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In: Anatomy and Physiology

Medical Report: Nephrology Consultation HISTORY OF PRESENT ILLNESS: This 57 year old white male was admitted...

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, 2017, 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 7/23/17: Na 134. K 4.7. CO2 80. Cl 100. BUN 128. Creatinine 10.0. Random blood glucose 117. Blood chemistry on 9/20/16: 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 these tests work?

3) Describe an IVP procedure.

4) Why has the patient's skin turgor decreased? How can you tell?

Expert Solution

Ans 1) The level of BUN and creatine are important indicator of renal function and overall health of the kidney. BUN is blood urea nitrogen and it helps in measuring the renal function by measuring the total amount of urea nitrogen in the blood. In an adult male the normal BUN level should be between 10 to 20mg/dL. The creatinine is a waste product which is formed from normal muscle breakdown and the creatinine clearance and its amount is an indicator of healthy performing liver. Without the kidney functioning properly, the level of creatinine tends to build up in the blood. The normal level of creatinine should be between 0.6 to 1.2mg/dL in an adult male. The test shows he has BUN level is 32mg/dL and creatinine level is 2.8mg/dL and hence he has very high content of both in his blood indicating renal failure and inefficient functioning of kidney. This means that urea and creatinine produced as waste product is not eliminated from urine due to the improper functioning of the kidney.

Ans 2) In this the function of the kidney is evaluated in both the lab test as the BUN and creatinine level helps in indicating the functioning of kidney and renal activity. It helps in estimating how well the kidney is able to eliminate the waste from the body. The BUN and creatinine tests work by determining the level of blood urea nitrogen and creatinine in blood and if it is high or low. When it is very high, it means that there is renal failure.

Ans 3) The IVP or intravenous pyelogram is a X-ray done to analyze the kidney, bladder and the ureters. It is helps in checking for kidney stones, prostate enlargement, presence of kidney stones or tumors, congenital problems etc. In this process a contrasting material is injected intravenously through hands or arm which travels to the kidney and urinary tract. After this an X-ray is taken which shows the urinary tract and kidney and how the urinary tract act while kidney empty in ureters. The dye moves and its movement is tracked and when its movement slows down, it indicates a blockage. The slow functioning or renal dysfunction can take an IVP procedure to complete in 4 hours whereas normally it takes an hour.

Ans 4) The main reason for decrease in turgor of the skin is dehydration caused due to decrease in the intake of the fluid. When there turgor decrease, there is abnormal change in skin and it takes very long time for the skin to change its shape and come back to its normal self. It is one of the most prominent signs of dehydration.

Sydney Mullin answered 1 year ago

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