Clinical Scenario:
You are admitting this patient from the ED and have completed
the following H&P.
CC: Abdominal Pain
HPI: Ms. ABC is a 40-year-old Caucasian female who presented
to the ED with a complaint of abdominal pain x 1week. She reports
LUQ and epigastric abdominal pain, which radiates to the back, is
constant, and gets better with sitting up or leaning forward. She
has had some associated nausea, vomiting, fever, constipation, and
fatigue. She has had multiple admissions for volume overload
secondary to CKD and has been evaluated by renal and each time they
have determined that HD initiation is not necessary. Upon
evaluation in the ED a CT of the abdomen was completed, CXR showed
pulmonary edema, an elevated lipase, and a CO2 of 9. The ED gave
her 1 amp of sodium bicarbonate at 0630 this am (Time is now 1000).
Repeat labs completed at 0815 showed a phosphorus of 12, a
creatinine of 12, and a H&H of 4.6/13.3, CO2 of 8, and an Anion
GAP of 26. The ED gave her a NS bolus of 500ml and performed a
stool guaiac which was negative. EKG showed sinus bradycardia and a
prolonged QT.
Review of Systems:
Constitutional: Positive for fever, malaise/fatigue. Negative
for chills and weight loss.
Skin: Negative for rash and itching.
HENT: Negative for headaches, hearing loss, and
tinnitus.
Eyes: Decreased vision from diabetic retinopathy.
Cardiovascular: Negative for chest pain, orthopnea, PND, and
palpitations. Positive for leg swelling.
Pulmonary: Positive for shortness of breath. Negative for
sputum production or cough.
Gastrointestinal: Negative for heart burn. Positive for
nausea, vomiting, constipation.
Positive for abdominal pain.
Genitourinary: Negative for dysuria, urgency, frequency and
hematuria.
Musculoskeletal: Negative for myalgias and neck pain. Has
chronic pain and joint pain. Has muscle cramps.
Endo/Heme/Allergies: Negative for environmental allergies.
Does not bruise/bleed easily.
Neurological: Negative for dizziness, tingling, tremors,
sensory change and speech changes.
Psychiatric: Negative for depression, suicidal and homicidal
ideations.
Past Medical History:
1.Chronic Kidney disease stage 5- not on hemodialysis
2.Hypertension
3.Diabetes Mellitus Type 2
4.Anemia secondary to CKD
5.Diabetic Retinopathy
6.Metabolic Bone Disease
Surgical History: None
Social History: Denies smoking, ETOH or drug use.
Family History
•Father: Negative
•Mother: Negative
•Uncle: Diabetes Mellitus Type 2
Home Medications:
•Lisinopril
•Hydralazine
•Amlodipine (Norvasc)
•Nephrovite
•Sodium Bicarbonate TID
•Lasix TID
•Insulin 70/30
•Calcium and Vitamin D
•Erythropoietin
•Phos lo with meals
Allergies: NKDA
Physical Exam:
Vitals: 36.3-61-16-98/53, 96% on RA. LMP 10 days ago
Constitutional: Alert and oriented x3. Appears well
developed.
Head: Normocephalic and atraumatic.
Eyes: Pupils are equal, round, and reactive to light. No
nystagmus. No scleral icterus.
Neck: Neck supple. No JVD present. No tracheal deviation
present. No thyromegaly or thyroid nodules noted.
Cardiovascular: Normal rate, S1 normal, S2 present, without
S3, S4, gallop, friction rub or murmur. +3 pitting edema of the
bilateral lower extremities.
Pulses: Brachial, Radial, dorsalis pedis, and posterior tibial
pulses are 2+/4+ bilaterally.
Pulmonary/Chest: Respirations regular and even. Lungs with
rales in the posterior bilateral lung fields.
Abdominal: Soft. Bowel sounds are active. Tender in the
epigastric and LUQ regions. No hepatosplenomegaly. There is no
rigidity, rebound, or guarding.
Lymphadenopathy: No cervical lymphadenopathy.
Neurological: Alert and oriented x3. CN 2-12 intact.
Skin: Skin is warm, dry and intact. No abrasion, no bruising,
no burn, no laceration, no lesion and no rash noted.
Psychiatric: Mood and affect normal. Calm and cooperative
behavior. Judgment intact.
Diagnostic Results:
Sodium 135 mEq/L
Potassium 6.0* mEq/L
CO2 8*
Chloride is 91* mEq/L (mmol/L)
BUN 138* mg/dL
Creatinine 12.73* mg/dL
Anion Gap 25* mEq/L
Glucose 94 mg/dL
INR 1.3
Calcium 4.8* mg/dL
WBC 9.66
Magnesium 3.1* mEq/L
Hgb 4.6
Phosphorus 12.2* mg/dL
HCT 13.3
Alk Phosphates 175* units/L
MCV 78.7
Albumin 3.6 g/dL
Platelets: 333,000
Lipase of 800 U/L
UA- Negative for glucose, ketones, blood, nitrites, bilirubin.
Positive for leukoesterase and protein of 300.
CXR: Pleural Effusion of the right lung, pulmonary
edema.
CT of Abdomen completed: Results not available.
Questions:
1.Develop a list of differential diagnoses specific to the
epigastric abdominal pain. What are the four most important
differential diagnoses to consider?
2.Based on the available clinical data, what is the most
likely diagnosis for the chief complaint?
3.What additional diagnostic tests should be ordered to
further evaluate the epigastric abdominal pain?
4.Write an assessment and treatment plan for each of the
electrolyte disorders and the acid base disorder this patient is
experiencing. You must include all the electrolyte and acid base
disorders and have a complete treatment plan for each disorder. All
written orders must have complete instructions. For instance, a
medication order must have the name, dose, frequency, and route.
Lab orders must include the lab name and frequency. If an order
should be done now, stat, urgent or routine that also should be
indicated.
5.What is the most appropriate level of care for this
patient?
6.What physician specialty or other interprofessional consults
should be ordered?
7.What anticipatory guidance/patient education should you
provide to the patient?