44 year-old female presents to the emergency department with 3 days of nausea, vomiting, and diarrhea. She complains of mild epigastric pain but 8/10 pain to the left lower quadrant. Pain is non-radiating and described as a sharp, stabbing, and intermittent. There have been 3 episodes of non-bloody, non-bilious vomiting over the past 2 days. She has had decreased oral intake and came to the emergency department because she couldn’t hold anything down. She has been taking ibuprofen and acetaminophen at home without relief. The patient lives at home with her 3 children all under the age of 10, none of whom have any symptoms. She had otherwise been healthy and feeling well prior to this illness. There are no fevers, chills, chest pain, shortness of breath, rashes skin changes, or urinary symptoms. She had not recently traveled.
PMH: DM, CKD stage 3
PSH: None
Meds: metformin, enalapril
Allergies: NKA
Social: No drugs, alcohol, or tobacco. Sexually active with husband only.
FH: none
PE: Tm: 98.6, HR: 110, RR: 18, BP: 116/79
GEN: Lying in bed, well-dressed and comfortable
PULM: Breathing comfortably, speaking full sentences, Clear to auscultation bilaterally
CV: Tachycardia, regular rate and rhythm.
ABD: Hyperactive bowel sounds, soft, minimally tender to left lower quadrant, no rebound or guarding.
GYN: Normal external and internal, No cervical motion tenderness.
Ext: No cyanosis clubbing or edema.
Labs:
Na: 133, K: 2.9, Cl: 92, Bicarb: 20, BUN: 28, Cr: 2.1 (baseline 1.7), Glucose: 103
Protein: 4.8, Albumin: 3.4, AST 16, ALT 17, Alk Phos 120, Tbili: .4
WBC: 11, Hb/Hct: 12/36, Plt: 156
Lipase: 11
pH 7.32, PaCO2: 36 and HCO3: 20
BHCG: negative
Lactate 3.8
ECG: sinus tachycardia
UA: LE negative, Nitrite negative, ketone+
Pelvic ultrasound: unremarkable
You notice this patient has a lactic acidosis and start treatment with IV fluids. Despite analgesia, the patient continues to complain of pain. You consider a CT abdomen with IV contrast.
Explain the patient’s metabolic acidosis?
Is the contrast load too high for this patient given the Acute Kidney Injury?
Are there any interventions to minimize contrast-induced nephropathy?
Steven Greenstein
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