Touching all the bases

Internal medicine requires knowledge, deduction, and many skills – history taking, physical examination, analyzing diagnosis tests. When confronting a new patient problem, we use our brains to work on finding a diagnosis. Much like police detectives, we would like to have brilliant diagnostic epiphanies, but often we make our diagnoses by painstakingly collecting all the clues and doing the necessary boots on the ground work. We had a woman admitted to our service with confusion, decreased appetite and weight loss. In the ED, they diagnosed CKD Stage V – creatinine > 5 and BUN > 90. She had a 10 year history of type II DM. She had a history of ingesting high doses of salicylates and had a mildly elevated level. The next morning as we are making rounds in the ICU she was on the bed pan. We asked the nurse to check a residual urine, because that is what we must always do with an unknown elevated creatinine. In fact her residual urine was 245 cc, despite no hydronephrosis on renal ultrasound. The next day her appetite had returned and she no longer was confused. Three days later her creatinine was 1. Urological evaluation is the main plan now. We had no good reason to suspect urinary obstruction, but we often are surprised with apparently newly elevated creatinine levels. We see such patients all too often. Finding obstruction when we did saved many resources. While we love our diagnostic eureka moments, more often we get to the diagnosis through a deliberat...
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs