THIS IS THE CASE STUDY. I HAVE ALREADY DONE A DIAGNOSIS AND PLAN OF MANAGEMENT.

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SOLUTION
 
Case Study # 3
HPI:  66 y.o. Caucasian male presented to the emergency room with weakness, nausea without vomiting, decreased oral intake in past 48-72 hours, and dysuria. 
Past Medical Hx:  Hypertension, DM2, osteoarthritis.
Medications:  Lisinopril/HCTZ 20/12.5 mg one tablet QD, Metformin 1000 mg ER one tablet daily with evening meal, ibuprofen 400-600 mg 1-2 times per day as needed for pain.  Patient states he’s been compliant with his medication regimen and has been taking the ibuprofen as well most days of the week.
Physical Exam:   Height 5’11”, weight 207 lbs, Temp 37.0, BP 106/56, HR 102.
Labs/Testing:  CBC:  Hgb 11.2, 33.6, WBC 9.9, plt count 202K. CMP showed sodium 125, potassium 2.3, magnesium 1.2, calcium 9.0, bicarb 41.0, BUN 79, creatinine 2.5.  Last recorded creatinine 6 months ago was noted to be 1.3.  Renal ultrasound showed no hydronephrosis, calculus or sign of obstruction.
MY CONCLUSIONS FOR THIS CASE:   ADD GUIDELINES TO BELOW WITH THREE HIGH CALIBER REFERENCES LIKE JAMA, UPtoDATE, OR JOURNAL OF UROLOGY AND NEPHROLOGY.  You may use the text below because it is my words.
Impression/Diagnosis

Acute kidney injury– secondary to volume depletion due to nausea and vomiting. The etiology of interstitial nephritis secondary to Ibuprofen to be ruled out
Nausea/vomiting- gastroenteritis, gastritis, or peptic ulcer disease secondary to Ibuprofen
Metabolic alkalosis
Hyperchloremic
Hypokalemic
Hyponatremia due to volume depletion
Hypomagnesemia

Plan of Management:

Hold all medications listed. Hold Lisinopril in the setting of renal failure.  It can worsen it and cause hyperkalemia. HCTZ can explain or worsen the electrolyte imbalances shown in this patient.  It can cause hypochloremia, hypokalemia, and metabolic alkalosis which can also occur with vomiting. Metformin is contraindicated in this patient with renal failure.  It can also cause lactic acidosis.  Hold Ibuprofen to GI side effects and potential for kidney harm
EKG- check for abnormalities i.e., hypokalemia
Need to replace serum magnesium 1-2GM’s IV as the patient is unable to tolerate PO and needs to be promptly addressed. Recheck two hours after and correct as needed.
Need to perform a Urine analysis and culture to rule out infection and other abnormalities of the urine sediment. R/o Urinary tract infection
Patient needs and IV PPI i.e., Omeprazole or similar for prophylaxis and or treatment
IV isotonic normal saline will replace volume deficit, sodium, and chloride. Add potassium chloride 20-40 mEq per liter.

Long term plans for this patient:
Control hypertension with a calcium blocker i.e., Amlodipine and use Tylenol for arthritis which is less toxic. Since the patient is a diabetic an ARB (Valsartan) could prove to be a better choice than the Lisinopril Ace inhibitor.
Consider BPH causing lower urinary symptoms however this does not appear to be severe in the absence of obstructive uropathy not shown on U/S.  With the information given it is safe to assume that the patient does not have inflammatory arthritis and that his symptoms are related to the degenerative joint disease.

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