chbare Posted July 12, 2007 Author Share Posted July 12, 2007 From her prior history you gather the following: -She has a long history of NIDDM. -She has a long history of elevated lipids. -She has a long history of obesity. -She has a long history of HTN and GERD. -She has had a diagnosis of renal insufficiency in the past couple of years related to her diabetes. Her home medications include: -Lisinopril 20 mg po q day. -Ranitidine 150 mg po q day -Metformin 1000mg po bid -Atorvastatin: 10 mg po q day Take care, chbare. Link to comment Share on other sites More sharing options...
JPINFV Posted July 12, 2007 Share Posted July 12, 2007 Any of those medications new? theory: Based on the labs, it looks like her kidneys are shot. Either she isn't on dialysis or maybe she hasn't been going to dialysis like she normally could due to her stomach problems. Over that time, the concentration of the drugs in her system have built up and are causing the symptoms seen now. Link to comment Share on other sites More sharing options...
EMSGeek Posted July 12, 2007 Share Posted July 12, 2007 The patient's NIDDM is tied to Metabolic syndrome (syndrome has 4 key features: diabetes, hypertension, obesity/overweight, and high cholesterol). Suspect significant renal degradation leading to her current condition. Recommend a flat plate of the abdomen for kidney size, intravenous pyelogram, a 24-hr urine catecholamine, a serum cortisol, a plasma renin level, a 24-hr urine aldosterone determination, a cystoscopy, and retrograde pyelography. The patient is exhibiting some symptoms of later chronic renal failure. My "diagnosis" is renal distress with the need for immediate tertiary care. Link to comment Share on other sites More sharing options...
Dustdevil Posted July 12, 2007 Share Posted July 12, 2007 You're definitely on the right track with renal failure. The remaining question is 'why.' This appears to be an acute condition. But with her history of multiple chronic illness and polypharmacological lifestyle, it's not surprising. I'm going to put porphyria towards the top of my list. Wherever she is going needs to have a quality lab and dialysis availab.e Link to comment Share on other sites More sharing options...
chbare Posted July 12, 2007 Author Share Posted July 12, 2007 Good, we are headed in the proper direction. The question to ask is why indeed. Something acute happened during her stay at the hospital. The question is what. Allow me to throw in an ABG to further muddy the water. PH: 7.29 CO2: 20 O2: 108 Bicarb: 12 Base Deficit: -8 Take care, chbare. Link to comment Share on other sites More sharing options...
katbemeEMT-B Posted July 12, 2007 Share Posted July 12, 2007 Hey ch, I was just wondering if you were up here in Minnesota when my grandmother was ill. You are describing her hx, tx, and subsequent symptoms to a tee. I will be curious to see where this ends up. Any signs of edema? If so to what extent? Benign stroke assessment? Did she exhibit any pain when doing a rapid physical exam? Clots? Why does this hospital want to transfer her? Link to comment Share on other sites More sharing options...
chbare Posted July 12, 2007 Author Share Posted July 12, 2007 this scenario was actually created from scratch. The hospital is sending the patient to a facility that can provide a higher level of care. This is their reason for the transfer. She does have +1 pitting edema to her feet bilat, but this is a baseline finding. No facial droop and the crainial nerves are assessed with unremarkable findings. The patient is very lethargic however. I think a couple of people are very close; however, we need to put the pieces together and come up with a working hypothesis for what happened. Let me know if you need a hint, but I bet if you study the previous posts and do a little research, you will arrive at the answer. Take care, chbare. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted July 12, 2007 Share Posted July 12, 2007 CHBARE, any crystals on her skin? Is her skin covered in a crystallike sheen? I'm leaning towards complete renal failure with significant neuro involvement. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted July 12, 2007 Share Posted July 12, 2007 add the potassium level to this and we need to get her to dialysis if I am guessing right. sounds like acute kidney failure Link to comment Share on other sites More sharing options...
katbemeEMT-B Posted July 13, 2007 Share Posted July 13, 2007 Is it possible that she has developed lactic acidosis as a result of taking the Metformin. This would be common in some one who has kidney disease? She may also be septic. Link to comment Share on other sites More sharing options...
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