LVL4NCM104CASEPRES FINAL

University of Perpetual Help Dr. Jose G. Tamayo Medical University

Sto. Niño, City of Biñan, Laguna

ACUTE RENAL FAILURE 2° URINARY

TRACT INFECTION

A CASE PRESENTATION

SUBMITTED BY:

BSN 4 –ABATCH 2011

July 06, 2010

Introduction

Acute renal failure (ARF) is a nonspecific term describing a sudden or gradual

deterioration in renal function resulting in the accumulation of nitrogenous waste in the kidneys.

It renders the body to be incapable of maintaining proper fluid balance and disrupts systems for

regulating electrolytes, eliminating waste and preserving acid and base balance. It also disrupts

blood pressure regulation, red blood cell production, and the mechanism for depositing calcium

in the bones. It affects some 3-7% of patients admitted to the hospital and approximately 25-30%

of patients in the intensive care unit. Acute renal failure occurring in a community setting is

distinct from ARF in an in-hospital setting. Patients who present to the emergency department

with ARF frequently differ in etiology, treatment, and overall mortality. For example,

community-acquired renal failure is usually reversible and caused by volume depletion, but

hospital-acquired ARF, as in this case, usually occurs along with other organ disease processes

that contribute to or complicate the patient’s treatment and outcome.

The myriad causes of acute kidney injury are commonly categorized into prerenal,

intrinsic, and postrenal. Prerenal causes of renal failure results from conditions that impair blood

flow to the kidneys. These include systemic causes, such as low blood volume, low blood

pressure, and heart failure, as well as local changes to the blood vessels supplying the kidney. On

the other hand, intrarenal causes come from direct injury or damage to the kidneys. These can

be due to damage to the glomeruli, renal tubules, or instertitium. Lastly, postrenal causes are

usually synonymous with obstructive conditions that prevent urine from flowing down into the

lower urinary tract. These may be related to benign prostatic hyperplasia, kidney stones, or an

obstructed ureter.

Symptoms may include oliguria, anuria, hypertension, edema , azotemia, uremia, multiple

electrolyte abnormalities, and metabolic acidosis.

Even though ARF has no strict definition, diagnosis of a 50% or greater increase in serum

creatinine above baseline is a widely accepted criterion. (A normal serum creatinine is

considered less than 1 mg/dl.) Other tests done are urinalysis, creatinine clearance and blood urea

nitrogen. Moreover, a kidney or abdominal ultrasound is the preferred test for diagnosing kidney

failure. Blood tests may also help reveal the underlying cause of kidney failure.

The management of acute renal failure hinges on identification and treatment of the

underlying cause. Once the cause is found, the goal is to restore kidney function and prevent

fluid and waste from building up in the body while the kidneys heal. Antibiotics may be given to

treat or prevent infection. Diuretics ("water pills") may be used to help the kidneys lose fluid.

The patient is recommended to have a low salt, low potassium, low fat, low protein diet.

Treatment may also include renal replacement therapy such as hemodialysis and peritoneal

dialysis depending on the severity.

Patient Profile

I. General Data

Name : T.F.

Age : 55 years old and 9 months

Gender : Male

Birthday : September 07, 1954

Weight : 55 kg. (121 lbs.)

Height : 5’6”

Civil Status : Married

Nationality : Filipino

Religion : Catholic

Home Address : Pasay City

Occupation : Unemployed

Wife : J.F.

II. Admission Profile

Chief Complaint : Left flank pain

Attending Physician : Dr. N

Admission Date : June 22, 2010

Admission Time : 5:30 am

Admitting Diagnosis : Complicated UTI (urinary tract

infection)

Final Diagnosis : ARF (acute renal failure) secondary to

Complicated UTI (urinary tract

infection)

Patient History

History Admission

History of Present Illness

5 days prior to admission patient had Left flank pain and anuria. This was followed by fever (Temp. max = 38°C). 4 days prior to admission, he sought consult at San Juan de Dios Medical Center. Assessment was UTI, he was advised to transfer to East Avenue Medical Center since he has been having his regular check-up in this institution. Persistence of Left flank pain and fever prompted consult of subsequent admission.

BP : 140/90 mmHg PR : 88 bmp RR : 21 cpm T : 36.3 °C

Past Medical History The patient has been hospitalized last 2005 and was diagnosed S/P Nephrectomy Right with Renal Stones.

Family History Father has Hypertension

Physical History Positive smoker for 5 years (10-20 sticks a day)

Positive alcohol drinker (4-5 bottles of beer a day)

Dietary History High Sodium, High Fat, High Protein Food

Anatomy and Physiology

The Kidney

The kidneys are two bean shaped organs of

the renal system located on the posterior wall of

the abdomen one on each side of the vertebral

column at the level of the twelfth rib. The

kidneys measure about 10cm in length and, 5cm

in breadth and about 2.5 cm in thickness.

One quarter to one fifth of cardiac output

passes through the kidneys at all times. This

means that the kidneys filter approximately 1.2

liters of blood every minute.

The kidneys are protected by three highly specialized layers of protective tissues. Each Kidney is

enclosed in a transparent membrane called the renal capsule which helps to protect them against

infections and trauma.

The cavity attached to the indented side of the kidney is called the renal pelvis which extends into the

ureter.

The kidney is divided into two main areas: a light outer area called the renal cortex (mainly

responsible for filtration), and a darker inner area called the renal medulla (for reabsorption and

secretion).

Within the medulla are 8 or more cone-shaped sections known as renal pyramids. The areas

between the pyramids are called renal columns.

The kidneys receive their oxygenated blood supply from the renal arteries which come off the

abdominal portion of the aorta. Venous blood from the kidneys drains into the renal veins to join the

abdominal portion of the inferior vena cava.

The hilum of the kidneys is located toward the smaller curvature. The opening in the hilum

allows for the entry and exit of blood vessels and nerves. The funnel shaped extension of the kidneys is

called the renal pelvis and it connects the kidneys to the two ureters. This structure facilitates the

collection of the urine from the kidneys and drainage to the urinary bladder.

The Nephron

The nephron is a functional part of the

kidneys.

The Glomerulus is a collection of capillaries

which are surrounded by the Bowman’s capsule.

The afferent arteriole enters this capsule and the

efferent arteriole leaves it. In the glomerulus, the

blood pressue is high and it pushes small

structured molecules out (e.g water, salts, glucose

and urea). However larger molecules (proteins and

glycogen) stay within the capillary network. The

particles which are pushed out with water (filtrate)

enter the proximal convoluted tubule. The following portion is straight and narrow; hence it is

called the straight collecting tubule, also referred to as the Loop of Henle. Water, salts and other

electrolytes are reabsorbed in the Loop of Henle..The filtrate is then selectively reabsorbed in the

distal convoluted tubules. Urine concentration occurs here.

The functions of the renal system include the following:

Elimination of wastes.

Kidneys eliminate wastes by filtering the waste products such as urea and creatinine from the blood

when it enters the glomerular corpuscle and then removed from the body through micturition.

Regulates fluid and electrolytes balance.

Direct control of water excretion in the kidneys is exercised by vasopressin, or anti-diuretic hormone

(ADH), a peptide hormone secreted by the hypothalamus. ADH causes the insertion of water

channels into the membranes of distal convoluted tubule and collecting ducts, allowing water

reabsorption to occur. Aldosterone which is released by the adrenal cortex causes active

reabsorption of sodium in the ascending limb of Loop of Henle. The reabsorption of the cation

sodium is always accompanied by reabsorption of the anion chlorine, sometimes of bicarbonate,

and by principle of solvent drag water.

Regulates acid and base.

Kidneys are responsible for excretion of the fixed acids and this is also a critical role even

though the amounts involved (70-100 mmols/day) is much smaller. In acid-base balance,

the kidney is responsible for 2 major activities: the Reabsorption of filtered bicarbonate:

4,000 to 5,000 mmol/day and Excretion of the fixed acids (acid anion and associated

H+): about 1 mmol/kg/day.

Regulates red blood cell production

Kidneys produce a hormone known as erythropoeitin (EPO), which is carried in the blood to the

bone marrow where it stimulates the production of red blood cells. These cells carry oxygen

throughout the body.

Regulates blood pressure.

Healthy kidneys make hormones such as renin and angiotensin. These hormones regulate

how much sodium (salt) and fluid the body keeps, and how well the blood vessels can

expand and contract. This, in turn, helps control blood pressure.

http://www.renalinfo.com/us/resources/glossary/index.html#renin

Pathophysiology

Non-modifiable risk factors

Gender: Male Age: 50 years old and

above

Modifiable risk factors

Solitary Kidney (Left) Lifestyle

alcohol abuse (4-5 bottles of beer a day) food intake (beef, pork, and beans)

Smoking (10-20 sticks a day for 10 years now)

Increase uric acid level

Formation of urine crystals

Obstruction of the renal calyseal region

Pyelonephritis

Decreased glomerular filtration

Formation of lithiases (uric acid stones)

ACUTE RENAL FAILURE

Anuria Azotemic

Hypertension Multiple Electrolytes Imbalance (hyperkalemia, hypernatremia)

INTERPRETATION

Further scrutiny of the above figure for pathophysiology of acute renal failure, the non-modifiable risk factors cited were gender, particularly males and those who are 50 years old and above. Based from our research, acute renal failure, specifically the post renal type is more common in males because men are more prone to vices like alcohol. The elderly are more susceptible because cells tend to degenerate and die when we get older; and nephrons, the functional unit of the kidney are made of cells.

Moreover, the modifiable risk factors are solitary kidney, lifestyle specifically the food intake and alcohol abuse, and smoking. The patient has only one kidney due to the removal of the patient’s right kidney, 5 years ago because of the renal stones. It is hard for an individual with one kidney to filter out or cleanse the blood that’s why eventually the gloremular filtration will be diminished. Smoking can increase the blood pressure because cigarette contains nicotine. Nicotine is a chemical that is responsible for constricting the blood vessels, thus it decreases blood circulation especially to the kidneys, which is made of Nephrons, which is the functional unit of the kidney. Nephrons are cells and it would degenerate once it is suppressed from oxygen and energy that is necessary for cell metabolism. According to a certain study, Foods containing uric acid and the compounds that metabolize into uric acid include most animal meats, such as beef, pork and seafood. On the other hand, an excessive alcohol intake specifically beer also contributes to the increase of uric acid level in the blood. Beer is produced from malt by fermentation with yeast fungus, and since malt contains considerable amounts of purines, beer also contains high levels of purines. In the human body, most ingested purines are metabolized to the end-product uric acid.

There is an increase in uric acid level because of excessive alcohol and food intake high in purine. There will be formation of urine crystals because too much of uric acid in the urine for a prolonged period leads to the formation of uric acid stones to the renal calyseal region. Acute renal failure will take place due to the obstruction at the renal calyseal region will lead to back flow of blood to the kidney that would cause dilatation, and enlargement and inflammation of the kidney which is pyelonephritis that would further destroy the nephrons. The stones in the kidney is a good breeding of bacteria that’s why infection also take placed. The glomerular filtration rate (GFR) shows how efficiently your kidneys are removing wastes from your bloodstream. There is a decreased in glomerular filtration rate due to the destruction of the nephrons.

Anuria is the absence of urine output; technically defined as urine output of less than 50 ml over a 24 hour period. The patient has anuria because of the presence of kidney stones that obstructs the blood flow that causes less urine output.

Azotemic is a laboratory diagnosis, which the BUN and serum creatinine is high. The patient experienced this due to the decreased glomerular filtration rate of the kidney and the obstruction of the blood flow in the kidney. Therefore there would be an increase in BUN and

creatinine level. Urea is an end product of muscle energy metabolism while creatinine is the result of protein metabolism, hence these are waste products that needs to be eliminated from the body through urination.

Multiple electrolytes imbalance is an abnormal level of electrolytes in the body such as Na, K, Ca. The patient has hypernatremia or high sodium level and hyperkalemia or high potassium level due to the impairment of the renal tubules that are responsible in the reabsorption of electrolytes in the renal medulla.

Hypertension is an increase in blood pressure will also take place because the kidney will produce more renin that would eventually become aldosterone, and ADH (anti-diuretic hormone) that would reabsorb the Na that would attract water along with it.

Medical Management

DATEDOCTOR’S ORDERS

RATIONALE

6/22/105;45am130/80 mmHg86 bpm24 cpm37.3C

Please admit to room 5019F under the service of Dr.N/Q/V

Please secure consent for admission and management.

Strict aspiration precaution please.

Moderate to high back rest.

Uremic diet: low salt, low potassium, low fat, low protein diet

Monitor vital signs Q1 and record please

To facilitate medical procedure and treatments.

The purpose of the informed consent is to assure that the patient understands, in general terms, the nature of and purpose of the intended intervention.

To prevent possible aspiration of food into the lungs

To facilitate proper inspiration and exhalation.

To control the uric acid level in the blood by proper food intake.

To determine if the patient’s blood pressure, temperature, pulse rate and respiratory rate are maintained in normal range, it is essential because

Monitor I and O Q1 and record please

WOF: change in seasonal fever, persistent # Complicated UTI

DIAGNOSTICS:- Urinalysis

- Urine CS

- Na, K, BUN, Creatinine, Uric Acid

the patient has seasonal fever and hypertensive.

To determine if hydration status is balance.

To determine any underlying condition.

U/A to diagnose urinary tract or kidney infection, to evaluate causes of kidney failure.

Urine C/S is to know the certain bacteria present in the urine.

Serum Na and K is tested to check if the essential electrolytes in the body are normal. BUN and Creatinine is used to measure kidney function if the wastes are properly filtered out and eliminated. The uric acid test is ordered when a doctor suspects high levels of uric acid because elevated level of uric acid can cause kidney stone formation

- CBC

- CXR (PA)

- 12L ECG

- KUB Ultrasound

TherapeuticsPNSS 1Lx 20gtts/min

- Ceftriaxone 1g/IV OD, ANST ()

Please inform Dr.Q/V once admitted.

Please inform WAPOD (Ward Attending Physician on Duty) once at ward.

SIIC/JIIC (Senior Intern In-Charge/ Junior Intern to complete database.

To monitor normal values and to obtain abstract for blood components and composition.

To diagnose conditions affecting the chest, its contents, and nearby structure.

To record electrical activity of the heart.

To visualize the kidneys, ureter, and urinary bladder.

This is the only IV fluid that has no potassium.

Treatment for susceptible infection.

For continuity of care and management.

For referral and management.

To complete data needed.

For continuity of care and

Refer. management.

8:30 am110/70 mmHg89 bpm22 cpm36.8 CAwake andOriented

IVF: PNSS 1L x 20gtts/min

Please facilitate urine CS, CXR (PA), KUB Utz.

Monitor vital signs, and I and O Q1, record please.

Refer.

Plain normal saline solution will prevent electrolyte imbalance.

Urine C/S is to know the certain bacteria present in the urine, CXR is to diagnose conditions affecting the chest, its contents, and nearby structure, KUB is to visualize the kidneys, ureter, and urinary bladder.

To monitor if there is abnormalities and, to determine if hydration status is balance.


6/23/10 9amBP: 140/90 mmHgPR: 88 bpmRR: 21 cpm

IVF: PNSS 1Lx20gtts/min This is the only IV fluid that has no potassium.

T: 36.3 CAwake(-)DOB(-)chest painDifficulty urinating, globular abdomen, NABS AP, HR-irregular rhythm12L ECG Irregularity

Still for urine CS

Please facilitate KUB UTZ tom.AM Follow-up CXR result.

Start Aspirin 80mg/tab, 1tab OD after lunch.

For 2D echo may be done as OPD basis.

Continue meds:-Ceftriaxone 1g/IV OD

Monitor on moderate to high back rest.

Please insert IFC now then hook to urine bag

Monitor VS Q1 and I and O Q1.

Start Enalapril 10mg/tab 1tab OD

To follow up the previous order.

To follow up the diagnostic procedure to be done.

Treatment of mild- to moderate pain and fever

A diagnostic procedure that scans of the heart for early detection of cardiac abnormalities.


To promote proper respiration.

To promote urination and to be able to measure the amount of urine accurately.

To strictly monitor any deviation in the vital signs.

Used in treatment of hypertension.

Refer For continuity of care.

6/23/104:10pmIFC was inserted at 11am since there was no urine output notedBP 180/100 mmHg

Give furosemide 40mg/IV now

Monitor I and O Q1 and Record please

Refer

Treatment of edema associated with renal disease and hypertension.

To strictly monitor hydration status.

For continuity of care.

6/23/106pmCXR= 415#ARF secondary to complicated UTI.pH= 7.286pCo2= 21.2 mmHgpO2= 42.3 mmHgHCO3=10 meqs/LO2 sat= 76.1 %D fil2=37%(5LPM)

Give furosemide 80mg IV.

Start furosemide drip D5W 250ml+ 250mg furosemide x 5gtts/min to be titrated by +/- 5ugtts/min every 1 hour to maintain urine output >30cc/hr.

Hook pt. to 02 inhalation @5LPM via nasal cannula

Refer.

WOF pulmonary congestion, dyspnea, changes in sensorium

Treatment of edema associated with renal disease and hypertension.

Furosemide drip will increase the urine output of the patient.

To add in the oxygen saturation of the blood.


Because it can be a result of the low saturation level and fluid retention.

6/24/10 9 Am Please facilitate urine GS/CS if not yet done;

Blood GS/CS

For repeat ABGs

Refer

Urine GS/CS is to know the certain bacteria present in the urine and blood.

To determine acid-base balance.


10:30 Am Continue Furosemide Drip

Refer

The urine output of the patient is still less than 50ml


6/24/102:10 pm140/80 mmHg92 bpm24 cpm36.9 CAwake,AgitatedCBS(+)edemaI-3000O-200 Na+ 156mmol/L

Shift IVF to D5water x KVO

Still for urine CS

For HBsAg, Anti-HBs, Anti-Hcv

For blood typing, BUN, Crea today

Cont. Meds:

Ceftriaxone 2g/iv OD (D2)

D5 water is a hypertonic solution and it contains less sodium content compare to PNSS.

To follow up lab exam

To evaluate patient hepatic or liver profile.

Used to determine patient’s blood type that can be use for possible transfusion.BUN and creatinine as function tests for kidney.


Furosemide drip (D5 Water 250 cc+250 cc furosemide) x 5 ugtts then +/- 5 ugtts every 1 hr. to maintain urine output >_ 30 cc/hr

Maintain 02 at 5LPM via NC

Please D/C Enalapril, shift to Amlodipine 10mg/tab OD

Refer to Nephro for further evaluation and mgt.

Refer to surgery for emergency IJ Catheter insertion once with materials.

Monitor VS, I&O Q1 and record strictly.

Refer accordingly.

Furosemide drip will increase the urine output and maintain the standard output per hour.

To make O2 saturation within normal range.

Prolonged use of enalapril is contraindicated to patients with renovascular diseases.

For more intensive medical management.

In preparation for hemodialysis to be done.

To strictly monitor any deviation in the vital signs


6/25/10 2:30 AM

For Emergency dialysis c/o Nephro Technique of removing waste materials or poisons from the blood using the principles of dialysis.

For CXR

Ketorolac 30 mg TIV Q6 PRN

Refer accordingly.

To visualize proper location of IJ catheter and facilitate the preparation for Hemodialysis.

Treatment of moderate- severe pain.


8:10 am CXR initial revealed IJ catheter at level of T6.

Referred to Dr. R. through SIOD, the result.

May proceed with Hemodialysis as ordered.

Refer.

To locate if the catheter is in place.

For further evaluation and management.

To start the invasive procedure if ready.


6 pm For HD (Hemodialysis) tom. At 5 pm

Follow up referral to nephro

Refer.

To remove waste materials or poisons from the blood using the principles of dialysis.

For more intensive medical management

For continuity of care

6 pm

Pls. follow up the referral. For preparing for Hemodialysis.

6/26/10 11:30 am

Hgb=59gm/L Pls. secure 2 ‘u’ PRBC properly typed and

crossmatched

Pls. transfused 1 ‘u’ when available.

Refer to RIC (Resident In-Charge)/WAPOD (Ward Attending Physician on Duty) once transfusion is done

Still for blood CS, repeat crea, K, ABG today.

Awaiting for urine CS result

For HD today @ 5 PM

D/C of Furosemide drip

Use for Blood transfusion

To prevent mismatching of blood and for Hemodialysis.

To correct abnormal blood values


To recheck if the laboratory results are within normal range.

Schedule of Hemodialysis

The patient’s urine output already

BP = 150/90 mmHg

Start furosemide 40 mg/iv Q12

Monitor VS, I&O Q1 and record please

WOF change in sensorium and decrease in urine output

Refer

maintained.

Used as diuretic to lower patient’s blood pressure.

To strictly monitor any deviation in the vital signs.

Few hours after Hemodialysis, the patient may suffer disequilibrium syndrome that may change the sensorium of the patient due to sudden change in electrolytes level and mostly happens to a first time Hemodialysis.


6/27/10 9:30 am

Maintain Indwelling Foley Catheter

Monitor UO Q1 and record please

Please retrieve previous OR record done 2005.

Suggest for CT Stonogram if ok with service

To have an accurate measurement of urine output.

To strictly determine the status of the patient base from the urine output.

To check the status of the patient and the operation done previously.

To have a detailed and proper visualization of the kidney, ureter

Will follow up patient and refer. and bladder.


6/27/10 11:30 AM

IVF : PNSS 1L x KVO

Still for BT of at least 3 ‘u’ of PRBC type specific and crossmatched

Pls. give furosemide 40 mg./IV every after each ‘u’ of BT

For rpt crea, CBC today

Refer



Furosemide will increase urine output thus prevent congestion.

Serum creatinine is to determine the level of creatinine in the blood and CBC is to monitor normal values and to obtain abstract for blood components and composition. This is also to monitor hemoglobin in connection to blood transfusion.


6/28/10 IVF : PNSS 1L x KVO

May proceed with CT Stonogram.


The patient can now undergo the diagnostic exam.

For CT sonogram, scheduled tomorrow at pm

Advise relatives to have Hemodialysis at least 3x a week.

Please follow up repeat CBC, creatinine results

Refer.

The CT stonogram is now scheduled to be done tomorrow.

To further filter the wastes in the blood of the patient.

To follow up lab result.


6/29/1012 pmBP: 120/80 mmHgPR: 85 bpmRR: 20 cpmT: 36.9 CAwake, GCS=15CBS(+) IJ cath on LeftGlobular abdomen(+) hypogastric pain(+) constipationI = 1120 mlO = 50 ml

Please give Dulcolax suppository now

For repeat CBC, Creatinine, K, ABG today

For BT, type, specific, and crossmatched

Cont. Meds.

Refer

Treatment of constipation.

To check if the CBC, Crea, K and ABG are within normal range.



Refer any abnormalities or changes in the patient’s status.

Lab and Diagnostic Tests

Date: June 22, 2010

SERUM

TEST NAME RESULTS NORMAL VALUES RATIONALE

Blood urea Nitrogen 23.4mmol/L 3.2-8mmol/L Increased BUN levels may indicate renal disease, urinary tract obstruction, and increased with the protein catabolism.

Creatinine 415umol/L 53-133umol/L Elevated creatinine level in the blood indicates diminished renal function particularly secretion of waste products, and generally indicate renal disease that has seriously damaged 50% of more of the nephrons.

Sodium 156mmol/L 135-145mmol/L High sodium in the blood, second main function of the kidney which is reabsorption is impaired because there is an electrolyte imbalance and indicates hypertension

Potassium 5.3mmol/L 4-4.5mmol/L Increased potassium level indicates hyperkalemia and also impaired reabsorption of electrolytes.

Uric Acid 17.4mg/dL 2.1 to 8.5 mg/dL Elevated uric acid level indicates hyperuricemia and formation of uric acid stones in the kidney.

URINALYSIS Normal Findings Findings RationaleColor Colorless or Amber Dark Yellow Due to the presence of

pus and RBC in the urine

Transparency Clear Slightly Turbid Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine or may develop from crystallization or precipitation of salts or presence of pus/WBC.

Reaction (pH) 5.5 – 7.0 6.0 NormalSpecific gravity 1.010 – 1.025 1.010 NormalPus cells 0-3/HPF 30-32/HPF Elevated level of pus cells

in the urine indicates infection.

RBC 0-3/HPF 8-10/HPF Presence of red blood cells may indicate infection, obstruction, inflammation and trauma

Epithelial cells 0-5/HPF Few Normal Date: June 22, 2010 X-RAY REPORTExamination: CHEST AP

Radiological Findings:

There is crowding of the basal lung markings with haziness in both lung bases. The right minor fissure is prominent. Heart is transversely oriented. Aorta is unremarkable. The left costophrenic sulcus is blunted. Both hemidiagphrams are high in position. Right costophrenic sulcus and visualized bones are intact.

Impression: Consider pneumonia, both lung bases with inter fissural thickening and fluid collection.Consider pleural adhesion and/ minimal hydrothorax, left. Clinical correlation is suggested. The rests of the findings are consistent with poor inspiratory effort.

Date: June 23, 2010HEMATOLOGYComplete Blood Count

TEST NAME RESULTS NORMAL VALUES RATIONALERBC 2.18 10^12/L 4-5.6x10 Decreased RBC

indicates anemiaHemoglobin 75 g/L 140-170g/L Below normal-

hemoglobin levels may lead to anemia that can

be a result of iron deficiency or other deficiencies, such as B12 and folate

Hematocrit 0.21/L 0.40-0.54gm/L Decreased level may indicate anemia.

MCV (mean corpuscular volume)

95 f/L 80-96 f/L Normal

MCH (mean cell hemoglobin)

34.6 pg 27.5-33.2 pg Elevated MCH indicates Vitamin B12and/or Folic Acid deficiency and it also associated with alcoholism

MCHC (mean corpuscular hemoglobin concentration)

365g/L 334-335g/L Elevated MCHC is usually seen in burn patients and with hereditary spherocytosis,it is a relatively rare congenital disorder.

RDW/RDCW (red blood cell distribution width)

12.4% 11-15% Normal

WBC 28.60 x109 L 5-10x109 L May indicate body’s immune response to infection

Platelet Count 69x109 L 200-400x109 L Low level of platelet count may result in spontaneous bleeding or may cause delay in the normal process of clotting

DIFFERENTIAL COUNTNeutrophil 96% 50 – 60% Elevated level indicates

urinary tract infectionLympocyte 3% 20 – 40% A very low level may

indicate poor immune system

Monocyte 1% 2 – 9 % Low level of monocytes may indicate poor protection against bacteria

Date: June 23, 2010

TEST NAME RESULTS NORMAL VALUES RATIONALE

http://en.wikipedia.org/wiki/Vitamin_B12


BUN 45.44mmol/L 3.2-8mmol/L Increased BUN levels may indicate renal disease, urinary tract obstruction, and increased with the protein catabolism

Creatinine 574.8umol/L 53-133umol/L Elevated levels may indicate diminished renal function, and generally indicate renal disease that has seriously damaged 50% of more of the nephrons.

Date: June 24, 2010CLINICAL CHEMISTRY:

Creatinine 0.58-High mmol/L (0.06-0.14)

Data Collected June 08, 2010Time Collected: 00:14Creatine: 0.58 H

Date: June 23, 2010ULTRASOUND REPORT

Examination: KUB (Kidney and Urinary Bladder)

The right kidney is surgically absent.The left kidney is enlarged, measures approximately 15.0x8.5x8.4cm (LxWxAP) exhibiting poor cortico medullary differentiation. There are at least two shadowing echogenic foci in the calyceal region, largest of which is in the lower pole measuring about 2.2cm. The renal pelvis is not dilated.The urinary bladder is sufficiently filled with an indwelling foley catheter balloon in place.

Impression: Enlarged left kidney with lithiases CT scan correlation is suggested for further evaluationDate June 25, 2010 SERUM

TEST NAME RESULTS NORMAL VALUES RATIONALECreatinine 840umol/L-HIGH 53-133mmol/L Elevated levels may

indicate diminished renal function, and generally indicate renal disease that has

seriously damaged 50% of more of the nephrons

Potassium 3.6mmol/L 4-4-5mmol/L Increased potassium level may indicate hyperkalemia.

Date: June 26, 2010

HEMATOLOGY

Normal Values

Result Rationale

Hemoglobin 120-150 gm/L

59gm/L Decreased hemoglobin indicates blood loss

and bone marrow suppression. Hematocrit 0.40-0.54

gm/L0.175gm/L Decreased hematocrit indicates anemia

Neutrophil 0.54-0.75% 0.84% Elevated level indicates urinary tract infection

WBC 5.0-10.0x109/L 30.5x10^9/L

Elevated number of WBC may indicate bacterial infections, inflammation, leukemia, trauma, intense exercise, or stress.

Lymphocyte 0.20-0.35 0.14% A decreased in lymphocytes may indicate viral infection

Monocytes 0.0-.06 0.02% Normal

Platelate Count 200-400x10 L 160x10^9/L Low level of platelet count may result in

spontaneous bleeding or may cause delay in the normal process of clotting

MCV 80-100 f/L 96.2 f/L NormalMCH 27-31 pg 32.6 pg Elevated MCH indicates Vitamin B12and/or

Folic Acid deficiency and it also associated with alcoholism

MCHC 320-360 g/L 339 g/L NormalRDW 11.6-14.6 % 13.4 % Normal

Date: June 29, 2010

HEMATOLOGY

Normal Values

Result Rationale

Hemoglobin 120-150 gm/L

79gm/L Decreased hemoglobin indicates blood loss

and bone marrow suppression. Hematocrit 0.40-0.54 0.230gm/L Decreased hematocrit indicates anemia


http://www.labtestsonline.org/understanding/conditions/leukemia.html

gm/LNeutrophil 0.54-0.75% 0.88% Elevated level indicates urinary tract

infectionWBC 5.0-

10.0x109/L 26.27 x109/LElevated number of WBC may indicate bacterial infections, inflammation, trauma or stress.

Lymphocyte 0.20-0.35 0.09% A decreased in lymphocytes may indicate a viral infection

Monocytes 0.0-.06 0.03% Normal Platelate Count 200-400 202x10^9/L Normal MCV 80-100 91.8fL NormalMCH 27-31 31.3pg Elevated MCH indicates Vitamin B12and/or

Folic Acid deficiency and it also associated with alcoholism

MCHC 320-360 341g/L NormalRDW 11.6-14.6 14.4% Normal

Date: June 30, 2010

TEST NAME RESULTS NORMAL VALUES

RATIONALE

Creatinine 464umol/L 53-133umol/L Elevated creatinine level in the blood indicates diminished renal function particularly secretion of waste products, and generally indicate renal disease that has seriously damaged 50% of more of the nephrons.

Sodium 162mmol/L 135-145mmol/L High sodium in the blood, second main function of the kidney which is reabsorption is impaired because there is an electrolyte


imbalance and indicates hypertension

Potassium 4.2mmol/L 4-4.5mmol/L Normal

June 29, 2010

CT Stonogram

Non-contrast spiral CT scan of the whole abdomen using 10 mm collimation and pitch of 1.5 increments show the following findings:

The right kidney is not appreciated in the study. The left kidney is markedly enlarged measuring about 14.5cm x 11.7 cm x 11.3 cm

(LxWxAP) with no normal renal parenchymal differentiation appreciated. There is a large hyperdense focus slightly more attenuating than muscle that is expanding the dependent portion of the left kidney which may represent settled blood products. Pockets of air are noted within the left pelvocalyceal system with associated perirenal fat stranding that appears to involve the ipsilateral psoas muscle.

The left ureter is note properly appreciated in the study. No radiopaque densities are seen along the KUB tract. The urinary bladder is physiologically distented with diffuse thickenin of its walls. The visualized bones are intact.

IMPRESSION: Consider markedly enlarged left kidney with emphysematous pyelonephritis; probable perirenal hematoma, and left psoas muscle inflammation. Cystitis.

Blood Type O Blood Type ORH POSITIVE RH POSITIVE

Source: PNRCSerial #: 2009-041341

Serological Test done: Screen @ PNRC

Blood Component PRBCHIV, HbsAg, HCV NON-REACTIVEMalaria Negative

Remarks: Done in three phases

Major Crossmatch compatible

Minor Crossmatch compatible

Extraction Date: 06/26/10

Expiration Date: 07/28/10

Date: June 22, 2010

Time Input Output6 am 70 ml 0 ml7am 50 ml 0 ml8 am 90 ml 0 ml9 am 60 ml 0 ml10 am 70 ml 0 ml11 am 100 ml 0 ml

12 nn 130 ml 0 ml1 pm 60 ml 0 ml2 pm 40 ml 0 ml3 pm 150 ml 0 ml4 pm 50 ml 0 ml5 pm 90 ml 0 ml6 pm 80 ml 0 ml7 pm 120 ml 0 ml8 pm 170 ml 0 ml9 pm 40 ml 0 ml10 pm 70 ml 0 ml11 pm 100 ml 0 ml

Date: June 23, 2010

Time Input Output12 mn 70 ml 0 ml1 am 100 ml 0 ml2 am 60 ml 0 ml3 am 90 ml 0 ml4 am 60 ml 0 ml5 am 80 ml 0 ml6 am 50 ml 0 ml7am 90 ml 0 ml8 am 80 ml 0 ml9 am 40 ml 0 ml10 am 50 ml 0 ml11 am 80 ml 0 ml12 nn 150 ml 10 ml1 pm 70 ml 5 ml2 pm 90 ml 0 ml3 pm 60 ml 0 ml4 pm 120 ml 3 ml5 pm 100 ml 4 ml6 pm 60 ml 0 ml7 pm 70 ml 8 ml8 pm 100 ml 11 ml9 pm 80 ml 5 ml10 pm 60 ml 6 ml11 pm 50 ml 0 ml

Date: June 28, 2010

Time Input Output12 mn 0 ml 3 ml

1 am 50 ml 5 ml2 am 40 ml 7 ml3 am 60 ml 10 ml4 am 50 ml 6 ml5 am 40 ml 0 ml6 am 20 ml 0 ml7am 70 ml 0 ml8 am 90 ml 0 ml9 am 60 ml 0 ml10 am 100 ml 4 ml11 am 50 ml 0 ml12 nn 60 ml 2 ml1 pm 80 ml 0 ml2 pm 40 ml 0 ml3 pm 30 ml 0 ml4 pm 80 ml 0 ml5 pm 50 ml 0 ml6 pm 90 ml 4 ml7 pm 60 ml 0 ml8 pm 50 ml 0 ml9 pm 90 ml 0ml10 pm 80 ml 0 ml11 pm 60 ml 0 ml

Date: June 29, 2010

Time Input Output12 mn 80 ml 3 ml1 am 70 ml 4 ml2 am 50 ml 0 ml3 am 40 ml 0 ml4 am 60 ml 5 ml5 am 80 ml 0 ml6 am 40 ml 10 ml7am 30 ml 2 ml8 am 40 ml 0 ml9 am 50 ml 0 ml10 am 40 ml 0 ml11 am 60 ml 2 ml12 nn 70 ml 10 ml1 pm 50 ml 3 ml2 pm 40 ml 0 ml3 pm 30 ml 0 ml4 pm 50 ml 2 ml5 pm 70 ml 0 ml6 pm 40 ml 0 ml

7 pm 40 ml 4 ml8 pm 50 ml 5 ml

Documents

LVL4NCM104CASEPRES FINAL