Case 42: Introduction

History of Present Illness (HPI)

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A 55 year old man with a past medical history of hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD) is brought to the emergency department (ED) by ambulance for shortness of breath and altered mental status.

Per his partner, the patient developed progressively worsening shortness of breath and productive cough over the past week. He developed fever, fatigue, and today became somnolent and confused. He has not had diarrhea, constipation, or vomiting. His urine output has declined significantly. He has no known personal or family history of kidney disease. He is a former smoker (quit 5 years ago) and does not drink alcohol or use illicit drugs.

Upon arrival to the ED, the patient is minimally responsive to questioning.

Preliminary vital signs are obtained.
Click here for vitals:
Temp 100.6F
Heart Rate 125 beats/min
Blood pressure 80/52 mmHg
O2 saturation 80% with non-rebreather mask

He is urgently intubated for hypoxia and airway protection and is admitted to the intensive care unit (ICU). He receives 4L of isotonic intravenous (IV) fluid and subsequently requires initiation of vasopressors. Broad spectrum antibiotics are given for septic shock likely secondary to pneumonia.

On day 2 of his ICU stay, urine output is recorded as <100cc over the last 24 hours. You are the nephrologist on-call and asked to further assist in his care.

Click here for the physical exam!