SOAP Note Case

SOAP Note Case

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Case- Kidney Injury, Acute (Chapter 28):

 

CC: Mr. T is 77-year-old man with acute kidney injury (AKI).

 

Mr. T felt well until 3 days ago, when he had a shaking chill followed by a fever and the onset of a cough productive of rusty colored sputum. His fever has persisted, his cough has worsened, and he feels lethargic. His past medical history is notable for well-controlled hypertension and prostate cancer treated with radiation therapy 5 years ago. His current medications are hydrochlorothiazide and lisinopril. He smokes a few cigarettes a day and has 1 drink per week. One month ago, his creatinine was 1.4 mg/dL. Six months ago, his PSA was 1.0. Laboratory test results now include WBC, 16,000/mcL (70% PMNs, 20% bands, 10% lymphocytes); Hgb, 10.2 g/dL; Hct, 32%; MCV, 88 mcm3; Na, 140 mEq/L; K, 5.4 mEq/L; Cl, 100 mEq/L; HCO3 19 mEq/L; BUN, 40 mg/dL; creatinine, 3.8 mg/dL; glucose, 102 mg/dL.

Mr. T receives 1 L of normal saline, with no change in his BP. Urine is obtained prior to the fluid bolus and results include urine sodium, 40 mEq/h; urine chloride, 57 mEq/mL; urine creatinine, 45 mg/24 h, and urine urea nitrogen 250 g/24 h; urinalysis showed specific gravity, 1.010; leukocyte esterase, negative; glucose, negative; blood, negative; protein, trace; RBC, 1/hpf; WBC, 1–2/hpf; positive granular casts.

 

Mr. T’s FENa is 2.41%, and his FEurea is 53%. He is treated with IV antibiotics and fluids, with normalization of his BP. A repeat creatinine, done several hours later, is again 3.8 mg/dL.

 

The ultrasound shows normal kidneys, with no hydronephrosis. Mr. T’s BP remains stable, and at discharge 1 week later, his creatinine is 2.0 mg/dL. He returns to see you 2 weeks later, reporting that his osteoarthritis “flared” after so much time in bed, and he has been using celecoxib for relief. His creatinine is 2.5 mg/dL. You advise him to stop the celecoxib, and a repeat creatinine 2 weeks later is 1.5 mg/dL.

S: 77-year-old male, with past medical history of well-controlled hypertension & treated prostate cancer (5 years ago), presents with 3 day complaint of shaking chill, persistent fever, and onset of productive cough with rusty colored sputum. Admits to taking hydrochlorothiazide and lisinopril, and smoking a few cigarettes/day and having 1 drink/week.

 

O: WBC, 16,000/mcL (70% PMNs, 20% bands, 10% lymphocytes); Hgb, 10.2 g/dL; Hct, 32%; MCV, 88 mcm3; Na, 140 mEq/L; K, 5.4 mEq/L; Cl, 100 mEq/L; HCO3 19 mEq/L; BUN, 40 mg/dL; creatinine, 3.8 mg/dL; glucose, 102 mg/dL.

Temperature, 38.6°C; BP, 90/60 mm Hg; pulse, 110 bpm; RR, 24 breaths per minute. His mucous membranes appear dry. Lung exam is notable for decreased breath sounds and crackles at the right lung base.

 

Urine collection displays urine sodium, 40 mEq/h; urine chloride, 57 mEq/mL; urine creatinine, 45 mg/24 h, and urine urea nitrogen 250 g/24 h; urinalysis showed specific gravity, 1.010; leukocyte esterase, negative; glucose, negative; blood, negative; protein, trace; RBC, 1/hpf; WBC, 1–2/hpf; positive granular casts. FENa is 2.41%, and his FEurea is 53%. He is treated with IV antibiotics and fluids, with normalization of his BP. A repeat creatinine, done several hours later, is again 3.8 mg/dL.

 

 

A: AKI, Chronic renal failure

 

 

P: After discharge (1 week later), creatine= 0.2mg/dL. Patient returns 2 weeks later, reporting his osteoarthritis has “flared” after much time in bed so he has started using celecoxib as relief. Creatine is 2.5mg/dL at current visit. After advising to stop celecoxib, patient is asked to return in 2 weeks to repeat creatine.

 

 

Summary: Acute kidney injury (AKI), otherwise known as acute renal failure, is a condition in which the kidneys suddenly cannot filter waste from the blood. Similar to Mr. T, general symptoms include decreased urinary output, swelling due to fluid retension, nausea, fatigue, and shortness of breath. Symptoms may be subtle or may not appear at all. Treatment includes fluids, medications (diuertic), and dialysis (medical procedure; clinical purification of blood as a substitue for the normal function of the kidney). An additional differential diagnosis related to this case is chronic renal failure (CKD). This longstanding kidney disease features an asymptomatic patient and leads to renal failure. Because symptoms develop slowly and aren’t specific to this disease, a blood (lab) test is requried for diagnosis. This is a less likely diagnosis for Mr T.’s specific case because he did present with certain symptoms (shaking chill, fever, productive cough with sputum). Treatment for CKD varies depending on severity, featuring medications that help manage symptoms. Later stages would require dialysis (machine filtering blood) or even a renal (kidney) transplant. A kidney transplant is a surgical procedure, placing a health kidney from either a live or deceased donor into a person whose kidneys no longer function properly. Interestingly, a living donor kidney functions from 12 to 20 years on average, while a deceased donor kidney functions from 8 to 12 years. Those patients who receive a transplant prior to dialysis live an average of 10 to 5 years longer than if they had stayed on dialysis.