18 Oct An 87 year male is brought to the emergency department from a nursing home by his family with concerns about his functional status. They state that over the past week he is very somnolent and not participating in his own care very much.

An 87 year male is brought to the emergency department from a nursing home by his family with concerns about his functional status. They state that over the past week he is very somnolent and not participating in his own care very much. The family is worried that he has had a stroke or is overmedicated by the nursing home staff. Medical record from the nursing home shows that he is disruptive and has daily wrist restraints ordered.

 

The patient is arousable but somnolent when no one is speaking with him. His past medical history is unremarkable. He was placed in the nursing home due to his age and inability to care for himself at home. His family states that he is usually quite alert and interactive. The patient is widowed and has been at the nursing home for about 2 months.

 

He has no routine medications but several PRN mediations including haloperidol, valium, and milk of magnesia.

 

BP 100/53 T 98.3 HR 88 RR 14

 

Mucous membranes are dry. Pulmonary, cardiovascular, abdominal, and extremity examinations are normal. Chest x-ray shows no infiltrate and voided urine shows no evidenced of UTI.

 

LAB DATA:

 

-Sodium 162

 

-Potassium 3.4

 

-Chloride 130

 

-Bicarbonate 23

 

-BUN 38

 

-Creatinine 1.8

 

-Glucose 97

 

-Calcium 10.3

 

What is your working diagnosis for this patient? How would you treat it?                                              

 

Question 2          A 70 year old man is 4 hours post right heme-colectomy for a tumor. The NP is called due to falling urine output since surgery.

 

Past medical history – hypertension, type 2 diabetes, gout

 

Medications – lisinopril, allopurinol, and spironolactone (all last given this morning).

 

Physical exam – BP 100/60. HR 110 regular weight 60 kg

 

Lungs are clear, abdominal wound is clean with no drainage, No JVD

 

Urine output

 

1700 hr. 35 ml

 

1800 hr 22 ml

 

1900 hr 15 ml

 

2000 hr. 8 ml

 

Urine dipstick is normal

 

How would you classify his renal status? How would you treat it?                                             

 

Question 3          A 25 year old man with schizophrenia is admitted to the psych unit for medication stabilization. The patient is responsive but sleepy. Vital signs are within normal limits and muscle tone is normal. The patient has a large container of sweet iced tea which is nearly empty.

 

His admission labs include:

 

-Sodium 122

 

-Potassium 4.0

 

-Chloride 101

 

-Bicarbonate 21

 

-BUN 67

 

-Creatinine 0.9

 

-Glucose 91

 

What is our working diagnosis? How would you treat it?                                               

 

Question 4          A 44 year old female is NPO following surgery for a bowel obstruction. She weighs 166 pounds. How would you calculate her daily maintenance IV fluid need while she is NPO?                                       

 

Question 5          A 57 year old female is admitted to the oncology unit for chemotherapy related to her to acute leukemia. Her initial dose of chemo was 2 days ago. While rounding today, the patients tells the NP that she feels so weak. The NP notes her heart rate is 44 today (down from 68 2 days ago). She has had less than 100 cc of urine out over the last 24 hours.

 

Labs from this morning include:

 

LAB DATA:

 

-Sodium 131

 

-Potassium 7.8

 

-Chloride 105

 

-Bicarbonate 17

 

-BUN 67

 

-Creatinine 5.8

 

-Glucose 83

 

-Calcium 7.6

 

-Phosphorus 6.8

 

-Uric acid 16.3

 

What is your working diagnosis for this patient? How would you treat her?                                         

 

Question 6          52 year old female with history of chronic kidney disease and acute onset of lower extremity weakness. Historically has been non complaint with her dietary restrictions BP = 166/94, HR = 105, no fever, bilateral lower extremity weakness.

 

EKG: Peaked T waves, prolonged P-R interval, QRS widening

 

Labs:

 

Sodium 135

 

Potassium. 9.1

 

Glucose 174

 

BUN. 117

 

Cr 12.9

 

What is your working diagnosis for this patient? What are the critical interventions?                                       

 

Question 7          How would you calculate the fractional excretion of sodium? What does this calculation tell you about the patient’s acute kidney injury?                                   

 

Question 8          Describe the different etiology of pre-renal, intra-renal, and post-renal acute kidney injury and provide examples of clinical conditions that cause each.                                

 

Question 9          The NP is admitting a 55 year old septic patient to the ICU. What IV fluid and dose would you prescribe for the initial fluid bolus?                                    

 

Question 10        Describe the difference between crystalloid and colloid fluid. What type of fluid would you use for fluid resuscitation in a hypotensive patient?