This 66-year-old female presented with general weakness for 5 days. She had a history of tongue cancer, diabetes, hypertension, chronic kidney disease stage 3, and hypothyroidism. On examination, she had bilateral lower limb edema and decreased muscle strength. Laboratory tests showed hyponatremia, hypoalbuminemia, and deteriorated renal function. A chest x-ray was unremarkable. She was diagnosed with acute kidney injury exacerbating her chronic kidney disease, along with hyponatremia likely due to diuretics, desmopressin, and poor oral intake. Her condition improved with fluid restriction and discontinuing medications exacerbating her hypotension.
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3. Case 4
66 y/o female with general weakness for 5 days
4. CASE 4. 病例摘要
主訴:
General weakness for 5 days
簡單病史:
This 66 y/o female has history of 1. Tongue cancer, pT2cN0 post wide excision on 2016/12/5, post adjuvant RT alone 2.
Type 2 Diabetes Mellitus many years under OADs 3. Hypertension 4. Chronic kidney disease stage III 5. Membranous
nephropathy refractory to steroid, post cyclosporin 6. Hypothyroidism under Eltroxin. She suffered from general weakness
for 5 days. She also complained of poor appetite(+), fatigue(+), nausea(+) and bilateral lower limb edema in recent 2 weeks.
She denied fever, headache, chest pain, dyspnea, abdominal pain, dysuria, decreased urine amount, diarrhea, tarry or
bloody stool. BW loss up to 10kg in recent 3 months was mentioned. She came to our ED for problems above. At ED,
bilateral lower limb edema and decreased muscle powers in four limbs (4+) noticed on physical exam. Lab revealed anemia
(Hb 8.8), Hyponatremia (Na 116 mmol/L), Hypoalbuminemia ( 3.0 gm/dL), deterioration in renal function (BUN /Cr 63 / 3.74
mg/dL). CXR showed no active lung lesion. Under impression of Acute on Chronic Kidney Disease, and Hyponatremia she
was admitted for further management.
5. Chief Complaint
General weakness for 5 days
HTN / DM / MGN with CKD stage 3b under diuretics + ARB
Hypothyroidism under Eltroxin
Tongue cancer stage II s/p wide excision on 2016/12/5, s/p adjuvant RT
Minirin (Desmopressin) for Urinary incontinence
Postan + Augmentin (susp. lower facial defect & cellulitis s/p I & D at OPD)
History
Current OPD medication
Patient
9. Lab data
Na 116 mmol/L
K 5.1 mmol/L
Ca 9.2 mg/dL
BUN 63 mg/dL
Creatinine 3.74 mg/dL
ALT (SGPT) 9 IU/L
Glucose AC 244 mg/dL
HGB 8.8 g/dL
WBC 7.68 10 3/μL
WBC DC
Platelet 427 10 3/μL
Neutrophil 80.7 %
Lymphocyte 9.4 %
Monocyte 8.5 %
Eosinophil 1.3 %
Basophil 0.1 %
ALBUMIN 3 gm/dL
VBG
PH 7.465
PCO2 24.2 mmHg
PO2 98.3 mmHg
HCO3- 17 mmol/L
BE -5.5 mmol/L
O2SAT 97.9 %
10. Lab data
Urine Routine
Specific Gravity 1.015
PH 5
Protein 1+
Glucose +/-
Urobilinogen 0.1 EU./dL
Bilirubin -
Nitrite -
WBC -
P/C Ratio 300 mg/g Cr
Color Yellow
Ketones -
Occult Blood -
RBC 5 /HPF
WBC 5.5 /HPF
Squa.Epithelial cell 4.4 /HPF
Bacteria 0.08 10 5/mL
11. Finial Diagnosis
1. Hyponatremia
○ Desmopressin, diuretics, hypoalbuminemia, poor intake related
2. Acute kidney injury on chronic kidney disease
○ NSAID related
3. Tongue cancer, stage II
○ post wide excision on 2016/12/5, post adjuvant RT
4. Type 2 Diabetes Mellitus, with nephropathy
5. Hypertension
6. Membranous nephropathy refractory to steroid, post cyclosporin
7. Hypothyroidism under Eltroxin
12. Discharged on 8/17.
We encouraged patient to intake more.
The following lab on 8/15 improved
Creatinine(3.74mg/dL → 1.84mg/dL)
Cease Postan Minirin
Water restriction
Hold ARB and Diuretics due to hypotension