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Medical Report: Nephrology Consultation

HISTORY OF PRESENT ILLNESS: This 57 year old white male wasadmitted to the hospital yesterday with a history of progressivelethargy, weakness, dysphagia, constipation, and generalizedmalaise. These symptoms have been present for the last 3 to 4days.

During his last hospitalization on January 20, 2017,preoperative investigation revealed a BUN of 32 and a creatinine of2.8, and there was no documentation of any BUN or creatinine at thetime 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 littlelethargic, well oriented. His BP was 136/74 mmHg. Tongue pink and alittle dry. Neck: carotid pulsations normal. Skin: decreased inturgor at present. Heart sounds normal. No gallop. Lungs withnormal breath sounds. Abdomen is full, with operative scar in theright hypochondrium, with ascites present. Extremities: noperipheral 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. Bloodchemistry 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 acid19.7. Total protein 5.8. Albumin 2.4. Mg 3.4. Alkaline phosphatase41.2. 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 severalyears' duration with compromised renal function. His postoperativecourse was uneventful except for complaint of slight reduction ofurinary output. There has been no documentation of renal functionat the time of discharge. The patient was given Bactrim, followingwhich the patient developed symptoms of uremia, and oninvestigation, the patient's renal function has markedlydeteriorated in the course of 5 days. It is my presumption that thepatient's chronic renal failure, which was in a delicate balance,has further deteriorated with Bactrim. The Bactrim has beendiscontinued for 24 hours now. There has been improvement in thecreatinine level, from 10 to 7.6 mg%. His BUN is still high, and itappears that the patient is still in hypovolemia and needs furtherhydration.

In addition, the patient has pyelonephritis of several years'duration, and analysis of the urine yesterday does not reveal anyevidence of persistence of the infection. The patient might alsohave renal function impairment secondary to chronicpyelonephritis.

Review of the record and the patient reveals no evidence ofacute ischemic renal failure. His serum magnesium is high, and thepatient received some Milk of Magnesia at home. If the patient doesnot show any further improvement in the next 24 hours, suggestobtaining a renal scan with blood flow studies.

1) Were the results of the preoperative BUN and creatininestudies abnormal? How can you tell?

2) Which organ function is evaluated with those two laboratorytests? How do these tests work?

3) Describe an IVP procedure.

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