood Gas Results

pH 7.35 PaO₂ 87mm Hg PaCO₂ 29mm Hg SaO₂ 95%

Patient Case Table 30.1 Arterial Blood Gas Results
pH 7.35	PaO₂ 87mm Hg	PaCO₂ 29mm Hg	SaO₂ 95%

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ACUTE RENAL FAILURE

VS

See Patient Case Table 30.2

Patient Case Table 30.2 Vital Signs

BP 92/45 RR 30 WT 185lbs

P 115 T 101.3°F HT 5'11"

Skin

Pale

Poor turgor

Warm to touch

Patient denies itching

Patient Case Table 30.2 Vital Signs
BP 92/45	RR 30	WT 185lbs
P 115	T 101.3°F	HT 5'11"

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ACUTE RENAL FAILURE

HEENT

PERRLA

No funduscopic abnormalities

EOMI

Conjunctiva pale

Non-erythematous TMs

Nose clear w/o exudates or lesions

Mucous membranes pale and dry

Tongue rugged

Slight erythema in throat

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ACUTE RENAL FAILURE

Neck/LN

Supple

No JVD or HJR

No lymphadenopathy or thyromegaly

No carotid artery bruits

Heart

Normal S₁ and S₂

Faint S₃

No murmurs or friction rubs

Normal sinus rhythm

Lungs

No crackles bilaterally

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ACUTE RENAL FAILURE

Abd

Diffuse tenderness

No guarding or rebound

Soft and no.n-distended with hyperactive bowel sounds

No HSM

Genit/Red

Prostate exam normal

Slightly heme-positive stool in the rectum

No grossly visible blood

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ACUTE RENAL FAILURE

MS/Ext

Normal muscle strength bilaterally

No CCE

Peripheral pulses weak at 1 + bilaterally

Patient denies any muscle tenderness

Neuro

A & O X 3

CNs intact

Motor function-no focal weakness

Slightly decreased patellar reflex, otherwise normal reflexes

Normal coordination and gait

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ACUTE RENAL FAILURE

Laboratory Blood Test Results

See Patient Case Table 30.3

Patient Case Table 30.3 laboratory Blood Test Results

Na             144 meq/L Cr                   2.6 mg/dL Alb              4.3 g/dL PMNs              29%

K                4.7 meq/L Glu, random         155 mg/dL Hb              13.9 g/dL Lymphs           66%

Cl               111 meq/L Ca                    9.1 mg/dL Hct              48% Monos             3%

HC0₃          19 meq/L Phos                4.1 mg/dL Plt              190,000/mm³ Eos                  1%

BUN            57 mg/dL Mg                   2.8 mg/dL WBC          11,700/mm³ Basos              1%

Patient Case Table 30.3 laboratory Blood Test Results
Na 144 meq/L	Cr 2.6 mg/dL	Alb 4.3 g/dL	PMNs 29%
K 4.7 meq/L	Glu, random 155 mg/dL	Hb 13.9 g/dL	Lymphs 66%
Cl 111 meq/L	Ca 9.1 mg/dL	Hct 48%	Monos 3%
HC0₃ 19 meq/L	Phos 4.1 mg/dL	Plt 190,000/mm³	Eos 1%
BUN 57 mg/dL	Mg 2.8 mg/dL	WBC 11,700/mm³	Basos 1%

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ACUTE RENAL FAILURE

UA

Clear, pale yellow urine

Microscopy was negative for cells, casts, pigments, and crystals

SG 1.019

(-) bacteria

(-) glucose

(-) protein

WBC 1/HPF with no eosinophils

RBC 1/HPF

Na concentration = 14 meq/L

Osmolality = 769 mOsm/kg H₂O

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ACUTE RENAL FAILURE

Clinical Values for Case Study Problem-Solving

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Clinical Values for Case Study Problem-Solving

Abbreviations

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Abbreviations

Renal system physiology

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Renal system physiology