Course 8, question 63
Case 11
Kas 8-11E: Patient with dyspnea and anuria
MUDr. Martin Havrda
Male, 62 years, lawyer.
Reason for examination: Dyspnea, chest pain, anuria.
Family history: Father passed away at 53 following myocardial infarction. Mother has diabetes. Brother
is healthy. Doughter is healthy.
Habits: He´s been smoking for 20 years 25 cigarettes daily. Alcohole – he drinks 2-3 glasses of wine
and a glass of whisky every day.
Past diseases: Common child diseases. Medication for high blood pressure since the age of 40.
Cholecystectomy at 45 because of stones. Impaired glucose tolerance discovered at the age of 50, he
goes to the diabetologist regularly, diet management.
Current complaints: He got mild pressure on the chest, sweating and difficult breathing 2 days ago. He
concluded that this was due to a heavy dinner (he did not respect the diet for gallbladder disease). He
took some painkiller and went to bed. His symptoms improved, but did not resolve completely. He fell
asleep thanks to the hypnotic tablet. He did not feel well the following day (yesterday), but he had no
more chest pain, only mild pressure on the chest which resolved completely during the day. Then he
woke-up in the middle of the night, he could not breathe, he was sweating a lot, he got head-spinning.
His breathing was better in sitting position then in recumbent position. He called for emergency, he
was brought to the hospital and admitted to the intensive care unit 4 hours ago. Urinary catheter was
introduced after admission. His urine output per hour was 50ml .. 20ml.. 0ml ..0ml.
Examination: BP 80/40 mmHg, P 110-160 bpm irregular BT 36,9°C.
Patient lying with elevated head and chest, somnolent, apathic, pale, grey colour of skin, light bluish
„marble-like“ spots at the extremities. Sweating. Tachypneic (30 bpm). White sclera, pink coniunctiva.
Dry tongue. Jugular veins filled to the angle of mandibula. Thyroid gland not palpable. Percussion of
the chest clear, breathing sounds vesicular with unaccentuated inspiratory rales over half of the lung
fields. Left border of the heart by percussion in the anterior axillary line. Heart sounds irregular, rapid,
gallop. Abdomen above the chest level, mild distension, lower border of the liver palpable 4cm below
the right costal margin. Spleen not palpable. Sporadic bowel sounds. Percussion of the loins bilaterally
negative. Bimanual palpation of the kidneys negative, kidneys not palpable. Ankle edema.
Laboratory assessment: Blood count: WBC 15,3 Hgb 130 Htc 42,0 Plt 152. Na 133 mmol/l K 4,5
mmol/l urea 11,0 mmol/l creatinine 135 umol/l cholesterol 7,5 mmol/l triglycerides 3,2 mmol/l, level of
troponin I highly elevated, glucose 8,2 mmol/l ALT 3,5 ukat/l AST 3,4 ukat/l ALP 2,0 ukat/l gammaGMT 1,3 ukat/l. Blood gas analysis: pH 7,521 pCO2 3,5 kPa pO2 6,5 kPa HCO3 24,0 mmol/l BE 0
mmol/l. Concentration of Na in the urine 1 hour after the admission … 10mmol/l.
ECG: Atrium fibrillation with rapid ventricular response, left bundle branch block, which was not
demonstrated in the ECG 4 months ago.
Sonography of the kidneys: Normal size and morphology of both kidneys, pelvis and calyces not
dilated.
Questions:
1) What is the reason for anuria in this patient? Which type of renal involvement plays a role?
How can you interpret the urinary sodium concentration?
2) What is the underlying main disease of the patient – reason for admission?
3) How can we restore diuresis in this patient?
4) Will you prescribe diuretics in this case? Which? When? Which route of administration?
Patophysiology: Functional response of kidneys in shock.
Pathology: Morphological alterations in shock – kidneys and other tissues.