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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Assess a patient with AKI using clinical and laboratory data.

  • Classify AKI in a patient.

  • Distinguish between AKI resulting from prerenal and that from intrinsic injury.

  • Recommend changes to the pharmacotherapeutic regimen of a patient with AKI.

  • Justify appropriate therapeutic interventions for a patient with AKI.

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PATIENT PRESENTATION

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Chief Complaint

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“I feel really weak.”

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HPI

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Everit Mitchell is a 72-year-old man who presents to the ED with complaints of severe weakness that started this morning and recent stomach pain for the past week. He was feeling normal until he developed stomach pain 1 week ago that worsened with meals. Two days ago the pain worsened to the point where he avoided eating, and last evening he felt more tired than usual and went to bed early. He had difficulty sleeping due to the pain and since waking this morning he has been in too much pain and too weak to perform his normal ADLs. His wife brought him to the ED because his physician is away on vacation.

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PMH

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  • HTN × 30 years

  • CAD × 20 years

  • MI × 2 with most recent 2 months ago s/p PCI with drug-eluting stent placement

  • s/p CABG 20 years ago

  • HF × 4 years

  • RA × 1 year

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FH

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Father died of an acute MI at age 52; mother had diabetes mellitus and died of a stroke at the age of 65.

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SH

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Retired and living at home with his wife. Before retirement, the patient was employed as an accountant. No alcohol, no tobacco use.

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Meds

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  • Aspirin 81 mg PO daily

  • Amlodipine 10 mg PO once daily

  • Furosemide 40 mg PO once daily

  • Metoprolol succinate 50 mg PO once daily

  • Enalapril 20 mg PO once daily

  • Prasugrel 10 mg PO daily

  • Naproxen 500 mg PO BID

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All

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NKA

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ROS

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In addition to weakness and stomach pain, the patient complains of feeling cold but denies chills or fever. No changes in vision. Denies SOB, CP, and cough. Complains of feeling lightheaded. Has been having frequent loose black stools over the past 3 days and abdominal pain that has become severe in the last two days. Has noted a decrease in the frequency of his urination over the past 24 hours. Denies musculoskeletal pain or cramping.

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Physical Examination

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Gen
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Pale, elderly Caucasian man who appears in moderate distress and generally weak and lethargic

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VS
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BP 89/43 mm Hg (77/32 mm Hg on standing), P ...

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