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With the increase in operative magnitude buy prednisolone 20 mg allergy symptoms heart palpitations, the risks of ulcer recurrences are reduced but risks of “postgastrectomy” and/ or “postvagot - omy” syndromes increase purchase prednisolone line allergy symptoms oregon. Most ulcer operations can now be performed laparo- scopically prednisolone 40mg low price allergy skin test results, which provides pat ient s wit h addit ional recovery benefit s. For pat ient s wh o are not able t o t olerat e a lengt hy operat ion, an alt ernat ive procedure is ulcer excision wit h vagot omy and pyloroplast y. Most patients who present with perforated duodenal ulcers and without exten- sive prior hist ory of ulcers and/ or ulcer t reat ment s can have oment al patch closure of the ulcers and medical management + H. A 44-year-old man with a 1-cm duodenal ulcer that is causing epigastric pain for 3 weeks. A 57-year-old man with a history of gastric ulcer that was biopsied 4 months ago and found to be benign. P r o st aglan d in com p o u n d s su ch as m iso p r o st ol p r om o t e r esolu t ion of gast r ic u lcer s by in h ibit in g the pr ot on p u mp, t h er eby d ecr easin g acid production C. W hich of t he following best describes characterist ics of duodenal ulcer disease? Typ e I gast r ic u lcer s are u su ally lo cat ed in the p r ep ylo r ic r egion of the st omach C. U lcer su r ger ies r em ain h igh ly effect ive fo r the co n t r ol of acid secr et io n C. Surgical therapy is almost exclusively performed for the treatment of gast r ic ou t let ob st r u ct ion d u e t o P U D 17. Three months later, he presents with progressive weight loss and gast ric out let obst ruct ion. W hich of t he following is a t rue st atement regarding t his sequence of event s? Bio p sy of h is u lcer at h is in it ial evalu at ion m igh t h ave p r even t ed the gast ric out let obst ruct ion C. H ighly selective vagotomy should have been performed at the time of his ulcer diagnosis E. Gastric outlet obstruction from refractory ulcer disease is the most com- mon cause of gastric outlet obstruction 17. Truncal vagotomy and antrectomy are associated with lower rate of ulcer recurrence and better postoperative functional outcomes than truncal vago t o m y an d p ylo r o p last y B. Complications following vagotomy are extremely rare and do not influ- ence t he decision in operat ive t reat ment select ion D. Patients who develop recurrence following vagotomy and antrectomy should undergo gast ric acid analysis and serology t est ing for gast rin levels E. A gast r ic u lcer that is refract or y t o medical t h erapy aft er 4 mont h s sh ou ld be considered for surgical therapy. The operation to be performed can be excision of t he ulcer and vagot omy wit h drainage procedure or a part ial gast r ect omy that in clu d es the u lcer an d the dist al st omach. If in fect ion is document ed, t reat ment will in clu de ant ibiot ics to eradicate H. The end result is gen er ally h yp er acid ic gast r odu od en al envir on m ent that can be aggr avat ed by H. The patient described has a type I gastric ulcer and this ulcer is not usually contributed to by hyperacidity. Ulcer surgeries are highly effective at reducing acid production from the st omach. The drawbacks of surgical t reat ment are mot ilit y disorders affect - ing gast ric empt ying and reduct ion in gast ric capacit y. Surgical t reat ment is most commonly performed today to address bleeding that is refractory to medical interventions and to address perforated ulcer disease. T h e patient wit h an ap p ar en t gast r ic u lcer u n d er goes m ed ical t h er ap y an d 3 months later, develops gastric outlet obstruction. A plausible explanation for this sequence of event s is that the gast ric ulcer t h ought t o be benign in nature is actually a gastric malignancy that has progressed over the ensu- ing 3 months to cause gastric outlet obstruction. P at ien t s wh o d evelop r ecu r r en t u lcer s followin g vagot om y an d an t r ect om y suggest unusual causes of t heir ulcer diseases such as excess gast rin produc- tion related to gastrinomas (Z ollinger– Ellison syndrome). An ulcer recur- rence following vagotomy and pyloroplasty can be salvaged with the addition of an antrectomy rather than a tot al gastrectomy. Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. Beyond the stomach: an updated view of Helicobacter pylori pathogenesis, diagnosis, and treatment. The patient reports that the pain was colicky in nature at the onset but has become dull and persistent over the past few hours. He indi- cat e s that the sym p t o m s d e ve lo p e d sh o rt ly aft e r d in n e r the p re vio u s e ve - ning. Thinking that he had some bad food, the patient went to bed hoping that it would resolve. He woke up four times during the night and vomited copious amount of b ilious material. The p atient was well up to the time when symptoms began, and since the onset of symptoms, he has not passed flatus or stool. He has no current medical problems, except that 2 years ago, he had a la p a ro t o m y fo r p e rfo ra t e d a p p e n d icit is. His abdomen is distended, m ild ly t e n d e r t h ro u g h o u t, an d wit h o u t p e rit o n it is. Notethefluid-filled,dilatedsmallbowel lo o p s an d d e co m p re sse d sm all b o we l se e n in the rig h t lo we r q u a d ran t. H is abdomi- nal radiograph demonstrates a dilated stomach and dilated small bowel. All of the fin d in gs t oget h er are comp at ible wit h the d iagn osis of mech an ical small bowel obstruction. Next step in management: Place a nasogastric (N G) tube to help decompress his stomach and relieve his vomiting, initiate fluid resuscitation, place a Foley cat h et er t o h elp m on it or u r in e out put an d d et er m in e h is r esp on se t o flu id resuscitation. Complications associate with this disease process: Mechanical small bowel obstruction may cause bowel strangulation, bowel necrosis, bowel perforation, and sepsis. W hen unrecognized and unt reated, int ravascular fluid loss (from t hird-space fluid loss and vomit - ing) can cause prerenal azot emia and acut e kidney injury. Probable therapy: Explorat or y lapar ot omy or explorat or y lapar oscopy, because his clinical present at ion raises the concern for high-grade obstruction and the potential for bowel necrosis. Co n s i d e r a t i o n s An otherwise healt hy 37-year-old man present s wit h the sudden onset of colicky pain, vomit ing, abdominal distension, and obst ipation, which are typical signs and sympt oms compat ible wit h int est inal obst ruct ion. S ever e d ist en sion of the intestine is problematic because as the bowel gets more distended, venous con- gest ion in cr eases in the bowel wall, wh ich in t u r n con t r ibu t es t o the viciou s cycle of increased venous congest ion, bowel edema, worsening obst ruct ion, and eventually bowel ischemia. Other concerning features of this patient’s presentation include fever, t ach ycardia, leu kocyt osis, an d radiograph ic sign s of h igh -grade small bowel obstruction.
Glomerular injury may result from a variet y of insults and presents either as the sole clinical finding in a patient (primary renal disease) or as part of a complex syndrome of a systemic disorder (secondary glo- merular disease) 5mg prednisolone with visa allergy medicine effect on liver. For the purpose of this discussion discount generic prednisolone canada allergy testing uk food, glom er u lon ep h r i t i s includes only the inflammatory glomerulopathies quality 40 mg prednisolone allergy shots not refrigerated. Acute kidney injury, as manifested by a decrease in urine output and azotemia, results from impaired urine produc- tion and ineffective filtration of nitrogenous waste by the glomerulus. The presence of this constellation of signs in a patient makes the diagnosis of glomerulonephritis very likely. H owever, it is impor- tant to note that often patients present with an overlap syndrome, sharing signs of both nephritis and nephrosis. T h er efor e, con fir m at ion of the p r esu mp t ive d iagn osis of acu t e glom er u lon ep h r it is r equ ir es m icr oscop ic exam in at ion of a u r in e samp le from the suspect ed pat ient. The specific diagnosis can usually be established by clinical history and serologic evaluation, and often requires a kidney biopsy (Table 28– 3). Dia g n o st ic Ap p ro a ch t o Glo m e ru lo n e p h rit is The approach to the patient with glomerular disease should be systematic and undert aken in a stepwise fashion. The history should be approached met iculously, looking for evidence of preexist ing renal disease, exposure t o neph rot oxins, and especially any underlying syst emic illness. Once the appropriate serologic tests have been reviewed, a kidney biopsy may be required. Bot h illn esses can pr esent wit h G N occurring after an upper respiratory illness. In cont rast, IgA nephropathy may present with pharyngitis and glomerulonephritis at the same time. Tr e a t m e n t o f G l o m e r u l o n e p h r i t i s Treatment depends on the diagnosis of the glomerulonephritis, whether it is a primary renal disease or secondary to a systemic illness. H e is brought t o the emergency room disorient ed aft er collapsing on t he t rack. This in dividual is suffer ing from h eat exh au st ion, wh ich can lead t o rh ab- domyolysis and release of myoglobin. Myoglobinuria leads to a reddish appearance and posit ive urine dipst ick react ion for blood, but microscopic analysis of the urine likely will demonstrate no red cells. T h e a n t i st r e p t o lys in - O t it er s t yp ica lly a r e ele va t ed a n d s er u m co m p lem e n t levels are decreased in post st rept ococcal G N. An swer B would be more likely to be seen in a patient with Lupus Nephritis along with decreased comple- ment levels (C3 and C4). Answer D is more likely in a patient with glomeru- loneph rit is secondar y t o endocardit is wh ere valvular disease would also be present. Answer E is appropriate for glomerulonephritis secondary to cryo- globu lin em ia wh er e the patient is also likely t o t est p osit ive for H ep at it is C. Goodpasture (antiglomerular basement membrane) disease typically affect s young males, who present wit h hemopt ysis and hemat uria. She first n o t e d m ild a n kle swe llin g a p p ro xim a t e ly 2 t o 3 m o n t h s a g o. Sh e b o rro we d a few diuretic pills from a friend; the pills seemed to help, but now she has run out. She also reports that she has gained 20 to 25 lb over the last few months, despite regular exercise and trying to adhere to a healthy diet. Her medical his- tory is significant for type 2 diabetes, for which she takes a sulfonylurea agent. Sh e n e it h e r s e e s a d o c t o r re g u la rly n o r m o n it o rs h e r b lo o d g lu co s e a t h o m e. Sh e denies dysuria, urinary frequency, or urgency, but she does report that her urine has appeared foamy. He r p h ys ic a l e xa m in a t io n is s ig n ific a n t fo r m ild p e r io rb it a l e d e m a, m u lt ip le h a rd exudates, and dot hemorrhages on funduscopic examination, and pitting edema of her hands, feet, and legs. Her chest is clear, her heart rhythm is regular without murmurs, and her abdominal examination is benign. A urine dipstick performed in the office shows 2+ glucose, 3+ protein, and negative leukocyte esterase, nitrates, and blood. She has diabet ic ret inopat hy, some peripheral neuropat hy, and no other findings suggest ive of any ot her systemic disease. Understand the natural history of diabetic renal disease and how to diagnose and manage it. Co n s i d e r a t i o n s Patients develop significant proteinuria as a result of glomerular damage, which can result from many systemic diseases. The key feature of nephrotic syndrome is the heavy proteinuria, wh ich leads t o loss of albumin and ot h er serum prot eins. T h e hypoalbuminemia and hypoproteinemia result in decreased intravascular oncotic pressure, leading to tissue edema that usuallystarts in dependent areas such as the feet but mayprogress to involve the face, hands, and ultimately the whole body (anasarca). Both increased synt hesis and decreased clearance of lipoprot eins may lead t o hyperlipidemia. Patients typically present to the doctor complaining of the edema and have the laborat ory feat ures described earlier. Urinalysis usually sh ows few or no cellular element s and may show waxy cast s and oval fat bodies (wh ich look similar t o Mal- tese crosses under polarized light) if hyperlipidemia is present. Thus, a new diagnosis of nephrotic syndrome warrant s furt h er invest igat ion int o an underlying syst emic disease. Of these causes, diabetes mellitus is by far the most common, as in t he pat ient present ed in this scenario. Adults with nephrotic syndrome usually undergo renal biopsy, especially if the underlying diagnosis is unclear, or if there is a possibility of a treatable or revers- ible condit ion. Pat ient s wit h advanced diabetes who have heavy prot einuria and microvascular disease, such as retinopathy, but no active cellular components on a urinary sediment are generally presumed t o have diabet ic nephropat hy. T hese patients typically do not undergo renal biopsy because the nephrotic proteinuria represents irreversible glomerular damage. Treatment of nephrotic syndrome consists of treatment of the underlying dis- ease, if present, as well as management of t he edema and at t empt s t o limit t he pro- gr ession of the r en al d isease. For ed ema, all pat ient s r equ ir e st r ict salt restriction, but most patients will also need diuretics. Becau se bot h t h iazide an d loop diuret ics are highly protein bound, t here is reduced delivery to the kidney, and often very large doses are required t o manage the edema. Dietary protein restriction usually is recommended for patients with moderate proteinuria and chronic kidney disease, and is thought to protect against t he progression of glomerular scarring. Besides the edema, patients with nephrotic syndrome have other consequences of renal protein wasting. Pat ient s wit h evidence of t hrombus format ion require ant icoagu lat ion, oft en for life.
Containers for foam preparations must be shaken thoroughly before each use to ensure dispersal of the spermicide purchase generic prednisolone online allergy united. Suppositories should be inserted at least 10 to 15 minutes before intercourse to allow time for dissolution purchase prednisolone 40 mg fast delivery allergy testing logan utah. The contraceptive sponge [Today Sponge] is a soft order prednisolone 5mg with mastercard allergy testing long island, porous, polyurethane disk impregnated with 1000 mg of nonoxynol 9. When inserted to cover the cervix, it protects against conception by (1) releasing spermicide, (2) absorbing seminal fluid, and (3) blocking penetration of sperm. Unlike other spermicide products, which must be reapplied before each act of intercourse, a single sponge is effective for 24 hours, regardless of how often coitus takes place. The rates of unintended pregnancy with the sponge are high: 16% among typical nulliparous users, and 32% among parous users. In the United States nearly 50% of women aged 15 to 44 years report having had at least one unintended pregnancy. Progestin-Only Emergency Contraception Pills Three progestin-only products are available: Plan B One-Step, Next Choice One Dose, and Next Choice. These products are packaged and marketed specifically for emergency contraception. Plan B One-Step and Next Choice One Dose Plan B One-Step and Next Choice One Dose consist of a single, high-dose (1. The package insert calls for taking the tablet within 72 hours of unprotected intercourse. Plan B One-Step reduces the odds of pregnancy by 89% and Next Choice One Dose prevented 84% of expected pregnancies, which is better than it may seem. In the absence of these two medications, the pregnancy rate from a single act of unprotected intercourse is about 8% (i. Plan B One-Step and Next Choice One Dose work primarily by delaying or stopping ovulation. The major side effects of Plan B One-Step are heavier menstrual bleeding, nausea, abdominal pain, headache, and dizziness. Importantly, if pregnancy does occur, having used levonorgestrel will not increase the risk for major congenital malformations, pregnancy complications, or any other adverse pregnancy outcomes. These drugs will not terminate an existing pregnancy and will not harm a fetus if present. Because Plan B One-Step and Next Choice One Dose act before fertilization and implantation, they cannot be considered abortifacients. For women aged 15 years and older, Plan B One-Step and Next Choice One Dose are now available over the counter. For women who are not yet 15 years old, Plan B One-Step is still available, but a prescription is required. Prescriptions can be obtained from private physicians, clinics run by Planned Parenthood, and student health departments at colleges and universities. According to the package insert, women should take 1 tablet within 72 hours of intercourse and a second tablet 12 hours later. Like Plan B One-Step, Next Choice can be obtained without a prescription (by women 15 years and older) or with a prescription (by women younger than 15 years). Ulipristal Acetate Emergency Contraception Pill Ulipristal acetate [ella] is a drug that acts as an agonist-antagonist at receptors for progestin. Like levonorgestrel, ulipristal acetate prevents conception primarily by suppressing ovulation. Despite this similarity, ulipristal acetate and levonorgestrel differ in two important ways. First, ulipristal acetate remains highly effective when taken up to 5 days (120 hours) after intercourse, whereas levonorgestrel is most effective when taken within 3 days (72 hours) of intercourse. Second, whereas levonorgestrel [Plan B One-Step, Next Choice, Next Choice One Dose] is available without a prescription for women 15 years and older, ulipristal acetate [ella] requires a prescription for all women, regardless of age. The dosage for ulipristal acetate is 1 tablet (30 mg), taken up to 5 days after unprotected intercourse. Estrogen/Progestin Emergency Contraception Pills (Yuzpe Regimen) The Yuzpe regimen, first described in 1974 by Professor A. The first dose should be taken within 72 hours of unprotected intercourse and the second dose 12 hours later. Pregnancy is prevented by interfering with ovulation, fertilization, and implantation. However, if mifepristone is taken after this time, it may terminate pregnancy that has already begun and thus can be considered an abortifacient. In the United States the drug has one approved indication: termination of early intrauterine pregnancy; cotreatment with misoprostol is usually required. Investigational uses include breast cancer, ovarian cancer, meningiomas, Cushing syndrome, uterine fibroids, and endometriosis. In addition, mifepristone is the most effective drug known for emergency contraception, although it is not used routinely for this purpose. Mifepristone, followed by misoprostol, is a safe and effective alternative to surgery for termination of early pregnancy. Principal adverse effects are abdominal pain and vaginal bleeding, which are unavoidable aspects of abortion. In contrast to surgical abortion, which is generally unavailable before 8 weeks of gestation, abortion with mifepristone is performed early—within 7 weeks of conception. Although mifepristone also blocks receptors for glucocorticoids, this action does not contribute to abortion. First, blockade of progesterone receptors leads to decidual breakdown and detachment of the conceptus. Third, mifepristone increases uterine production of prostaglandins and renders the myometrium more responsive to the contractile effects of these prostaglandins. If mifepristone alone fails to induce abortion, the patient is given 400 mcg of oral misoprostol, a synthetic prostaglandin that reinforces uterine contractions induced by mifepristone. Clinical Trials In a study conducted in France, the abortion success rate with mifepristone/misoprostol was nearly 99%. Success was defined as termination of pregnancy with complete expulsion of the conceptus. All women in the study had amenorrhea for less than 50 days before receiving mifepristone. Dosing was done as follows: each patient received a 600-mg oral dose of mifepristone and, if abortion had not occurred within 48 hours, each was given a 400-mcg dose of oral misoprostol; a second dose of misoprostol (200 mcg) was offered if abortion had not occurred by 4 hours after the first dose. In the majority of patients (69%), abortion occurred within 4 hours of the first misoprostol dose. In the United States success with mifepristone/misoprostol has also been good —although not quite as good as in France. In 1999 American researchers reported that the abortion rate with mifepristone/misoprostol declined with increasing duration of gestation. Success was greatest (92%) when gestation was 49 days or less, falling to 83% during days 50 to 56 of gestation and to 77% during days 57 to 63.
Given his recent episode of pharyngitis buy cheap prednisolone 10mg on-line allergy forecast allen tx, the most likely cause would be post infect ious buy discount prednisolone 5 mg allergy shots for poison ivy, probably due t o st rept ococcal infect ion order cheap prednisolone online allergy symptoms heavy eyelids. In the outpatient setting, a dipstick urinalysis is readily available but will det ect only pat ient s wit h overt neph ropat hy (prot einuria >300 mg/d). Thus, a random urinary albumin/creatinine ratio of 30/300 is the best test to screen for early diabetic nephropathy. Finally, although most patients with nephrotic syndrome require a renal biopsy for diagnosis, a pat ient wit h worsening renal funct ion who has had long-st anding diabet es is assumed to have renal disease secondary t o diabet ic nephropat hy, and t he majority of these patients do not undergo a renal biopsy. Examination at that time reveals that he is afebrile, his heart rate is regular at 56 bpm, and his blood pres- sure is 109/65 mm Hg. His fundus reveals dot hemorrhages and hard exudates, his neck veins are flat, his chest is clear, and his heart rhythm is normal with an S gallop and no murmur or friction rub. H is funduscopic examination shows dot hemorrhages and hard exudat es, evidence of diabet ic ret inopat hy. In t his sett ing, t he baseline elevated creat inine level on admission likely represent s diabet ic nephropathy as well. Next step: Urinalysis and urine chemistries to determine whether the process is prerenal or renal, or less likely post renal. Be familiar with the management of hyperkalemia and indications for acute dialysis. Acu t e o b st r u ct ion, cor t ical necrosis, and vascular catastrophes such as aortic dissection should be considered in t he different ial diagnosis. Physiologically, it is the lowest amount of urine a person on a normal diet can make if he or she is severely dehydrated and does not ret ain uremic waste product s. Pat ient s wit h oliguric renal failure have higher mortality rates and less renal recover y t h an do pat ient s wh o are nonoliguric. Sometimes, the clinical presentation is straightforward, such as volume depletion from gast r oin t est in al flu id loss or h em or r h age; at ot h er t im es, the pr esen t at ion of patients with prerenal failure can be more confusing. For example, a patient with severe nephrot ic syndrome may appear to be volume overloaded because of the massive peripheral edema present, while the effective arterial blood volume may be ver y lo w a s a co n seq u en ce o f the s ever e h yp o alb u m in em ia. Similarly, a patient with severe congestive heart failure may h ave prerenal failure because of a low cardiac eject ion fract ion, yet be flu id over load ed wit h p er iph er al an d p u lm on ar y ed ema. Table 30– 1 provides an abbreviated list ing of the et iologies of prerenal failure. Postrenal failure, also refer red t o as obst r uct ive n eph ropat h y, implies blockage of urinary flow. T h e sit e of obst r uct ion can be anywh ere alon g the ur in ar y syst em, including t he int ratubular region (cryst als), uret ers (st ones, ext rinsic compression by tumor), bladder, or urethra. By far, the most common causes of obstructive nephropathy are ureteral obstruction due to malignancy, or prostatic obstruc- tion due to benign or malignant hypertrophy. The patient’s symptoms depend on wh et h er or not bot h kidneys are involved, the degree of obst ruct ion, and the t ime cou r se of the blockage. Intrinsic renal failure is caused by disorders that injure the renal glomeruli or tubules directly. D oes t he pat ient have signs or sympt oms of a syst emic disease, such as heart failure or cirrhosis, that could cause prerenal failure? D oes the pat ient have sympt oms of a disease, such as lupus, t hat could cause a glomerulonephrit is? Is the patient receiving an antibiotic and now has allergic interstitial nephritis? In addit ion t o t he hist ory and physical examinat ion, urinalysis and measurement of urinary electrolytes are h elpful in making t he diagnosis. In dividu- als wit h postrenal failure typically are unable to concentrate the urine, so the ur in e osmolality is equal to the serum osmolality (isosthenuria) and the specific grav- ity is 1. The microscopic findings vary depending on the cause of the obstruc- tion: hemat uria (cryst als or st ones), leukocyt es (prost at ic hypert rophy), or normal (extrinsic ureteral compression from a tumor). Tubulointerstitial nephritis classically p r o - duces urine that is isosthenuric (the tubules are unable to concentrate the urine), wit h mild proteinuria, an d on microscopy, r eveals leukocytes, white cell casts, and urinary eosinophils. F E represents the amount of Na sodium filtered by the kidneys that is not reabsorbed. N or mally, the excr et ed sodium repr esent s Na the dietary intake of sodium, maintaining sodium homeostasis. Fur t h er more, becau se the pat ient h as eit h er t r ue Na vo lu m e d ep let io n o r “effect ive” vo lu m e d ep let io n, ser u m ald o st er o n e will st im u lat e the kidneys to retain sodium, and the urinary sodium will be low (< 20 mEq/ L). D iuret ic medicat ions, wh ich int erfere wit h sodium reabsorpt ion, are often used in congestive heart failure or nephrot ic syndrome. Early in the course of Na postobstructive renal failure caused by ureteral obstruction, the afferent arteriole typically undergoes intense vasoconstriction, with consequent, low urinary sodium levels ( Table 30– 3). Becau se of the r isk of fat al cardiac ar rh yt h mias, sever e hyperkalemia is considered an emergency, best treated acutely medically and not with dialysis. Although it will not lower the serum potassium level, the calcium will oppose the membrane effects of the high potassium concentration on the heart, allowing time for other methods to lower the potassium level. One of the most effective methods for treating hyper- kalemia is administration of intravenous insulin (usually 10 units), along with 50 to 100 mL of 50% glucose solution to prevent hypoglycemia. Pot assium also can be driven int racellularly with a bet a-agonist, such as albuterol, by nebulizer. All t hree therapies have only a transient effect on serum potassium levels, because the total body potassium balance is unchanged, and the potassium eventually leaks back out of the cells. Definitive treatment of hyperkalemia, removal of potassium from the body, is accomplished by one of three methods: (1) administration of a loop diuretic such as furosemide to increase urinary flow and excretion of potassium, or, if the patient does not make sufficient urine, (2) administration of sodium poly- st yrene sulfonat e (Kayexalat e), a cat ionic exchange resin t hat lowers pot assium by exchanging sodium for pot assium in t he colon, or, finally, (3) emergency dialysis. On physical examination, she has normal jugular venous pressure, is normoten- sive wit hout ort host asis, and has a benign abdominal examinat ion. H is physical examinat ion is sign ificant for an elevat ed jugular venous pressure, clear lung fields, and h arsh syst olic and diastolic sounds heard over the precordium. His urine output has fallen to 300 mL over 24 hours, and his serum creati- nine has risen from 1. W hich of the fol- lowing laborat or y values would be most consist ent wit h a prerenal et iology of his renal insufficiency? Ren al u lt r asou n d is the n ext appr opr iat e st ep t o assess for h ydr on eph r osis and to evaluate for bilateral ureteral obst ruct ions, which are common sites of metastases of cervical cancer. Use of loop diuret ics may increase h er urine output somewhat but does not help t o diagnose t he cause of her renal failure or to improve her outcome. Further imaging may be neces- sary after t he ult rasound, but use of int ravenous cont rast at t his point may actually worsen her renal failure. The patient has uremia, hyperkalemia, and (likely) uremic pericarditis, which may progress to life-threatening cardiac t amponade unless the under- lyin g ren al failure is t reat ed wit h dialysis. As for the ot h er t reat ment s, in su- lin plus glucose would t reat hyperkalemia, and bicarbonat e would h elp wit h both metabolic acidosis and hyperkalemia, but in this patient, his potassium and bicarbonate levels are only mildly abnormal and are not immediately life threatening. Furosemide will not help because he does not have pulmonary edema and has renal insufficiency.