Acute Kidney Injury

HISTORY:

Presents for ‍newknown acute kidney injury



Lab results:

Creatininee ‍ ‍normal, BUN ‍ ‍normal, GFR ‍ ‍normal

Electrolytes ‍ ‍normal

Complete blood count ‍ ‍normal

Liver function tests ‍ ‍normal

Urinalysis ‍ ‍normal



‍fatigue

‍shortness of breath

‍leg swelling

‍confusion

‍nausea

‍dehydration

‍chest pain

‍obstructive urinary symptoms



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍



ASSESSMENT:

‍Acute kidney injury ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍BUN

- Urine: ‍urinalysis, ‍urine culture, ‍urine electrolytes

- Renal ultrasound

- CT scan of abdomen

- Normal saline ‍ cc bolus, then ‍ cc/hr

- Stop medications: NSAIDs, diuretic, ACE, ARB, metformin

- Dietary modifications: ‍low sodium diet, ‍low potassium diet, ‍low protein diet

- Avoid NSAIDs

- Avoid contrast agents

- Referral to nephrologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as swelling, shortness of breath, or decreased urine output