A Former Cocaine User Whose Specialist Told Her She's Dying

Catherine M. Divingian, MD, PhD; Mityanand Ramnarine, MD; Jeffrey Jordan, MD


February 02, 2021

Physical Examination and Workup

The patient appears anxious but is otherwise in no acute distress. She is obese, with a body mass index (BMI) of 35.1 kg/m2. Her temperature is 98.1°F (36.7°C). Her heart rate is 53 beats/min, and her blood pressure is 194/65 mm Hg. No edema is noted in her extremities, and auscultation reveals no cardiac murmurs, rubs, or gallops.

Her respiration rate is 17 breaths/min, and her oxygen saturation is 98% on room air. Lung crackles, wheezing, or rhonchi are not audible. She is breathing comfortably without using accessory muscles. There is no costovertebral tenderness. Her abdomen is soft and nontender. She is interacting appropriately, and no focal neurologic deficits are evident. Cranial nerves II-XII are grossly intact.

Laboratory findings are significant for the following parameters:

  • Potassium: 5.7 mEq/L (reference range, 3.7-5.2 mEq/L)

  • Blood urea nitrogen (BUN): 49 mg/dL (reference range, 8-24 mg/dL)

  • Creatinine: 3.9 mg/dL (reference range, 0.9-1.3 mg/dL)

  • Estimated glomerular filtration rate (eGFR): 13 mL/min/1.73 m2 (reference range, 90-120 mL/min/1.73 m2)

  • Blood glucose: 164 mg/dL (reference range, 82-115 mg/dL)

The patient's baseline creatinine and glomerular filtration rate are not known, because this is her first presentation at this hospital and she has not brought records from her nephrologist. However, because her eGFR is below the lower-end cutoff for stage IV CKD, she is considered to have acute kidney injury superimposed on chronic renal failure. All values for the complete blood cell count are within normal limits. Urinalysis reveals no casts, blood cells, ketones, or proteins.

The patient's electrocardiogram (ECG) shows sinus bradycardia at 51 beats/min and second-degree Mobitz type 2 atrioventricular block.

Her heart rate is maintained between 45 and 53 beats/min. She states that her heart rate is usually much faster, typically in the 80s, when assessed during office visits. The chest radiograph (Figure 1) is unremarkable.

Figure 1.


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