Post-admitting day

This morning I show up early and my registrar is there early too, so we walk around and try to see all the new patients (11 of them) and start to make management plans before she goes to give a presentation. Turns out the intern has to go to the same presentation so they both leave and tell me I’m in charge. Meanwhile, one of the new patients has a BP of 210/120 with headaches, so I try to get him IV labetolol (which they are out of) or PO (also out), and end up just doubling the dosages of the meds he was on. I got to do this all on my own though which was cool.

To start off on a depressing note, I found out this morning that Victor, the first patient I admitted o the men’s ward, died last night. I mentioned him before because he was in acute renal failure and was an interesting diagnostic dilemma that I ended up presenting for my morning report yesterday. He came in looking terrible but had been doing much better over the past 5 days or so and even started dialysis on Sunday. From what the nurse from last night reported, it sounds like he might have gone into flash pulmonary edema but I have no idea. This was a totoal surprise though because even though I knew he was very sick, he was looking so, so much better. I never would have expected him to die at this point.

Once the labs started coming back we discovered that no less than 4 of our patients have creatinines above 880 (which is equivalent of 10 in the states), in other words raging renal failure. One also has a BUN of 173.6. One of these patients is the one I mentioned last night, the newly diagnosed HIV patient which the not bad sounding lungs (however his CD4 is 66 so he could have PCP and everything else additionally). I pushed and pushed for an ABG (they kept saying they were out of reagant) and we finally got it and his pH was 7.09 and his potassium was originally 8.4!!! We thought it could be tenofovir toxicity or maybe HIV nephropathy. Regardless, we got him quickly on K+ binding therapy and started giving him bicarb while arranging to start dialysis. I left for lunch at 2 and by the time I came back at 3 he had passed. And this was the patient whose sister I had really liked and had started to get to know and had been explaining the plan to and everything. I felt so bad.

There is another patient in renal failure who has not passed urine in ?days, and who we have failed to insert a Foley catheter in 3 times because of obstruction and who has a suprapubic mass (um…most likely a very distended bladder) and who we are aggressively rehydrating; I was like we NEED to geet urine out of him because I really thought we might explode his bladder (not sure if this actually happens) but finally the registrar put in a needle suprapubic catheter temporarily and guess what – a ton of urine came out! So that was one win.

I have another young man – 17 year old – with type 1 diabetes here with chronic diarrhea and weight loss. I had orginigally been impressed with his insulin regimen (NPH in am and pm with hunalog at meals) because everyone else I’ve seen is only on insulin twice a day. Turns out his A1c is >15%...i.e. so high they can’t even calculate it! So much for what I thought was a good regimen. It is unclear if he just doesn’t understand how to give himself this regimen or how to adjust it for what he eats or if the diabetes clinic is failing him or what. One thing I have certainly learned while being here is that type 1 diabetes here are very bad off.