Question

NURS-60503: Chemistries Case Study A 29-year-old woman with a history of insulin-dependent diabetes mellitus was treated for a urinary tract infection. Twelve days later, she presented with persistent flank pain. Physical exam showed: She was a moderately ill appearing woman who was afebrile with a heart rate of 140. respiratory rate of 32, and BP of 98/50. She did not appear to be dehydrated. There was costo vertebral angle tenderness on the left and left lower quadrant (abdominal) tenderness with guarding, but without rebound tenderness Laboratory results: •White blood cells 12.700/ul Neutrophils 70% •Bands 12% Serum electrolytes • Sodium 127 meg! -Potassium 5.0 meg! -Chloride 92 -Bicarbonate 17 Glucose 640 mg/d! -BUN 32 -Creatinine 1.6 Urinalysis Appearance pink/cloudy Glucose 2- -Ketones 1+ -Protein 3+ Sediment - Many RBC are bacteria -25 WBC/HPF

Answer 1

1.

The patient may be experiencing the Systemic inflammatory response syndrome (SIRS) after the acute UTI. He underlying type 2 diabetes mellitus adds to the risk of developing SIRS after the primary infection.

In this patient, the 3 SIRS criteria out of 5 are met in the presence of suspected urologic infection.

Criteria :

1- Tachycardia ≥ 90 beats/min

2- Tachypnea ≥ 20 breaths/min

3- Leucocytes ≥ 12 000 cells/μL or ≤ 4000 cells/μL or bandforms > 10%

Additional symptoms present in the patient are hypotension flank pain, left costovertebral angle tenderness.

WBC – 12700/ul: indicates infection

Neutrophils – 70% : indicates bacterial infection

The band more than 10 %: the indication of sepsis

Pink/ Cloudy due to WBC and RBC – pyuria

Glucose 2+, Ketone 1 + due to high blood sugar level occurred as a consequence of SIRS

Sediment can be the debris from urinary tract

Protein 3+ indicates kidney damage due to underlying infection.

2. Patient BUN- 32

Normal BUN value is 7 to 20 mg/dL

Patient’s increased BUN can be due to acute kidney damage as a result of the sepsis after previous UTI. It is an indication of the progression of infection to the kidney.

3. Serum Sodium level: Normal value 135 and 145 milliequivalents per liter (mEq/L).

In this patient: 127, hypernatremia occurred due to the incapacity of kidneys to eliminate the water load. It can also occur due to the stimulated thirst mechanism stimulated by the increase in osmolality. Water retention may occur also to compensate for the low BP of the patient. Due to the hypo-osmolality, the ADH concentration also remains high, which further contribute to the hypo-osmolar or hypotonic hypernatremia.

4. bicarbonate : Normal range is between 23 and 29 mmol/L.

Inpatient : 17 mmol/L

It is an indication of metabolic acidosis, the Serum CO2 level may increase due to the low bicarbonate level in blood.