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 !