diagnostic

Diagnostics Assignment

Veronica Sanchez, Shannae Salas

Department of Nursing, United States University

MSN 572: Advanced Health and Physical Assessment Across The Lifespan A

Dr. Amber Shwartz

June 22, 2022

Body Systems: Constitutional: fatigue, weight change

Neuro: decreased mental clarity

CV: Reports history of hypertension

Pulm:shortness of breath worse when lying down and difficulty breathing

GI: nausea and vomiting, loss of appetite

GU: Family history of kidney disease, nocturia, history of recurrent UTI’s,

Endocrine: Historically obese 68 year-old hispanic male with fatigue, thirst, and known DM

Integumentary: bilateral leg swelling, itchy skin, leg numbness

Chronic Kidney Disease

Shannae Salas: Acute Kidney Disease Veronica Sanchez: UTI Shannae Salas and Veronica Sanchez: Chronic Kidney Disease

Acute Kidney Injury Also referred to as acute kidney failure or acute kidney disease, this is when there is a rapid decrease in kidney function caused by any number of factors. Changes occur in less than three months. Some of these factors include major and/or bypass surgery, intensive care unit hospitalization, age 65 years or older, congestive heart failure, chronic obstructive pulmonary disease, severe uncontrolled hypertension, peripheral artery disease, and severe dehydration (Acute Kidney Injury (AKI)). There would be little to no symptoms associated with a milder form of the disease, however urinating less, edema to the lower extremities, fatigue, shortness of breath, confusion, chest pain, seizures or coma are among the severe cases of this illness. In this patient, the symptoms of “fatigue, shortness of breath, bilateral leg swelling, decreased mental clarity” does point to a severe case of AKI. The lab work that can be performed to help diagnose would be kidney function tests like BUN, creatinine, as well as a urinalysis. Elevated values (above normal) for BUN or creatinine demonstrates low functioning kidneys so kidneys aren’t working the way they should. Urinalysis can rule out urinary tract infections, CT scan can rule out kidney stones which can cause an obstruction, and an ultrasound can help visualize renal

stenosis in the renal arteries. These radiology tests can be performed after diagnosing a renal impairment to determine the cause like nephrolithiasis or renal stenosis.

Lab work ● BUN: greater than 24 indicates kidneys are not working well (normal: adult men: 8

to 24 mg/dL) ● Creatinine more than 1.4 because kidneys are not working properly: normal in

men: 0.6 to 1.1 mg/dL ● Urinalysis:

○ Color: pale yellow/straw to amber ○ Clarity: clear ○ Specific gravity: 1.001-1.035 ○ pH: Normal 4.6-8.0 but in this case would be elevaed ○ Glucose: absent ○ Ketones: absent ○ Protein: positive ○ Urine dipstick: negative nitrites, negative leukocytes

(positive results would indicate an infection) (Cash, Glass, & Mullen, 2021) Radiology

An ultrasound can also be performed to visualize the blood flow to the kidneys to ensure there are no constrictions or impairment Computed tomography can also be utilized to rule out nephrolithiasis

Pyelonephritis/UTI A UTI for males ages fifteen to fifty is rare, however the incidence in geriatic males is nearly equivalent to the geriatic female. Common complaints include frequency, burning on urination, cloudy urine, or urgency. However geriatric patients may not present with clear symptoms or have incontinence, fever or mental confusion. This patient did not present with fever but did complain of decreased mental clarity, is an older gentleman, has a history of UTIs, and nocturia. Thus, a simple urinalysis clean-catch dipstick finding to rule out UTI is sufficient given that the patient lacked other presentations of infection such as offensive odor of the urine, fever, CVA pain, inguinal lymph enlargement, pain in the suprapubic region The patient also did not have signs of inflammation or discharge of the penus, nor swollen prostate. He also denies trauma, sexual inter course, anal sex, anololie sof his GU tract, HIV, and is circumcizzed. Given this patient history and negative dipstick finding no additional labs were necessary. Had the patient been positive for a UTI the microscopic examination of urine findings, Urine culture and sensitivity test, and STI culture could have been appropriate but in this case were not warranted. Lab work

○ Urine dipstick: negative nitrites, negative leukocytes (positive results would indicate an infection) (Cash, Glass, & Mullen, 2021)

Chronic Kidney Disease CKD has 5 stages. Chronic disease occurs in over 3 months versus acute which occurs in less than 3 months. Stages 1 and 2 are typically asymptomatic. Stage 3 has some complications but no clear presentations (Cash, Glass, & Mullen, 2021). Signs and symptoms include HTN, anemia, altered lipoprotein metabolism, left ventricular hypertrophy, salt and water retention and decreased renal potassium excretion. These complications will worsen in stage 4. Signs and symptoms can include bone density changes, fatigue and pallor, edema and decreased muscle mass. Stage 5 will present with signs and symptoms as stated above and also have chronic uremia, impaired sleep, nocturia, fatigue, anorexia, nausea, vomiting, weight change, pruritus, edema, respiratory symptoms, and peripheral neuropathy. Our male patient presents with complaints consistent with stage 5 CKD and has long standing HTN, a primary cause of Chronic Kidney Disease. The patient also has Diabetes. Nausea and loss of appetitie could be an indication of toxins building given that less urea is getting filtered out and could indicate azotemia. Thus, appropriate diagnostic testing includes laboratory testing. The principle test is a routine kidney function test which includes serum creatinine, blood urea nitrogen (BUN), urinalysis, and measuring the glomerular filtration rate (GFR). However patients with CKD should be assessed by formula-based estimation of GFR (eGFR). This can be assessed causing the calculations at MDRD for Adults (Conventional Units) | NIDDK (nih.gov) (Cash, Glass, & Mullen, 2021). Another laboratory assessment is proteinuria via albumin-specific dipstick and/ or albumin-to-creatinine ratio. First-morning specimens are preferred but random is acceptable. Urine dipstick and microscopy to detect proteinuria while albumin-specific tests detect albuminuria. Clients with positive dipsticks should perform a PCR within 3 months. Clients with two or more positive PCR require further management by a nephrologist. Given this patient is in stage 5, other tests to determine CKD complications are appropriate and include CBC and assessing for anemia. Tests include serum iron, total iron binding capacity, percent transferrin saturation, serum ferritin, white blood cell and differential, platelet count, and testing for blood in stool. Lipid profile and triglycerides are also appropriate. A comprehensive metabolic profile is also appropriate along with a prealbumin test and ANA to rule out any autoimmune disorder. Tests like Hepatitis B surface antigen and Hepatitis C are also appropriate to determine if the patient is a candidate for a transplant. Finally a renal doppler to rule out renal artery stenosis is also appropriate. Given the severity of this stage, diagnostics will be extensive and expensive in order to treat any underlying complications. Lab work/ radiology

● BUN: greater than 24 indicates kidneys are not working well (normal: adult men: 8 to 24 mg/dL)

● MDRD: GFR value 14 mL/min/1.73 m² (kidneys not filtering well: eGFR is below 15/ G1 > 90 ,G2 60 - 89, G3 30-59, G4: 15 - 29, G5 below 15)

● Hyperphosphatemia (kidney’s cant excrete phosphate/ normal: 2.5 to 4.5 mg/dL)

● Hypocalcemia (due to low levels of calcitriol because the kidney cannot convert Vit D properly/normal 8.6 to 10.3 mg/dL.)

● High levels of parathyroid hormone (due to hyperphosphatemia and hypocalcemia/normal: 10 to 55 pg/mL)

● Hyperkalemia (causes muscle weakness/normal: 3.6 to 5.2 mmol/L) ● Electrolytes and ABG to determine metabolic acidosis ● Low albumin level indicating malnutrition (normal: 3.4 to 5.4 g/dL) ● Kidneys cannot make adequate erythropoietin leading to serum iron is low (normal

male: 80-180 mcg/dL), TIBC is high (normal: 240 to 450 mcg/dL ), and ferritin is low ( men, 24 to 336 micrograms per liter) Creatinine: 3.5-7.7 mg/dL

● Elevated triglyceride levels (normal: less than 150 mg/dl) ● Creatine: elevated (men: 0.6 to 1.1 mg/dL) ● Urinalysis:

○ Color: pale yellow/straw to amber ○ Clarity: clear 3 ○ Specific gravity low: (normal: 1.005 to 1.030) ○ pH: Normal 4.6-8.0 ○ Ketones: absent ○ Protein: positive ○ Albuminuria: positive and but less than 30mg/day ○ Urine dipstick & sediment: negative nitrites, negative leukocytes

(positive results would indicate an infection) ○ Urine output less than 400 ml/day

References

“Acute Kidney Injury (AKI).” American Kidney Fund, 12 Apr. 2022,

https://www.kidneyfund.org/all-about-kidneys/other-kidney-problems

/acute-kidney-injury-aki#what-is-acute-kidney-injury-aki.

Cash, J., Glass, C., & Mullen, J. (2021). Family Practice Guidelines (Fifth Edition). Springer

Publishing Company.

Chronic Kidney Disease - osmosis. (n.d.).

https://www.osmosis.org/learn/Chronic_kidney_disease:_Clinical_practice