Mr. Aaron Turner is a 53-year-old male who works at the local Ford truck plant as a machinist. He comes to his primary care doctor, Dr. Koch, complaining of fatigue, nausea, vomiting, and leg swelling. He says the symptoms developed gradually over the week he returned to work after the new year, and now he really can’t eat very much without vomiting and just feels terrible. He hasn’t vomited any blood, but feels like he has a “sour stomach” and nausea all of the time whether he eats or not. He hasn’t had any abdominal pain or diarrhea, and no one else in his house or at work has been sick.
He usually takes Naproxen and Tylenol over-the-counter daily to manage his chronic lower back pain, and also takes Terazosin for prostate problems and Lisinopril and HCTZ for hypertension. He drinks a couple of beers most nights but never more than three at a sitting. He has otherwise been healthy and his health maintenance is mostly up-to-date, although he been reluctant to get his colonoscopy done so far despite his doctor’s advice. At the start of the new year, he made a resolution to get into shape and so he has been going to the gym 5 days a week as well. He has taken some extra doses of ibuprofen since his back has been bothering him more with this increased activity.
|Weight||24.1 lbs (up 18 lbs)|
Gen: ill appearing but not distressed.
HEENT: + JVD to angle of jaw at 60 degrees elevation. Mucus membranes moist and pink.
CV: S3 and S4 heard at lower sternal border, rhythm regular. Pulses strong all 4 extremities.
Pulm: rales bilaterally at the lung bases.
Abd: no bruits, no organomegaly appreciated. Bladder not palpable. Bowel sounds present. No pain with palpation. Rectal exam shows normal tone, enlarged prostate and brown stool.
Ext: 2+ pitting edema to knees bilaterally.
His doctor orders several tests. The first to return is his electrolyte panel, which is called to the physician on call later that night and is shown below:
The on-call physician, Dr. Lederer, checks the electronic record for the practice and sees that the patient’s former creatinine was 2.1 and his urine was negative for microalbumin a few months ago when routine labs were performed. She calls the patient and tells him to go straight to the ER. The patient asks if he can just be seen in the morning, but the physician is not comfortable waiting due to the elevation of his potassium and insists he go to the ER immediately. She then phones ahead to the ER to tell the ER physician, Dr. Cradley, that the patient is coming in and the reason for referral as well as report his baseline labs several months prior.
Dr. Cradley sees Mr. Turner after he has been triaged and repeats the physical exam, with no notable changes from the examination performed by Dr. Koch earlier in the day. He orders several additional tests and interventions to occur simultaneously. In addition to a repeat electrolyte panel, he orders a blood count, cardiac enzymes and ECG, urine sent for urinalysis, culture, and urine electrolytes, markers of inflammation, a B-natriuretic peptide level, and chest X-ray. The blood count shows:
|occasional granular casts seen|
Repeat electrolytes are unchanged with the exception of potassium of 7.1
ESR is 8, CRP is 3.1 (normal at this facility is < 5), and C3 and C4 are normal.
BNP level is 530 (normal <200 at this facility), Cardiac biomarkers are normal with the exception of troponin I, which is mildly elevated at 0.061 (the upper limit of normal is 0.04)
The ECG and CXR are shown below:
The interventions ordered include an indwelling urinary catheter (that Mr. Turner is not happy about), kayexalate orally and rectally, (also not making Mr. Turner happy, at all) IV calcium gluconate, IV insulin and dextrose, and IV bicarbonate.
Hospital day 1: All of his home medications are held, and IV Nifedipine, Isosorbide dinitrate, and Hydralazine are started for blood pressure control. He is placed on telemetry and noted to have intermittent asymptomatic 20- to 30-beat runs of ventricular tachycardia over the first hour of therapy. Potassium is rechecked 2 hours after initiation of treatment and is 5.7, with normalization of his EKG. He is admitted to the hospital on IV normal saline with frequent laboratory checks of his electrolytes. During the night, his potassium has begun to rise again, his crackles worsened and he required oxygen supplementation to keep his saturations over 95%. His BUN and creatinine are down to 37 and 3.1 in the AM, and IV furosemide in small doses is started at the recommendation of cardiology and nephrology. He is able to void independently and a renal and bladder ultrasound shows increased echotexture of the kidneys consistent with medical renal disease, so the indwelling catheter is removed. His fractional excretion of sodium returns at 2.1%
Hospital days 2 and 3: his telemetry has normalized, he has a net negative fluid balance of 3 liters per day, and his potassium has remained normal since the initiation of the furosemide. His hypoxia has resolved, and his BUN/Creatinine is 31/2.9. He is discharged on hospital day 4 on oral Nifedipine, Hydralazine, Isosorbide dinitrate, and furosemide with close follow-up that week with cardiology and nephrology.