Case #2
The patient is a 54 year-old male with a history of coronary artery disease who was admitted to the hospital for increasing lower extremity edema, abdominal swelling and shortness of breath. The patient had noted an ~30 pound weight gain over the past month and during the past week has had three pillow orthopnea.
On physical exam the patient is a well-developed, well nourished male in moderate respiratory distress. Blood pressure 140/80, pulse 95, respirations 28 and labored. Body weight 101 kg. HEENT was unremarkable. Cardiac exam had an S1, S2 and S3 without S4 or murmur. Pulmonary exam was remarkable for bilateral rales 2/3rd up both lung fields. Abdomen was enlarged with a positive fluid wave. Lower extremities were remarkable for 3+ pitting edema.
Laboratory Data
|
|
June | July 1 | July 2 | July 3 | Normal Values |
| Sodium | 130 | 133 | 134 | 133 | 136-140 mmol/L |
| Potassium | 4.9 | 5.7 | 5.8 | 6.0 | 3.5-5.3 mmol/l |
| Chloride | 100 | 90 | 91 | 93 | 98-108 mmol/L |
| Total CO2 | 22 | 20 | 17 | 15 | 23-27 mmol/L |
|
BUN |
20 | 87 | 94 | 101 | 7-22 mg/dl |
| Creatinine | 0.9 | 3.0 | 3.5 | 3.7 | 0.7-1.5 mg/dl |
Renal ultrasound- Right kidney 10 x 5.5, Left kidney 10.5 x 6.0. Both kidneys demonstrate normal echogenicity and are without masses or cysts. There is no hydronephrosis.
Urine lytes- (July 2nd) sodium 10 mmol/L
creatinine 130 mg/dl
Case #2 Questions
1. "The patient is a 54 year-old male with a history of coronary artery disease who was admitted to the hospital for increasing lower extremity edema, abdominal swelling and shortness of breath." What does this suggest?
2. " The patient had noted an ~30 pound weight gain over the past month ". What is the reason for his weight gain and explain why that occurs with your diagnosis?
3. " during the past week has had three pillow orthopnea.". What is orthopnea.? Why is he orthopneic?
4. Explain the significance of his cardiac findings. " Cardiac exam had an S1, S2 and S3 without S4 or murmur".
5. Pulmonary exam was remarkable for bilateral rales 2/3rd up both lung fields. What does this suggest to you?
6. " Abdomen was enlarged with a positive fluid wave. " What does this imply? Demonstrate fluid wave.
7. " Lower extremities were remarkable for 3+ pitting edema." Demonstrate how you will assess pitting edema. Where would you look for edema in a bed ridden patient with CHF?
8. "Renal ultrasound- Right kidney 10 x 5.5, Left kidney 10.5 x 6.0." What is the significance of this report?
9. Is the cause of this patient’s renal failure acute or chronic? What is your reasoning?
10. Calculate the fractional excretion of sodium.
11. Is this patient’s renal failure consistent with a prerenal cause or acute tubular necrosis? What is the rationale for your conclution?
12. What is the patient’s volume status?
13 What would you recommend to improve renal perfusion in this case?
14. When is it appropriate to order urine lytes to determine the fractional excretion of sodium in a patient with renal failure?
On July 3rd the patient had a hypotensive episode associated with a myocardial infarction.
Laboratory Data
| July 4th | Urine lytes Sodium 50 mmol/L Creatinine 40 mg/dl |
|
|
Sodium |
135 mmol/L | |
| Potassium | 6.3 mmol/L | |
| Chloride | 92 mmol/L | |
|
Total CO2 |
14 mmol/L | |
|
BUN |
120 mg/l | |
|
Creatinine |
4.7 mg/dl |
15. Calculate the fractional excretion of sodium on July 4th.
16. Is this patient’s renal failure consistent with a prerenal cause or acute tubular necrosis?
17. What is the most likely etiology of renal failure in this patient on July 4th?
18. What is acute tubular necrosis?