Renal physiology

Presentation: History and physical examination

In the morning while walking to the bathroom, C.J. began feeling a tightening followed by what he calls a “tearing” sensation between his shoulder blades. He does not endorse any pain in the left arm or up into the neck. He states that the pain was sudden and sharp and nothing he did would make it go away. He tried to sit down and relax but this did not help. He had not yet taken his morning medication of Metoprolol and Lisinopril, and thought perhaps that would help his symptoms. He waited 1 hour after taking the medication and with no remittance presented to the emergency department (ED). He further denies any abdominal pain, nausea, vomiting, recent fever or chills, shortness of breath, or any musculoskeletal pain. He has never experienced anything like this in the past, nor does he believe anyone in his family has ever experienced these symptoms.

He was evaluated by Vascular Surgery and admitted for further workup which included a computed tomography (CT) scan. As a member of the nephrology team, you were consulted after admission, laboratory evaluation, and imaging were complete.

On physical examination, C.J. is lying in bed, alert and oriented but in moderate distress. He is without any focal neurologic deficits, and auscultation reveals normal heart sounds, tachypnea, and normal lung sounds. His abdomen is soft, nondistended, and nontender to palpation in all four quadrants. He has 5/5 strength bilaterally and bounding 2+ pulses in his bilateral lower extremities, however his upper extremities differ with 2+ on the right and a diminished pulse on the left. His blood pressure is 176/96 mmHg, with a heart rate of 75 beats per minute, respirations of 22 breaths per minute, and a temperature of 37.0 °C. He is on supplemental oxygen via nasal cannula at 2L/min and has an oxygen saturation of 99%. Overnight he was given 3300 mL of continuous intravenous infusions, took in 880 mL of fluid by mouth, and received two 120-mL doses of radiocontrast for two separate CT scans. He is only making 10 to 15 mL of urine per hour and a bladder scan reveals only 30 mL of volume.