After reading the report, answer the eight questions that follow: Medical Report

Question

After reading the report, answer the eight questions that follow:

Medical Report: Nephrology Consultation

HISTORY OF PRESENT ILLNESS: This 57 year old white male was admitted to the hospital yesterday with a history of progressive lethargy, weakness, dysphagia, constipation, and generalized malaise. These symptoms have been present for the last 3 to 4 days.

During his last hospitalization on January 20, 2015, preoperative investigation revealed a BUN of 32 and a creatinine of 2.8, and there was no documentation of any BUN or creatinine at the time of discharge. He has a normal IVP.

It was noticed that he has a urinary tract infection with E. coli at that time, and hence he was discharged with Bactrim.

PHYSICAL EXAMINATION: Revealed a 57 year old man, a little lethargic, well oriented. His BP was 136/74 mmHg. Tongue pink and a little dry. Neck: carotid pulsations normal. Skin: decreased in turgor at present. Heart sounds normal. No gallop. Lungs with normal breath sounds. Abdomen is full, with operative scar in the right hypochondrium, with ascites present. Extremities: no peripheral edema. Well perfused. Peripheral pulsations normal.

LABORATORY: Blood chemistry on 7/23/15: Na 134. K 4.7. CO2 80. Cl 100. BUN 128. Creatinine 10.0. Random blood glucose 117. Blood chemistry on 9/20/10: Na 139. K 4.4. CO2 18. Cl 107. BUN 138. Creatinine 7.6. Fasting blood glucose 110. Ca 8.4. P 5.5. Uric acid 19.7. Total protein 5.8. Albumin 2.4. Mg 3.4. Alkaline phosphatase 41.2. SGPT 59. SGOT 62. CBC: WBC 6.2 with Hgb 13.3. Hct 38.5. platelets 246.000. Urinalysis has shown specific gravity of 1.012. No protein or hemoglobin present. WBC 2-3, RBC 0-1; bacterial cells +1.

IMPRESSION: The patient has chronic renal failure of several years' duration with compromised renal function. His postoperative course was uneventful except for complaint of slight reduction of urinary output. There has been no documentation of renal function at the time of discharge. The patient was given Bactrim, following which the patient developed symptoms of uremia, and on investigation, the patient's renal function has markedly deteriorated in the course of 5 days. It is my presumption that the patient's chronic renal failure, which was in a delicate balance, has further deteriorated with Bactrim. The Bactrim has been discontinued for 24 hours now. There has been improvement in the creatinine level, from 10 to 7.6 mg%. His BUN is still high, and it appears that the patient is still in hypovolemia and needs further hydration.

In addition, the patient has pyelonephritis of several years' duration, and analysis of the urine yesterday does not reveal any evidence of persistence of the infection. The patient might also have renal function impairment secondary to chronic pyelonephritis.

Review of the record and the patient reveals no evidence of acute ischemic renal failure. His serum magnesium is high, and the patient received some Milk of Magnesia at home. If the patient does not show any further improvement in the next 24 hours, suggest obtaining a renal scan with blood flow studies.

1) Were the results of the preoperative BUN and creatinine studies abnormal? How can you tell?

2) Which organ function is evaluated with those two laboratory tests? How do the tests work?

3) Describe an IVP.

4) Why has the patient's skin turgor decreased?

5) Has the patient experienced any decrease in urinary output? How do you know?

6) Where is the right hypochondriac region?

7) What is ascites? What causes it and how is it treated?

8) Did the patient have any swelling of the extremities? How do you know?

Explanation / Answer

1. The normal range of BUN is 7 - 20 mg/dL. Patients undergoing dialysis have BUN values of 40 - 60 mg/dl. Sicne the patient is not undergoing dialysis, BUN of 32 indicate slightly higher than the normal; and BUN of 138 indicate extremly abnormal value.

The normal range of creatinin is 0.5 to 1.5 mg/dl. The patient has blood creatinine of 2.8 and 10, which are pretty high. These two values are extremely high and show an abnormality.

2. BUN and creatinine are checked to asses kidney functions. Kidney is the organ that excretes nitrogen wastes. BUN and creatine are nitrogenous wastes. Creatinine is a metabolic end product of creatine, a major energy source of muscles. When kidneys are unable to excrete these two nitrogen wastes, it indicate a damage in glomerula filtration of kidney function.

3. IVP or intravenous pyelography is a non-invasive diagnostic test performed to check the kidney functions. A contrast dye is injected to test how quickly and efficiently the patient's kidneys are able to handle soluble wastes. The test typially used to diagnose kidney stones, enlarged prostate, scarring of the urinary tract, congenital anamolies of the urinary system, tumors and blockages in the kidney, ureters, and urinary bladder.

4. Decreased skin turgor is a late symptom of dehydration. In severe dehydration (more than 15% of fluid loss from the body), the skin cannot snap back readily to its normal position when it is grasped and released.

5. NO signs of decreased urinary output observed. All the electrolyes are at normal values.

6. The right hypochondriac region is present at the upper right side of the abdominal cavity, extends from 6th to 10 ribs, it covers the area of the upper and lower edges of the liver in the right side of the abdominal cavity.

7. Ascites is accumulation of fluid in the abdominal cavity (lining of the abdomen and abdominal organs). Ascites occur due to the following reasons:

* High blood pressure in vessels of liver

* Malnutrition of proteins, low levels of protein called albumin

* Liver damage, cancers in abdomen, colon, ovaries, uterus, pancrease

* Impaired kidney functions

Treatment: Restriction of salt in deit, use of diuretics, and paracentesis

8. The report says there is no peripheral edema. So, the patient does not have any swelling of the extermities.

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