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Original Question

A 73-year-old man, was admitted to the hospital with clinical manifestations of gastroenteritis and possible renal failure. The patient’s chief complaints are fever, nausea with vomiting and diarrhea for 48 hours, weakness, dizziness, and a bothersome metallic taste in the mouth. The patient is pale and sweaty. He had been well until two days ago, when he began to experience severe nausea several hours after eating two burritos for supper. The burritos had been ordered from a local fast-food restaurant. The nausea persisted and he vomited twice with some relief. As the evening progressed, he continued to feel “very bad” and took some Pepto-Bismol to help settle his stomach. No long after that, he began to feel achy and warm. His temperature at the time was 100.5°F. He has continued to experience nausea, vomiting, and a fever. He has not been able to tolerate any solid foods or liquids. Since yesterday, he has had 5-6 watery bowel movements. He has not noticed any blood in the stools. His wife brought him to the ER because he was becoming weak and dizzy when he tried to stand up. His wife denies any recent travel, use of antibiotics, laxatives, or excessive caffeine, or that her husband has an eating disorder. The client’s past medical history includes HTN 14 years, AMI 10 years, heart failure 8 years, no known renal disease or DM • Osteoarthritis 5 years. The client’s father died at age 50 from AMI and his mother has type 2 DM. The client is a retired pharmacy professor who is living at home with his wife of 34 years. He denies use of alcohol, tobacco, and illicit drugs. Meds are • Digoxin 0.125 mg po QD • Furosemide 40 mg po QD • Enalapril 20 mg po QD (recently added to furosemide to manage HTN) • OTC acetaminophen 500 mg po PRN. The client is a pale, diaphoretic, elderly Asian male in acute distress. His eyes appear sunken with dark circles around them. Skin is pale with poor turgor. Normal sinus rhythm. Lungs-No crackles bilaterally. Abdomen has diffuse tenderness, no guarding or rebound, oft and non-distended with hyperactive bowel sounds. Slightly heme-positive stool in the rectum. Arterial Blood Gas Results pH 7.35, PaO2 87 mm Hg, PaCO2 29 mm Hg, SaO2 95%. Vital Signs BP 92/45, RR 30, P 115, T 101.3°F. Lab results: Na 144 meq/L Cr 2.6 mg/dL Alb 4.3 g/dL PMNs 29% K 4.7 meq/L Glu, random 155 mg/dL Hb 13.9 g/dL Lymphs 66% Cl 111 meq/L Ca 9.1 mg/dL Hct 48% Monos 3% HCO3 19 meq/L Phos 4.1 mg/dL Plt 190,000/mm3 Eos 1% BUN 57 mg/dL Mg 2.8 mg/dL WBC 11,700/mm3 Basos 1%; Urinalysis: Clear, pale yellow urine • Microscopy was negative for cells, casts, pigments, and crystals • SG 1.019 • (-) bacteria • (-) glucose • (-) protein • WBC 1/HPF with no eosinophils • RBC 1/HPF • Na concentration 14 meq/L • Osmolality 769 mOsm/kg H2O Discussion Questions What are the abnormals and their clinical significance? Prioritize the top 3 abnormals. List the 5 most important interventions for the top priority (from question #2) and provide the rationale for each intervention. List four major risk factors that are likely to be contributing to the patient’s kidney failure. What is the importance of the absence of JVD and absence of pulmonary crackles? Why might the serum glucose level be abnormal? Would you expect electrocardiogram abnormalities in this patient? Why or why not? Which laboratory data suggest that the infection is probably viral and not bacterial? Which therapeutic measure should be considered “first and foremost” and may be very beneficial in reversing the signs of acute renal failure? Would dialysis be appropriate treatment for this patient at this time? (Opinion Question) What should the client and spouse know about the client’s current illness, treatment, and prognosis?

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