Question

F.F., a 58-year old with non-insulin dependent diabetes mellitus (NIDDM), presents at the ED with severe R-flank and abdominal pain, nausea, and vomiting. The abdomen is soft and without tenderness. The right flank is extremely tender to touch and palpation. VS are 142/80, 88, 20, 99.0^oF; urinalysis shows hematuria; an IV of 0.9% NS is started and is to infuse at 125 mL/hr.

An intravenous pyelogram confirms the diagnosis of staghorn-type stone in the R-renal pelvis. The right kidney looks enlarged. He states that he did not sleep well last night and has not eaten much today. He is obviously very fatigued. His laboratory results are as follows: Na 144 mEq/L; K 4.0 mEq/L; Cl 101 mEq.L; CO₂ 25 mEq/L; BUN 30 mg/dL; creatinine 3.6 mg/dL; glucose 260 mg/dL; uric acid 5.0 mg/dL; Ca 9.0 mg/dL; phosphate 2.6 mg/dL, total protein 7.8 g/dL; albumin 4.0 g/dL; total bilirubin 0.3 mg/dL, direct bilirubin 0.1 mg/dL; chloride 200 mg/dL; alkaline phosphatase 61 U/L; LDH total 100 U/L; AST (SGOT) 13 U/L; ALT (SGPT) 13 U/L; GGTP 40 U/L; amylase 98 U/L.

1. F. F. is treated with IV morphine for pain. It is late afternoon before he is admitted to your unit and scheduled for lithotripsy in the morning. What specific priorities do you identify for F. F.?
2. The physician has prescribed gentamicin 80 mg IVPB q 8h. You question the physician about giving this large a dose of gentamicin to F. F. You are met with angry and belittling statements. Articulate why you should question this specific order for F. F.
3. How should you handle the situation with the physician in order to protect the patient and promote a collegial relationship?
4. Hydronephosis is a potential complication for F. F. What may be the impact of this problem on his long-term kidney function.
5. Analyze the relationship between creatinine and GFR and predicting kidney function.
6. Later, as you walk past his bed, you notice F. F. crawling off the end of the bed. What are you going to do?

F. F. is going to be admitted. You call the unit nurse to give report. You tell her he’s been up all night with pain that has just been relieved by IV morphine. You don’t know whether he’s going to have lithotripsy or surgery; surgery is unlikely because the stone is so large.

7. You tell F. F. he is going to be admitted and will probably need surgery for his kidney stone. He looks at you, panicked, and says, “I can’t do that. I don’t have any insurance. This is costing me a wad already.” How are you going to respond?

Answer 1

Here the patient is known case of non insulin dependent diabetic. The patient is having severe pain due to the staghorn calculus. Before lithotripsy, special consideration should be given to his blood sugar control, fluid and electrolyte supplement, pre operative antibiotics. Blood sugar monitoring should be done. A proper one anesthetic consultation should be carried out.

The patient's creatinine is 3.6mg/dL which is abnormal. It indicates improper functioning of kidneys. So the nephrotoxic drugs like aminoglycosides should be avoided. Here physician started gentamicin which is an aminoglycoside antibiotic. Address this issue very politely to the physician for giving a safe antibiotic.

Hydronephrosis is an irreversible condition that may progressive and eventually leads to renal failure and the only treatment is renal transplant

As the creatinine increases the GFR decreases. Creatinine can be considered as a marker of glomerular function.