74 yo M h/o stroke 2 years ago residual R sided hemiparesis p/w 4d h/o reduced urinary output, abd pain, N, lethargy. 2 recent hospitalization for PNA for past 3 mo, each time bladder catheterized, removed upon discharge. Failure to catheterize this time. VS 36.9 110 24 160/100, JVD with JVP 8 cm. PE shows tender lower abd area without guarding or rebound and trace LE edema. Lab: BUN 43 Cr 4.2 K 5.6 HCO3 20, otherwise NL including CBC. US shows distended bladder and B/L hydronephrosis. ECG shows sinus tachycardia. Next appropriate step (answer) is placement of a suprapubic catheter, which I agree with. But:
Q1) BUN:Cr ratio low at 10.2. Does it indicate that the patient likely has an intrarenal damage from hydronephrosis?
Q2) What would be the likely cause of his sudden decrease in urinary output ?
Urethral stricture, stenosis, bladder outlet obstruction from repeated prior catheterization? Vesicoureteral reflex? I think renal stones are unlikely given patient's lack of relevant symptoms. Can it be BPH, prostatic cancer, intrapelvic neoplasms, but can it present this acutely and also without B symptoms (fatigue, malaise, low grade fever, weight loss, etc.)?
Q3) In this case, what can explain for the sudden change in patient's vitals? Does the obstruction of the urine flow also decrease glomerular filtration? Can activation of RAAS from decreased GFR has caused the elevated BP?
I would greatly appreciate all your help in clarifying my concerns.
Q1) BUN:Cr ratio low at 10.2. Does it indicate that the patient likely has an intrarenal damage from hydronephrosis?
Q2) What would be the likely cause of his sudden decrease in urinary output ?
Urethral stricture, stenosis, bladder outlet obstruction from repeated prior catheterization? Vesicoureteral reflex? I think renal stones are unlikely given patient's lack of relevant symptoms. Can it be BPH, prostatic cancer, intrapelvic neoplasms, but can it present this acutely and also without B symptoms (fatigue, malaise, low grade fever, weight loss, etc.)?
Q3) In this case, what can explain for the sudden change in patient's vitals? Does the obstruction of the urine flow also decrease glomerular filtration? Can activation of RAAS from decreased GFR has caused the elevated BP?
I would greatly appreciate all your help in clarifying my concerns.
