A 32 year old Aboriginal woman presents to the ED with lethargy. She is previously well, and has not been seen by medical services for the previous 10 years.

Her VBG reveals:

1. What is the most likely cause for this VBG? Describe and interpret the abnormalities.

Compensated metabolic acidosis.

Expected pCO2 = 8 + (1.5 x 12) = 26 (about right)

Anion gap = 30 – profoundly raised

Delta ratio = AG-12/24-Hco3 = 18/12 = 1.5 = RAGMA

i.e widened anion gap probably from uraemia (consider ketosis)

Mild hyperkalaemia – ?artefact ?renal failure

mild hyperglycaemia – untreated DM

Ca Hypocalcaemia from renal failure

Anaemia would be consistent with renal failure, consider other causes/ acute blood loss

expected anaemia to be normocytic/normochromic with renal failure

Summary

Most likely cause is renal failure with uraemia, hyperkalaemia, hypocalcaemia

and anaemia. In the setting of untreated diabetes.

2. Her creatinine is 1842 and urea 62.

List 4 possible causes for these findings in a 32 year old Aboriginal woman, with the most common causes first.

Post strep GN

DMII nephropathy

Other forms of GN

Causes of ARF

3. What are the principles of management?

symptomatic – fluid status, K

definitve – prepare for dialysis – contact renal team, place vascath

IDC – monitor urine output

glucose control

4. She becomes agitated and appears to be getting ready to leave the ED. What would be some strategies to stop her leaving?

Get ALO/ILO

Create rapport by asking where she is from, introducing oneself

Explore: try to find why she wants to leave, can we assist with that, what are her concerns, what is her understanding of what is going on

Appropriate body language

Do not force eye contact

Gender preference for doctor

5. Describe cultural competency in health practice

Cultural competence allows us to work effectively in cross-cultural situations.

Includes:

– treating the patient with their specific cultural context in mind,

– ensuring that patients feels safe,

– knowledge of different ethnicities and their health statuses

– knowledge of different cultures and their beliefs and experiences around health

– being aware of how our own culture impacts on our health practice

– approaching those of other ethnicities with a mixture of empathy, respect, self-reflection and curiosity, ensuring that the patient does no feel judged based ontheir cultural background

– positively integrating cultural aspects when devising management plans

• continuing to improve our skills in these areas