Emergency Room Consult: Acute Kidney Injury
A 65-year-old woman presents to the emergency room with a complaint of weakness. She is accompanied by her son.
In the Patient's Words
Clinical Data
Metformin 500 mg twice a day |
Lisinopril 20 mg daily |
Omeprazole 20 mg daily |
Ibuprofen 400 mg twice day as needed |
Time | Temperature (F°) | BP (mm Hg) | Pulse (BPM) | Respiratory Rate | Oxygen Saturation |
12:00 AM | 100.4 | 101/70 | 110 | 16 | 95% RA |
4:00 AM | 100.1 | 110/72 | 100 | 14 | 95% RA |
8:00 AM | 98.9 | 122/74 | 103 | 14 | 96% RA |
Cumulative Intake (ml) | Cumulative Output (ml) | |
2:00 AM | 1250 | 0 |
5:00 AM | 2000 | 100 (urine) |
8:00 AM | 2500 | 125 (urine) |
12:00 AM | |
General | Female, appears ill, weak |
HEENT | Oropharynx clear |
Mucus membranes dry | |
Neck | No JVD |
3 cm right cervical node | |
Chest | Tachycardia |
No murmur | |
Lungs | Reduced at the right base |
Abdomen | Soft, NT/ND, + Hepatosplenomegaly |
Lower Extremities | 3 to 4 cm right inguinal adenopathy |
1 to 2 + bilateral pre-tibial edema | |
Palpable distal pulses |
6 months ago | 1:00 AM | 9:00 AM | |
Na (meq/L) | 137 | 144 | 142 |
K (meq/L) | 4.3 | 5.7 | 5.7 |
Cl (meq/L) | 104 | 114 | 111 |
BUN (mg/dl) | 21 | 42 | 43 |
Cr (mg/dl) | 0.9 | 4.5 | 4.6 |
HCO3 (meq/L) | 23 | 15 | 15 |
Glucose (mg/dl) | 88 | 130 | 200 |
Albumin (g/dl) | 4 | 2 | 2.1 |
Calcium (mg/dl) | 9.5 | 11 | 10.8 |
WBC (cells/mm3) | 5000.00 | ||
Hgb (g/dl) | 10.5 | ||
Platelets (cells/mm3) | 100,000 | ||
Neutrophils | 54% | ||
Lymphocytes | 37% | ||
Monocytes | 6% | ||
Eosinophils | 2% | ||
Urinalysis (automated) | |||
Glucose | None | ||
pH | 6.5 | ||
Specific gravity | 1.01 | ||
Leukocyte esterase | None | ||
Blood | Large | ||
Nitrites | None | ||
Protein | 2+ | ||
RBCs (per HPF) | 20 to 30 | ||
WBCs (per HPF) | 3 to 5 | ||
Hylaine casts | Few | ||
Granular casts | Few |
1:00 AM | |
Chest Xray | Normal cardiac silhouette |
No infiltrates | |
Right moderate pleural effusion |
12 AM: Arrives by EMS |
12:20 AM: IV line established |
1 AM: 1 L Normal Saline administerd |
Cefepime 1 gram administered |
2 AM: Vancomycin 1 gram administered |
1 L Normal Saline |
3 AM: indwelling urinary catheter placed |
Case Responses
After your watch the video and review the data, you will write a case response. This represents your assessment and plan for the acute kidney injury consultation (like in real-life). The focus should be placed on the differential diagnosis for the AKI (as opposed to other related diagnoses). You will create the following as part of your response:
1) A Problem Representation:
This is a concise summary statement that incorporates the key findings from the history, physical, and diagnostic tests in order to characterize the acute kidney injury. It is equivalent to the brief “summary statement” or “one-liner” that we use to communicate about the patient on rounds.
2) A Differential Diagnosis with Justification:
This means a differential diagnosis for the acute kidney injury with data to support a lead diagnosis by using language such as “most likely” or “probably.” Justify why other diagnoses are possible, but less likely.
3) A Diagnostic Plan with Justification:
You will recommend tests or procedures that aim to increase the certainty of the lead diagnosis and exclude less likely diagnoses. Incorporate data from the case to justify the recommendations.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.