Physical Examination and Workup
Upon physical examination, the patient's oral temperature is 99°F (37.2°C). Her pulse is regular, with a rate of 75 beats/min. Her blood pressure is 112/60 mm Hg, and she has a respiratory rate of 18 breaths/min with an oxygen saturation of 98% while breathing room air. She appears uncomfortable and generally fatigued, but is alert and oriented.
The patient's extraocular muscles are intact, with no nystagmus. Her pupils are symmetric and equally reactive to light, and the optic discs appear normal. Her mucous membranes are moist, and the remainder of the head, ear, nose, and throat examination is normal. Her lungs are clear to auscultation, and the patient exhibits normal respiratory effort. The heart rhythm is regular, without murmurs, rubs, or gallops. Her abdomen is nontender, without masses, and no costovertebral angle tenderness is noted. The extremities are without edema, and the radial pulses are strong bilaterally. The skin is clear, without rash, petechiae, or ecchymoses.
Cranial nerves II-XII are normal and symmetric. Otherwise, the neurologic examination reveals 2/5 strength throughout both upper and lower extremities, with 1/3 patellar, triceps, and Achilles reflexes bilaterally. The patient has negative Babinski and Hoffmann signs. Finger-to-nose coordination and gait could not be assessed as a result of her weakness.
An ECG (Figure 1), urine analysis, and basic metabolic panel are completed.
She has a serum glucose concentration of 97 mg/dL (reference range, <140 mg/dL) and a hemoglobin level of 13.4 g/dL (reference range, 12-15.5 g/dL). As a result of a low bicarbonate finding on the metabolic panel, arterial blood gas measurement is subsequently performed; this shows a pH of 7.25 (neutral, 7), a partial pressure of carbon dioxide of 22 mm Hg (reference range, 38-42 mm Hg), a partial pressure of oxygen of 100 mm Hg (reference range, 75-100 mm Hg), and a bicarbonate level of 9 mEq/L (reference range, 23-30 mEq/L). The urine analysis shows a pH of 7 (reference range, 4.6-8), with moderate blood, negative nitrates, and small leukocytes.
Renal ultrasound is completed before admission (Figure 2).
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