Nursing Case Study On Creatinine

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REASON
CHIEF COMPLAINT: Hypertensive nephropathy.

BLANKLINE
Mr. Porter is a 54-year-old gentleman with severe vascular disease who was probable hypertensive nephropathy. His creatinine was 1.9 in 2009, 2.1 in 2011, 2.0 in 2012, 2.4 in 2013, and in 12/2016 it was still 2.4. Unfortunately, in association with a foot wound and vancomycin and Zosyn infusion that he has had this month his creatinine is now up to 3.7. Other labs: Past renal ultrasound unremarkable. Microalbumin to creatinine ratio elevated at 440. No urine protein on dipstick. ANA negative. A 06/2015 ultrasound negative. Sodium lower at 129, potassium 3.6, bicarb 16, glucose 289, BUN 45, creatinine 3.7, anion gap 7, so this is all renal disease. Calcium 7.4, hemoglobin …show more content…

Peripheral vascular disease, associated foot wounds, status post angioplasties and surgeries in the past.

PHYSICAL EXAMINATION
Temp 94, blood pressure 147/83. An ill-appearing gentleman lying in bed, getting an infusion. Heart: Regular rate and rhythm. Lungs: Clear. Extremities: No edema.

ASSESSMENT AND PLAN
1. Acute on chronic renal failure, hypertension and vascular disease are the most likely cause of his chronic kidney disease due to the long duration of diabetes and lack of proteinuria. Baseline creatinine can be summarized as being around 2.5 from 2014 to 12/2016. It is now 3.7, due to his wound infection and possibly vancomycin toxicity.
2. Hypertension. Adequate control given illness. We do not want his pressure to run too low.

3. Hyponatremia. Mild, would avoid excess free water and continue to monitor, if it drops lower will need to fluid restrict.

4. Acidosis, due to the acute renal failure. Non gap.

SUMMARY
1. I would suggest check the vancomycin trough that is pending, it is almost certainly going to be high and the vancomycin will need to be held. The cultures seem to indicate that this may be more of a gram-negative problem, in which case the vancomycin can be stopped. I would try to minimize the vancomycin if the creatinine continues to rise, perhaps changing to linezolid or daptomycin would be worth

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