Nephrology emergencyNephrology emergency
Dr Kok Lai Sun Dr Kok Lai Sun
Department of MedicineDepartment of Medicine
Hospital Pulau PinangHospital Pulau Pinang
At casualty At casualty
56 / male/ taxi driver 56 / male/ taxi driver
With diabetic nephropathy with baseline With diabetic nephropathy with baseline creatinine 300umol/L creatinine 300umol/L
Presented to casualty with palpitation for 1 Presented to casualty with palpitation for 1 day day
Question 1Question 1
• What other histories do you want What other histories do you want to ask from this patient ?to ask from this patient ?
Question 2 Question 2
He was just started on perindopril 4mg od He was just started on perindopril 4mg od 2 weeks ago . What are the potential 2 weeks ago . What are the potential adverse effects of this medication? adverse effects of this medication?
On physical examinationOn physical examination
His is tachypnoea with deep sighing His is tachypnoea with deep sighing breathingbreathing
Afebrile , BP= 150/94mmHg , PR =100Afebrile , BP= 150/94mmHg , PR =100
CVS- normalCVS- normal
Lungs are clear with no abnormalitiesLungs are clear with no abnormalities
Question 3 Question 3
What other clinical examination would you What other clinical examination would you do for this patient ? do for this patient ?
Question 4Question 4
What are the investigations you would do What are the investigations you would do for him ? for him ?
Question 5 Question 5 please interprete this ECG please interprete this ECG
His potassium level was 7 mmol/LHis potassium level was 7 mmol/L
It is very important to identify this in order It is very important to identify this in order to save the patient because lab results to save the patient because lab results come back much later!!!come back much later!!!
Question 6Question 6
How do you manage his hyperkalemia ?How do you manage his hyperkalemia ?
Question 7Question 7
This is his ABG result . Please interprete.This is his ABG result . Please interprete.– PHPH = 6.80= 6.80– PaO2PaO2 = 11 kPa = 11 kPa – PaCO2PaCO2 = 3.8kPa= 3.8kPa– HCO3HCO3 = 10= 10– BEBE = -8= -8
Question 7 Question 7
What are the causes for his ABG What are the causes for his ABG abnormality?abnormality?
How to manage this ? How to manage this ?
22ndnd case case
20/full time model , NKMI20/full time model , NKMI
recurrent syncopal episodes over the past recurrent syncopal episodes over the past 2 days2 days
Question 1Question 1
What other histories do you want to ask What other histories do you want to ask from this patient ?from this patient ?
the patient reports increased weakness the patient reports increased weakness and weight loss over the past 3 months. and weight loss over the past 3 months.
On physical examinationOn physical examination
blood pressure -125/80 mm Hg, blood pressure -125/80 mm Hg, temperature -37.5°C, heart rate -90 bpm, temperature -37.5°C, heart rate -90 bpm, regularregular
38kg38kg
head, neck, pulmonary, and abdominal head, neck, pulmonary, and abdominal examinations are all unremarkableexaminations are all unremarkable
diffuse weakness in all major muscle diffuse weakness in all major muscle groups otherwise no other neuro deficitgroups otherwise no other neuro deficit
What are the investigations you would do What are the investigations you would do for her ? for her ?
While waiting other investigations, your nurse show you While waiting other investigations, your nurse show you this. please interprete this ECGthis. please interprete this ECG
K+ level of 1.6 mmol/LK+ level of 1.6 mmol/L
rest of the electrolytes, notably the rest of the electrolytes, notably the magnesium, were within normal limitsmagnesium, were within normal limits
Normal thyroid functionNormal thyroid function
patient was questioned further and admitted patient was questioned further and admitted to a long history of self-induced vomiting to to a long history of self-induced vomiting to help reduce her weight, with a recent help reduce her weight, with a recent increase in frequency over the last several increase in frequency over the last several months.months.
How do you manage her hypokalemia ?How do you manage her hypokalemia ?
Thank you !Thank you !
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