1. Step 6
1.1. Review session 1
1.2. Report new knowledge
1.2.1. Kidney filtration physiology
1.2.1.1. trauma and muscle injury? how does it compensate
1.2.2. acute renal failure
1.2.2.1. Pathophysiology
1.2.2.2. Types
1.2.2.2.1. Tubular necrosis
1.2.2.3. clinical features
1.2.2.4. diagnosis
1.2.2.5. complications
1.3. 30 minutes
1.3.1. The scribe does not have to write in this step!
2. Step 8
2.1. Diagnostic decision
2.1.1. Acute kidney injury due to ATN
2.2. Mechanism
2.2.1. he was dehydrated for two days
2.2.2. immobility
2.2.3. lack of access of food
2.2.4. hypotension and poor kidney perfusion
2.2.5. oliguria
2.2.6. pressure and damage in lower limb resulting in rhabdomyolysis
2.2.7. acute tubular necrosis
2.3. Presentation
2.3.1. Confused, dehydrated, hypotensive, legs are swollen
2.4. Supporting data
2.4.1. history and physical examination
2.4.2. urine biochemistry
2.4.3. blood biochemistry
2.4.4. CBC
2.4.5. X-ray
2.4.6. US
2.5. 10 minutes
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complaint
3.1.1.1. his daughter found him 48hrs later
3.1.1.2. BP: 90/55
3.1.1.3. Pulse: 100
3.1.1.4. dr. inserted cannula with saline
3.1.1.5. Mucous membrane
3.1.1.6. JVP could not be seen
3.1.2. Previous medical / surgical history
3.1.2.1. hypertensive
3.1.2.1.1. from age 56
3.1.2.2. control of BP i9s bad but recently good
3.1.2.3. earlier serum electrolyte urea creatinine were normal
3.1.2.4. noctouria
3.1.2.4.1. once per month
3.1.2.4.2. within the last 6 yrs
3.1.3. Drug history / allergy
3.1.3.1. ACE + Indipamide
3.1.3.2. prenidepril
3.1.3.3. temazepam
3.1.3.3.1. since his wife died 4 yrs ago
3.1.4. Family history
3.1.5. Social / occupational history
3.1.5.1. he used to work as electrician
3.1.5.2. independant in all activities
3.1.5.3. his daughter 20 mins from his house
3.1.5.4. smoked till 56
3.1.5.5. 30/40 g per week
3.1.6. Systemic review
3.1.7. Physical examination
3.1.7.1. CONFUSED DISORIENTED
3.1.7.2. twitching movement oif arm
3.1.7.3. dry arm
3.1.7.4. bad smell
3.1.7.5. rectal temp: 33.2 C
3.1.7.6. right lower limb was swollen, tender
3.1.7.6.1. all right leg movements restricted by pain
3.1.7.6.2. peripheral pulses absent bilaterally below femoral artery
3.1.7.6.3. ischemic area of skin in right buttocks
3.1.7.6.4. Capillary retain poor in right leg
3.1.7.7. CVS
3.1.7.7.1. BP 100/60 lying
3.1.7.7.2. 80/60 sitting
3.1.7.7.3. P 100
3.1.7.7.4. JVP not evident\
3.1.7.8. Respiratory is normal except increase respiratory rate
3.1.7.9. abdomen diffusely tender, no rebound
3.1.7.10. neurologic: confusion and deminitioned sensation along the lateral aspect of the right foot
3.1.8. tests results
3.1.8.1. X-ray