A Case Conference of Internal Medicine regarding Acute Kidney Injury, the first presentation during my first year internship

1. 查 房 教 學
C A S E C O N F E R E N C E O F
I N T E R N A L M E D I C I N E
報告⼈人：Intern 1 陳佳菁
NYMUH, 2017/08/16

2. PART01
Patient Profile, Chief Complaint
History of Present Illness
PART02
Past Medical History, Family and Personal History,
Review of Systems, Physical Examination
PART03
Assessment
Plan
PART04
Mini-Topic
CONTENTS

3. ABOUT HIM
1
A 45 year-old man, with a history of
Hypertension / Type II DM/ Hyperlipidemia, who
presents with a chief complaint of epigastralgia
with nausea and vomiting for 1 day
M R . TA N G ,

4. Mr. Tang has a history of hypertension,
Type II DM, Hyperlipidemia. He was in his
usual state of health until several hours
prior to admission to NYMUH when he was
presented with epigastralgia, nausea, and
vomiting.
I S T O R Y O F P R E S E N T I L L N E S S
H

5. H P I M A N A G E M E N T

6. H P I M A N A G E M E N T

7. 2
Past Medical History, Family and Personal History,
Review of Systems, Physical Examination
P A R T
CASE CONFERENCE 2017/08/16

8. MEDICAL HISTORY
PAST
Surgical, Medical History and Medication

9. ？H I S T O R Y
1991 / 1994, L2-3-4-5 HIVD Operation
2006, Appendectomy
2016, Fasciectomy for cellulitis over left lower extremity
SURGICAL
W I T H O U T A D V E R S E E F F E C T O F A N E S T H E S I A O R B L O O D T R A N S F U S I O N

10. MEDICATION
PMH

11. Family members -
Father - Hypertension, DM
HISTORY
FAMILY
No common disease runs in his family

12. Mr. Tang, a chef, could perform
ADL and IADL independently.
HISTORY
PERSONAL
‣ Cigarette: 1 pack per day for 30 years
‣ Alcohol: Nil
‣ Drug abuse: Nil
‣ Betel nuts: Nil
‣ No TOCC

13. REVIEW
General - Left lower leg pain, (-)Weight change, (-)Fatigue, (-)Fever, (-)Weakness
HEENT - (-)Headache, (-)Dizziness, (-)Rhinorrhea, (-)Nasal Congestion, (-)Sore throat
Cardiovascular - (-)Chest pain, (-)Dyspnea, (-)Palpitation
Respiratory - (-)Cough, (-)Sputum, (-)Tachypnea
Gastrointestinal - (+)Epigastralgia, (+)Nausea, (+)Vomiting, (-)Dysphagia, (-)Diarrhea,
(-)Constipation
Genitourinary - (-)Frequency, (-)Urgency, (-)Hesitancy, (-)Dysuria, (-)Hematuria
OF SYSTEMS ,

14. A
General Appearance
No cardiopulmonary distress
B
Vital Signs
T/P/R: 35.8C / 72 bpm / 18/min, BP: 150/103 mmHg
BW: 51.8kg
C
Heart
Inspection: No jugular vein engorgement
No murmurs, RHB
No tachycardia or bradycardia
No S3, S4 gallop
D Chest
Symmetrical expansion of chest wall
Breath sounds: Normal
Palpation / Percussion: Normal
PHYSICAL EXAMINATION

15. E
Abdomen
Inspection: No spider angioma or scar
Auscultation: Normactive bowel sound
Palpation: Normal
F
Neurology
Motor function: Normal ROM
Sensation: Intact
G
Hemogram
HGB 12.5 g/dl, HCT 34.7%, PLT 196,000/ul
WBC 9,990/ul, SEG 75.9%
H
BCS
Glucose 149 mg/dl, CRP 1.44
CK-MB 9.8 U/L, CK 136 U/L, Troponin I < 0.1
TBIL 0.78 mg/dl, ALP 67 U/L
BUN 44 mg/dl, Creatinine 5.24 mg/dl
Amylase 40 U/L; ALT 20 U/L
Na 138 mmol/L, K 4.4 mmol/L
PHYSICAL EXAMINATION

16. P A R T
3
A S S E S S M E N T
P L A N

17. PATIENT’S MAJOR PRESENTING PROBLEM IS
T
A C U T E R E N A L FA I L U R E
W I T H U R E M I C S Y M P T O M S
HE

18. - G E N T L E H Y D R AT I O N A S N S 1 0 0 0 M L Q D
F O R A C U T E R E N A L FA I L U R E
- R E N A L E C H O O N 8 / 9
- A N T I E M E T I C A G E N T P R O M E R A N F O R
U R E M I C S Y M P T O M S
- S E L F P R E PA R E I N S U L I N A N D
A N T I H Y P E R T E N S I O N M E D I C AT I O N F O R
T Y P E 2 D M C O N T R O L
- P E S O N 8 / 1 4 D U E T O E P I G A S T R A L G I A
W I T H S U S P E C T G U

19. COURSE
HOSPITAL
V I TA L S I G N , P E , L A B , M A N A G E M E N T, P R O G R E S S

20. VITAL SIGN, BW, PULSE OXYGEN SATURATION

21. I N PAT I E N T C O U R S E

22. PRESCRIPTION
I N PAT I E N T C O U R S E

23. PRESCRIPTION

24. PRESCRIPTION

25. PRESCRIPTION

27. 4
MINI-TOPIC
A C U T E K I D N E Y I N J U RY
PART04
AKI

28. A K I
INTRODUCTION
-AN ABRUPT DECLINE IN KIDNEY FUNCTION
-USUALLY REVERSIBLE DECLINE IN THE GLOMERULAR FILTRATION
RATE (GFR)
-ELEVATION: SERUM BLOOD UREA NITROGEN (BUN), CREATININE,
AND OTHER METABOLIC WASTE PRODUCTS
-POTENTIALLY LIFE-THREATENING COMPLICATIONS - VOLUME
OVERLOAD, HYPERKALEMIA, ACIDOSIS, AND UREMIA

29. INPATIENT
ACUTE TUBULAR NECROSIS
OTHERS
Ischemia
Nephrotoxin Exposure
Sepsis
Volume Depletion
Urinary Obstruction
Rapidly Progressive
Glomerulonephritis
Acute Interstitial Nephritis
PATHOGENESIS

31. ❖ Hypovolemic - Acute hemorrhage / Diarrhea /
Unreplenished insensible losses
❖ Hypervolemic - HFrEF
❖ Renal vascular autoregulation - afferent arteriole
vasoconstriction NSAIDs
PRERENAL

33. ❖ Nephritic - proliferative glomerulonephritis; active
urine sediment with dysmorphic red cells and white
cells; granular, red cell, and other cellular casts; and
a variable degree of proteinuria. e.g. Rapidly
progressive glomerulonephritis (RPGN)
❖ Nephrotic - Rare in hospitalization patient
INTRINSIC GLOMERULAR DZ

34. ❖ Most common - ATN, typically occurring following
radiocontrast or other nephrotoxin administration,
following cardiac surgery, or in the setting of sepsis or
shock
❖ Acute interstitial nephritis (AIN; which is often drug
induced) and cast nephropathy in multiple myeloma
INTRINSIC TUBULAR & INTERSTITIAL DZ

35. ❖ Tumor lysis syndrome (acute urate nephropathy)
@high tumor burden lymphoma or following C/T
❖ Crystalline nephropathy associated with acyclovir and
other medications
❖ Acute phosphate nephropathy following a phosphate-
containing bowel preparation
INTRINSIC TUBULAR & INTERSTITIAL DZ

36. ❖ Both small-and large-sized blood vessels
❖ Acute, small - small vessel vasculitides and diseases
that cause microangiopathy and hemolytic anemia
(MAHA), including thrombotic thrombocytopenic
purpura-hemolytic uremic syndrome (TTP/HUS),
scleroderma, atheroembolic disease, and malignant
hypertension
INTRINSIC RENAL VASCULAR DZ

37. ❖ Both small-and large-sized blood vessels
❖ Acute, large - renal infarction from aortic dissection,
systemic thromboembolism, or renal artery
abnormality (such as aneurysm) and acute renal vein
thrombosis
INTRINSIC RENAL VASCULAR DZ

39. ❖ No CKD - GFR substantial reduction ☛ Bil.
obstruction; Cause: Prostate Dz / Metastatic cancer
❖ Retroperitoneal fibrosis - Rare
❖ Untreated ☛ Irreversible tubulointerstitial fibrosis
OBSTRUCTIVE UROPATHY

45. A K I
VOLUME DEPLETION
-CLINICAL HX + PE HYPOVOLEMIA + OLIGURIA ☛ IV FLUID ADMINI.
-CRYSTALLOID SOLUTIONS, NON-POTASSIUM-CONTAINING
-PHYSIOLOGIC ENDPOINTS: MAP, URINE OUTPUT, CO
-RESPOND TO ADMINISTERED VOLUME ☛ PRERENAL? ATN?

46. A K I
VOLUME OVERLOAD
-ATN, ILL ☛ ANTI / BLOOD / IV DRUG / NUTRITION
-VOLUME EXPANSION, PULMONARY EDEMA
-DIURETICS, NOT PROLONG TO POSTPONE DIALYSIS
-LOOP DIURETICS, NATRIURETIC! IV FUROSEMIDE 40-80 MG

47. A K I
HYPERKALEMIA
-OLIGURIC PT, ESP. RHABDOMYOLYSIS, TUMOR LYSIS SYNDROME
-FEW S/S; VERY HIGH ☛ NEUROMUSCULAR, CARDIAC CONDUCTION
-DIALYSIS, UNLESS MILD HYPERKALEMIA <5.5, REVERSIBLE
-MEMBRANE, EC ☛ IC, OUT OF BODY

48. THANKS
C H I A - C H I N G , C H E N
F O R Y O U R L I S T E N I N G A N D C O M M E N T S