Case Published: June 2018

History of Present Illness (HPI)

A 79 year old man with insulin-dependent diabetes mellitus (last hemoglobin A1c 10.1%), mild dementia, and chronic kidney disease stage IV (last creatinine 2 mg/dL, three weeks ago) is brought to the Emergency Department by his wife for nausea, vomiting, and confusion.

She reports he has had declining health over the past several years, but over the past three days he developed worsening fatigue and symptoms of nausea, non-bloody non-bilious vomiting, minimal urination, and poor mental status. At baseline, he is alert and oriented x 2 (person, place) and requires some assistance from his wife for his activities of daily living.

He has had no fevers, chills, chest pain, shortness of breath, or peripheral edema. His wife does report he has been complaining of abdominal pain, but he has not had diarrhea, constipation, melena, or bright red blood per rectum. He has also had difficulty sleeping, for which she recently started giving him diphenhydramine at bedtime with good effect. He also takes lisinopril, insulin glargine, insulin lispro with meals, vitamin D, and donepezil.

You do a brief chart review, and the patient was last seen in clinic 3 weeks ago for routine follow-up. His creatinine at that time was 2 mg/dL and his urinary protein excretion estimation was 1.2 g/day. A renal ultrasound performed 6 months ago was normal, and a transthoracic echocardiogram from 3 months ago showed an ejection fraction of 60%, mild diastolic dysfunction, and no valvular disease.

The patient is admitted to the medicine service for further work-up and management.

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