Full of Air

A 64 year old lady presents with dysuria, suprapubic pain, and nausea and vomiting for 3 days. She also complains of right flank pain and fever since yesterday.

She has been on treatment for diabetes and hypertension for the last 8 years, with poor control, and is currently on insulin, losartan and amlodipine. She had temporarily stopped insulin for the last 3 days, given her reduced food intake.

She also underwent extracorporeal shock wave lithotripsy for recurrent renal calculi last year. A complete blood count is significant for a leukocyte count of 12,500/mm3, while a random plasma glucose level is 917 mg/dL.

Select Relevant Investigations
Metabolic Profile

Performed

Na+: 125 mEq/L (135-145)
K+: 5.6 mEq/L (3.7-5.2)
Cl-: 95 mEq/L (96-106)
HCO3-: 24 mEq/L (23-29)
Blood Urea Nitrogen: 44 mg/dL (6-20)
Serum Creatinine: 1.8 mg/dL (0.5-1.5)
Urinalysis + Urine & Blood Cultures

Performed

Urinalysis:
Appearance: Turbid
WBC: >100/hpf (normal: ≤5)
RBC: >100/hpf (normal: ≤3)
Bacterial: 4+
Casts: white cell casts present
Nitrates: positive

Culture reports will be available in 3 days.
Arterial Blood Gases

Performed

On Room Air
SaO2: 96% (94 - 100)
pH: 7.39 (7.38 - 7.42)
PaO2: 78 mmHg (75 - 100)
PaCO2: 40 mmHg (38 - 42)
HCO3: 23 mEq/L (22 - 28)
Noncontrast CT Abdomen + Pelvis

Performed

There is marked R/s hydronephrosis, with calculi, perinephric fat stranding, and gas in the renal pelvis and parenchyma.

The left kidney appears normal. No other abnormalities are noted.

Select Relevant Management
IV Antibiotics Stat
IV 0.9% Saline Bolus Stat
Insulin Bolus Stat
Urgent R/s Nephrectomy