Emergency medical services bring a 72-year-old woman to the emergency department after her… — USMLE Step 3

Emergency medical services bring a $72$ -year-old woman to the emergency department after her daughter found her profoundly weak and confused at home. According to the daughter, the patient has had severe nausea, vomiting, and non-bloody diarrhea for the past $3$ days.

The patient's medical history includes type 2 diabetes mellitus, hypertension, and osteoarthritis. Her home medications include metformin, empagliflozin, lisinopril, and naproxen as needed.

Vital signs are:

Parameter	Value
Temperature	$37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ )
Heart rate	$118/\text{min}$
Blood pressure	$86/54\text{ mmHg}$
Respiratory rate	$18/\text{min}$
Oxygen saturation	$96\%$ on room air

Physical examination reveals dry oral mucous membranes, poor skin turgor, and delayed capillary refill. She is lethargic but arousable and oriented to person.

Laboratory results are as follows:

Test	Result	Reference Range
Sodium	$132\text{ mEq/L}$	$136$ - $145\text{ mEq/L}$
Potassium	$5.2\text{ mEq/L}$	$3.5$ - $5.0\text{ mEq/L}$
Chloride	$98\text{ mEq/L}$	$95$ - $105\text{ mEq/L}$
Bicarbonate	$18\text{ mEq/L}$	$22$ - $28\text{ mEq/L}$
Blood urea nitrogen	$62\text{ mg/dL}$	$7$ - $18\text{ mg/dL}$
Creatinine	$2.6\text{ mg/dL}$	$0.6$ - $1.2\text{ mg/dL}$
Glucose	$175\text{ mg/dL}$	$70$ - $110\text{ mg/dL}$

*(Baseline creatinine from one month ago was $0.9\text{ mg/dL}$ )*

Which of the following pharmacologic interventions are most appropriate in the initial management of this patient? (Select all that apply)

Administer intravenous $0.9\%$ sodium chlorideCevap
Withhold the patient's home empagliflozin, lisinopril, and naproxenCevap
C
Administer intravenous furosemide
D
Administer oral sodium polystyrene sulfonate
E
Initiate an intravenous regular insulin infusion

Cevap

The correct interventions are administering intravenous

0.9\%

sodium chloride and withholding the patient's home empagliflozin, lisinopril, and naproxen.

The correct interventions address the primary life-threatening issue (hypovolemia) while preventing iatrogenic harm. This patient presents with severe hypovolemia secondary to gastrointestinal fluid losses, leading to hypovolemic shock and acute kidney injury (AKI), as evidenced by her hypotension, tachycardia, elevated BUN/creatinine ratio, and physical exam findings. The most urgent pharmacologic intervention is rapid volume resuscitation with an isotonic crystalloid, such as intravenous

0.9\%

sodium chloride, to restore intravascular volume and renal perfusion. Concurrently, it is critical to apply 'sick day rules' and discontinue home medications that can exacerbate AKI or pose severe risks during acute illness. Lisinopril (an ACE inhibitor) and naproxen (an NSAID) impair renal autoregulation (efferent dilation and afferent constriction, respectively) and worsen prerenal AKI. Empagliflozin (an SGLT2 inhibitor) induces osmotic diuresis, exacerbating hypovolemia, and significantly increases the risk of euglycemic diabetic ketoacidosis during periods of physiological stress or starvation.

Adım Adım Çözüm

Assess the patient's hemodynamic status and laboratory findings.

The patient exhibits hypotension, tachycardia, delayed capillary refill, and laboratory evidence of acute kidney injury (AKI) with a high BUN/creatinine ratio, indicating severe hypovolemic shock and prerenal AKI.

Establishing the etiology of the AKI dictates immediate management priorities.

Select the primary resuscitative intervention.

Identify intravenous

0.9\%

sodium chloride as the urgent treatment of choice.

Restoring intravascular volume is critical to re-establishing adequate renal and systemic perfusion.

Review the home medication list to implement 'sick day rules' (medication reconciliation).

Identify that empagliflozin, lisinopril, and naproxen must be discontinued immediately.

These medications exacerbate renal injury and volume depletion during acute illnesses, and holding them prevents further deterioration.

Anahtar Kavram

Management of acute hypovolemic acute kidney injury and implementation of 'sick day rules' for nephrotoxic and volume-depleting medications.

Tahmini Süre:1m 30s

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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