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Mr. Fowler is a 70-year-old male who has been referred to the Emergency Department (ED) by his primary care physician for further assessment due to an elevated creatinine level of 3.2 mg/dL. This elevated creatinine level has been observed in the context of a three-day history of persistent nausea and vomiting, which has progressed to dry heaves. He has also reported poor oral intake, a heightened sense of fatigue, reduced urine output, and is experiencing orthostatic hypotension, with a blood pressure of 108/60, as well as tachycardia, with a heart rate of 98 beats per minute.
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In his medical history, Mr. Fowler recalls a recent incident where he lifted a heavy object, resulting in low back pain approximately one week prior to seeking medical attention. Following this incident, he took over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), specifically Naproxen, twice daily for pain relief. His regular medications include lisinopril, metoprolol, and hydrochlorothiazide (HCTZ).
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It’s important to note that Mr. Fowler’s past medical history includes mild chronic renal disease, as evidenced by a creatinine level measured one month ago at 1.1 mg/dL and the presence of 400 mg albuminuria. This indicates a pre-existing condition affecting his kidney function.
Upon conducting a physical examination, several noteworthy findings emerge. Mr. Fowler exhibits dry mucous membranes, a clinical sign that may be associated with dehydration. Additionally, mild periumbilical tenderness is observed during the examination. Notably, there is no tenderness in the costovertebral angle (CVA), which suggests an absence of kidney-related pain, and no indication of bladder distention.
Given the constellation of symptoms, medical history, and examination findings, Mr. Fowler’s condition raises concerns about his kidney function and overall renal health. Further evaluation and diagnostic tests are essential to determine the underlying cause of his elevated creatinine level and associated symptoms. Additionally, it is crucial to assess the impact of the NSAID use on his renal function, as well as his medication regimen and its potential contribution to his clinical presentation.
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