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An 80-year-old male was transferred from his nursing home to the emergency room for generalized weakness of 3 days duration. His weakness got worse to the extent that he found it difficult to go to the bathroom. He also mentioned worsening dysuria and difficulty passing urine for the last week. There was no chest pain, fever, cough, abdominal pain, back pain, hematuria, diarrhea, melena, or rash.

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The patient has a history of dementia, benign prostatic hypertrophy (BPH), congestive heart failure (CHF) with an ejection fraction of 40% as measured 6 months ago, chronic kidney disease (CKD) stage III, diabetes mellitus type 2, and hypertension. He takes donepezil, memantine, tamsulosin, finasteride, lisinopril, metoprolol, amlodipine, torsemide, and metformin. The patient is a widower who has lived at the nursing home for the last 4 years. He has never smoked or drunk alcohol.

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Vital signs in the ER: blood pressure of 100/60, heart rate of 100, and respiratory rate of 20. He had a normal temperature and oxygen saturation on room air. The patient was closing his eyes during the physical examination and trying to sleep. His mucosa looked dry. Neck, heart, and lung examinations were unremarkable. There was mild abdominal tenderness in the hypogastric area with dullness to percussion. There was a +1 bilateral pitting edema. Neurological examination was within normal limits. Void collector on the bedside contained 30 cm3 of dark yellow urine.

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  • Initial workup:
  • WBC: 9000 with normal differential
  • Hemoglobin: 10
  • Platelets: 200,000
  • Sodium: 130
  • Potassium: 5.1
  • Chloride: 103
  • Bicarbonate: 16
  • Blood urea nitrogen: 95
  • Creatinine: 8.5 (patient's baseline is 1.8; last check was 1 month ago)
  • Glucose: 220
  • CXR: mild bilateral interstitial infiltrates and cardiomegaly
  • ECG showed sinus tachycardia with peaked T waves in the anterior leads

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1. What is the most important next step?

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2. How would you work up the patient's acute kidney injury (AKI)?

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Answers

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This is a case of an elderly patient with a history of CKD, CHF, and benign prostatic hypertrophy (BPH) who is presenting with weakness and difficulty passing urine. He had poor oral intake for a week prior to admission. On examination, he has hypogastric tenderness and dullness to percussion over that area. His heart rate is 100 and his blood pressure is 100/60. Labs showed severe AKI, severe hyperkalemia, and low bicarbonate.

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  1. The patient needs an immediate therapeutic and diagnostic plan. Foley catheter should be inserted to help in getting an accurate urine output (UOP) and to relieve any obstruction at the prostate level. Because of the decreased oral intake, tachycardia, and mild hypotension, intravenous normal saline should be started. Continuous oximeter and serial lung examinations are important in such patients with low ejection fraction. The unknown UOP is being treated with fluids. Metformin, ACE inhibitors, and diuretics should be held. Insulin is ...

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