Mr. T., a 52-year-old long-distance trucker with a history of hypertension and peptic ulcer disease, presents to the emergency department (ED) with a 7-day history of severe vomiting and abdominal pain. Mr. T.’s weight is 80 kg. He states that during the previous week he has been able to eat very little food and tolerates only occasional sips of water. He has become progressively weaker and is dizzy as he tries to stand. He has not taken his antihypertensive medication (hydrochlorothiazide and metoprolol) for the past 3 days. On physical exam, Mr. T. appears acutely ill, very weak, and pale. He has tenting of the skin over the clavicles, dry mucous membranes, weak peripheral pulses, flat jugular veins, and bilateral upper-quadrant tenderness with palpation. parameter IN SUPINE positionBP 96/50HR 110 min regular RR 24bpmTemp 99 F Vital Signs (supine)96/50 mm Hg110/ min/regular24 00M99°FVital Signs (sitting)72/38 mm Hg140 min/regularvitals signs (sitting)BP:72/38HR;140 min/regular An IV catheter was inserted 2 hours after his arrival in the ED, and an indwelling urinary catheter is inserted with a urine output of 150 mL. He last remembers voiding about 8 hours ago. His labs, drawn upon arrival in the ED, are as follows: Na 133 mEq/L, K 2.8 mEq/L, Cl 70 mEq/L, CO2 42 mEq/L, glucose 72 mg/dL, creatinine 4.2 mg/dL, BUN 108 mg/dL, hematocrit 51%, hemoglobin 17 gm/dL, WBC 10.2 x 10 3. What do Mr T.’s lab work and presenting features indicate? Clinical Update: Mr. T. was resuscitated with intravenous fluid and was taken to the operating room for surgical repair of a bleeding gastric ulcer. On postop day 1, Mr. T.’s urine output has decreased to 250 mL over the preceding 12 hours, and his lab results are as follows:(the results here will be downloaded as a file name table 1) The nephrologist is called in for consult and recommends a fluid challenge. What would be the purpose of administering fluids at this point?What is your interpretation of Mr. T’s BUN and creatinine?Clinical Update: On postop day 3, Mr. T. develops a temperature of 38.8°C (101.8°F), and his urine output remains low, at 20–25 mL/hour. A diuretic challenge was done after fluids were administered. He does not respond to diuretics. His weight is 8 kg above his preop weight. Some labs are indicated below. (the picture here will be table 2) A chest x-ray and physical exam indicate right lower-lobe (RLL) pneumonia. Why is Mr. T. at increased risk of pulmonary complications?You are concerned about Mr. T’s potassium level. What treatment might you expect the healthcare provider to prescribe?Clinical Update: By postoperative day 6, Mr. T.’s respiratory infection and azotemia have worsened, and his weight is now 14 kg above his preoperative weight.
