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Week 7 - Conditions of the Renal and Genitourinary Systems
NRNP 6550: Advanced Care of Adults in Acute Settings II i-Human: Ken Fowler V YOU ARE ALL WELCOME!!! Name: Ken Fowler Age: 70 years Sex: M Ht: 5'10" (178.0 cm) Wgt: 190 lb (86.0 kg) (BMI 27.3) NOTES FROM i-HUMAN ASSESSMENT:
- Observations: warm and sweaty
- Chief complaint: Nausea and fatigue QUESTIONS: (ask the patient up to 100 questions) 1. How can I help you today? "I went to see my doctor this morning because I have been feeling bad for the past few days. I'm tired, with nausea & vomiting. Well, he examined me and ordered some labs, and then told me that "kidneys are failing," something about a big change in my creatinine and that I needed to come to the emergency department. He told me to bring the test results here with me. [Test results today: creatinine 3.2 mg/dL; 1 month ago Test results 1.1 mg/dL; urine protein = 400 mg microalbuminuria] Do you understand what all that means? I sure don't!" 2. Do you have any other symptoms or concerns we should discuss? I also feel exhausted, probably from all the vomiting and not eating. 3. When did your nausea start? It started three days ago, I woke up feeling nauseous and started throwing up everything I ate. 4. What are the events surrounding this start of your nausea and vomiting? Nothing really happened that I can think of. 5. Do you have difficulty breathing? Uh… no.
- When do you fatigue start? Just the last few days. 7. Do you have a problem with fatigue/tiredness? Yup
- Does your fatigue come and go? No. 9. Have you gained or lost weight or intentionally, despite normal appetite and exercise? Uh… no. 10. Have you gained weight? No.
11. Has there been a change in your urination frequency? Actually, I have been peening less recently. 12. What is the color of urine, has it changed recently? It's usually fine, but I have been peeing less recently 13. Does anything make your fatigue/tiredness better or worse? No. 14. Do you have pain anywhere? If so where? I hurt my back last week, but that's fine now. 15. Have you noticed swelling in any part of your body? No
- Can you tell me about any current or past medical problems she had? I have high blood pressure. I take medications for that. I was told last month my blood pressure has caused some kidney damage. Something about my protein in my urine. Oh, about a week ago I pulled my back lifting a heavy carton when I was cleaning out my garage. It was pretty painful so I took something for the pain. My back is really pretty good right now, but then this nausea vomiting began. 17. Any previous medical, surgical, or dental procedures? Yes. I had my tonsils out as a kid and then my appendix out about 35 years ago now.
- What treatments have you had for the pain in your back? Just Naproxen. 19. Are you taking any prescription medications? I take lisinopril, metoprolol, and hydrochlorothiazide for BP. I have not taken anything for the last 24 hours because I feel so sick, can’t keep the pills down. 20. Do you have any pain in your back? Not anymore
- When you urinate, have you noticed any pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, or any changes in frequency? Uh, no. In fact, I am barely peeing at all. 22. When are the events surrounding the start of your difficulty urinating? That’s not a problem for me. 23. When you pee, is a stream or flow of urine weak or do you dribble? No 24. Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety or bloating? Yes, I have already told you about my nausea and vomiting. But none of the other stuff. My poop is normal 25. How severe is your nausea and/or vomiting? I have not eaten much of anything in the last three days, so I am not sure how to answer that question. Vomiting is and miserable business so for me it is bad. 26. Does anything make your nausea and/or vomiting better or worse? It does get worse when I eat, that's why I haven't eaten much. 27. What treatments have you had for nausea and/or vomiting? Nothing 28. Do you have any problems with fatigue, difficulty sleeping, or intentional weight loss or gain, fevers, or night sweats? Yeah I feel exhausted, but I think it is because of my nausea… just keeps me up at night. No fevers 29. Does your fatigue/tiredness improve after a good night's rest? No 30. What does your vomit look like? Clear or residual food particles, but I haven't eaten for over 24 hours
- When do you nausea and/or vomiting start? It started 3 days ago, I woke up feeling nauseous and started throwing up everything I ate. 32. Do you have diabetes? Uh… no.
54. Are you taking any over the counter or herbal medication? I am not taking anything now, but when I strained my back I started taking naproxen. I guess that was about 7 to 10 days ago. It took a couple of pills twice a day. It really helped my pain. Do you think they screwed my stomach and that is why I have so much nausea? 55. When that you last take your medication? This morning. 56. Do you have any problems with itchy scalp, skin changes, moles, thinning of the hair, or brittle nails? Uh… no 57. Do you have any problems with headaches that don't go away with aspirin or Tylenol, double blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throat, or difficulty swallowing? Nope 58. Do you experience chest pain discomfort or pressure, pain/pressure/dizziness with exertion or getting angry, palpitations, decrease exercise tolerance, or blue/cold fingers and toes? Not at all. But I am not worried about my heart or anything should I be? 59. Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or speeding production? No 60. Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, nick or shoulder pain, or hip pain? Nope 61. Have you noticed any bruising, bleeding gums, nosebleeds, or other sites of increase bleeding? No. 62. Do you have problems with heat or cold intolerance, increased thirst, increase sweating, frequent urination, or change in appetite? I feel a bit thirsty, but the nausea keeps me from drinking because I am afraid all I will do is vomit it up back up. I just hate vomiting. 63. Do you have any problems with, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? No this is, but I am a bit lightheaded when I stand up and when I feel weak and exhausted. Not tingling or numbness or actually passing out. 64. Do you have problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or seen things that you know are not there? Before getting sick, no. 65. Have you been feeling sad, depressed or hopeless, if so how often do you feel this way? Uh, no. 66. Have you been more irritable or angry lately? No. 67. How would you describe your moods? Pretty good. I don't think that's my problem. HINT: 2 of 5 You have asked 25 key questions. 8 key questions remain. You need: 1 more in Patient Orientation 4 more in Chief Complaint Sx/Sx Characteristics 3 more in Associated Symptoms Your current Hx efficiency is 28%.
68. Can you describe how you fell? Uh… why are you asking me this? 69. Can you describe what you were doing when you felt like headed? Nothing. I just stood up is all. 70. Do you have any other symptoms or concerns we should discuss? I also feel exhausted, proud from older vomiting and not eating. 71. Do you have any pain in your flanks? Uh… no
- Do you ever feel/have a problem with Lightheadedness?
- When did your lightheadedness is start? Just the last day or so. 74. Have you had problems with low blood pressure before? I don't have that problem 75. How severe is your blood pressure? Not bad period when I check it my blood pressure is usually 124 to 134 76. Do you have any history of high lipids or triglycerides? Uh… no 77. When do you have blood pressure start? About 10 years ago
- What do you think might be causing your symptoms? It's all jumbled to me. The lab results and all that. I hope you can figure out and make me feel better. 79. What did the pain in your back feel like? My back does not hurt anymore
- Have you recently lifted something heavy or used your back initial waist or posture? Yes the box in my basement and that's what caused the pain in my back. But that's gotten better now. 81. How do you injure yourself? I didn't hurt myself HINT: 2 of 5 You have asked 25 key questions. 8 key questions remain. You need: 1 more in Patient Orientation 4 more in Chief Complaint Sx/Sx Characteristics 3 more in Associated Symptoms Your current Hx efficiency is 23%. 82. Do you feel unwell, not normal or just “not yourself” (malaise) lately? Not generally, but I sure don't feel well right now.
- How is your overall health? Pretty good, up till now. 84. Are there any diseases that run in your family? My father had died when he was 65. He had high cholesterol and bad heart. My mother had rheumatoid arthritis but died from his stroke. My sister is in treatment for breast cancer. 85. When did you last urinate? Do you really need to know that? 86. Do you urinate frequently during the night? No more than most guys my age I suppose. 87. Have you passed any stones in your urine? No 88. Is your urine pink or red in color (blood in the urine)? No.
- When you urinate, do you feel that you could not completely empty your bladder? Nope 90. Does anything make your lightheadedness better or worse? Standing up is what causes it. I haven't kept anything down for the last three days. Maybe if I felt better I will get better.
Chief complaint Sx/ Sx characteristics:
- Have you had nausea and or vomiting like this before?
- Has there been any change in your nausea or vomiting overtime?
- Have you been vomiting anything that looks like blood or coffee grounds?
- Do you have any pain or other symptoms associated with your nausea or vomiting? Associated symptoms characteristics:
- Do you have frothy urine?
- Do you have any pain in your abdomen?
- Have you lost weight? Risk factors: PMH:
- N/A Environmental:
- N/A Etiology:
- N/A HPI/ROS:
- N/A
Height/weight 5' 10" (178.0 cm) - 190 lb (86.0 kg) (BMI 27.3) Temp: 99.9F BP: Left arm, 108/ Ortho BP (standing) 94/ RR: 20 HR: 100 (normal) A/Ox SpO2: 98%$ SpCO2: 1% eTCO2: 38 mmHg
PHYSICAL EXAM: Assessment: Skin, hair, nails: Inspect skin overall: general skin warm, drying; no pallor, jaundice, rash, scaling, or ulceration; no clubbing or cyanosis; sparse peripheral hair. Inspect hair color, distribution, thickness: thickness and distribution pattern typical for patient’s gender and age. Inspect nails: Nails without ridging, pitting, or peeling. Test capillary refills – fingers: blanche time of 3-4 seconds; suggestive of dehydration. Test capillary refills – toes: normal capillary refill Quincke’s test: blanching observed
HEENT:
Inspect/palpate scalp: Inspect/palpate head: Inspect eyes: Non-icteric; no conjunctival-rim pallor Perform ocular motor test: Examine pupils: right pupil and left people normal reactive. Look in eyes with ophthalmoscope: Inspect ears: Look in ears with otoscope: Test hearing: Inspect nose: Look up nostrils: Inspect mouth/pharynx: dry mucous membranes; No sublingual jaundice. Smell breath: no unusual odor Neck: Inspect neck: no visible scars, deformities, or other relations; trachea is in the midline and fully mobile; No asymmetry or access respiratory muscle used with quiet breathing. Palpate neck: Ask patient to swallow: Evaluate neck range of motion: Measure JVP (jugular venous pressure): flat, nodular venous tension. Auscultate carotid arteries: no bruits auscultated Breast: Breast exam: Lymphatic: Palpate all lymph nodes: Chest Wall/lungs: Visual Inspection – anterior and posterior chest: normal respiratory efforts and his question; no gynecomastia. Palpate – anterior and posterior chest: normal tactile fremitus; thorax non tender to palpation throughout; no maxillary, supraclavicular, or infraclavicular adenopathy. Percuss – anterior and posterior chest: Auscultate lungs: (remember to do the back): left lung and right lung normal breath sounds Heart: Palpate for PMI (Point of Maximum Impulse): slight lateral (left ward) and downward displacement of the PMI Measure JVP (Jugular Venous Pressure): flat, no jugular venous distention
point to point test legs (heels on shin): rapid altering movement – fingers: rapid altering movement – arms/hands: Romberg’s and pronator drift test: test range of motion: test stability: normal test strength: no proximal muscle weakness; normal symmetrical strength throughout straight leg raise: reflexes - deep tendon: 2+ triceps (C6/C7); 2+ biceps (C5/C6); 2+ Brachioradialis (C5/C6); 2+ knee/patella (L3/L4); 2+ ankle/achilles (S1/S2) reflexes – plantar/Babinski (L5/S1): negative on right and left extremity administer grass pain stimulus: Skew deviation: Dix-Hallpike: examine pupils: monofilament test: perform ocular motor test: sensory test (light touch, pain, position, temperature, vibration): Vestibulo- ocular reflex (VOR): Genitourinary: Genitourinary female exam: Genitourinary male exam: normal external genitalia; no masses for tenderness; not urethral discharge Prostate exam: Rectal: Visual inspection rectal area: Rectal exam: Vital signs tab: Blood Pressure Tab: Check blood pressure: / Check orthostatic BP (if indicated): / Documentation tab : Lung auscultation: cardiac auscultation: EXPERT FEEDBACK:
Vitals Documentation: o Pulse: Good, all correct. (FYI actual rate: 98) o Respiration: Good, all correct. (FYI actual rate: 18) o BP: Good, all correct. o Mental Status: Good, all correct Exam documentation: o Lung Auscultation: Good, all correct. o Cardiac Auscultation: Incorrect sound documented (Murmur - systolic/diastolic). Correct is Normal. o Eyes - Pupils: Good, all correct. Exams performed: Good, you performed 21 key exams for this case:
- Vitals: Temperature (provided)
- Vitals: BP
- Vitals: Respiration
- Vitals: Pulse
- Vitals: Mental Status
- Chest Wall & Lungs: auscultate lungs
- Heart: auscultate heart
- Vitals: orthostatic blood pressure
- Skin, Hair, Nails: inspect skin overall
- Skin, Hair, Nails: test capillary refill - fingers
- HEENT: inspect eyes
- HEENT: inspect mouth/pharynx
- Neck: measure JVP (jugular venous pressure)
- Chest Wall & Lungs: visual inspection - anterior & posterior chest
- Chest Wall & Lungs: palpate - anterior & posterior chest
- Heart: palpate for PMI (Point of Maximal Impact)
- Abdomen: visual inspection abdomen
- Abdomen: palpate abdomen
- Abdomen: percuss abdomen
- Extremities: visual inspection extremities
- Musculoskeletal: test strength You also performed/saw results of additional exams that were not required, but are never inappropriate.
- Vitals: SpO2 (provided)
- Vitals: Skin (provided)
- Vitals: SpCO (provided)
- Vitals: eTCO2 (provided) Missing: Oops. You missed 1 key exam. It is:
Expert’s feedback: o Orthostatic hypotension - MSAP o history of grinding through queen 2 with microalbuminuria - Related o nausea and dry hiving x 24 hours - related o reduced during output - related o nausea and vomiting 3-4 days – resolved - related o tachycardia - related o light headed when standing up quickly - related o New NSAID use - related o Fatigue - related o Dry mucous membranes - related o mild tenderness in epigastric and periumbilical region – unknown o Back pain last week, now significantly better - related The medical problem list do you have compile should be at least that includes everything that is out of the ordinary about the patient, even when it is not a problem in the true sense of the word. In this case, the most significant active problem (MSAP) is his orthostatic hypotension. It may feel hard to determine which is the most active problem, but since decreased intravascular volume can be life-training as well as cause kidney injury, this problem is the MSAP. Your approach to the other complaints should be to determine which ones might be the consequences of his dehydration and/or elevated creatinine and which might be either causal or not involved. For dehydration, as reflected by his orthostatic hypotension, tachycardia would be normal compensation as would a reduced urine output and Lightheadedness upon standing. He also complaints of nausea and vomiting that started a week ago that now has him dry heaving due to lack of oral intake. The question is whether the real problem with the elevation in his creatinine is causal in his nausea and vomiting or if he has a GI issue that has resulted in dehydration causing his renal issue? Review his presentation history and his physical findings to try to determine which is etiologic. Next, you have two different sites of pain. One is a mild tenderness in his epigastrium while the order is resolved back pain. What was the timing of each? How was each treated? How could either of these things be related to his current complaints or are they irrelevant? Finally, remember his chief complaint of fatigue and nausea and vomiting, that prompted his visit to his PCP. How are they related to his orthostatic hypotension and elevated creatinine? What things in the physical exam are helpful in ranking the diagnosis you are considering? Write Problem statement: (your own) Mr Ken Fowler is a 70-year-old male who arrived at the ED after being told by his PCP to come here because the results of his current labs. The patient was told the “his
kidneys are failing” and his current creatinine is 3.2 mg/dL. A month ago, his Creatinine was 1.1 mg/dL and urine protein was 400 mg microalbuminuria. He has been experiencing nausea, vomiting, fatigue, tiredness, lightheadedness upon standing, decrease PO intake, dry heaving, and decreased urine output. During assessment he was noted to be dehydrated with dry mucous membranes and positive for orthostatic hypotension. Sitting BP 108/60 and standing 94/46. Patient has a history of hypertension. Expert’s feedback: Mr Fowler it's a 7 year old male who is sent to the Ed by his primary care physician for further evaluation of a grinding of 3.2 mg/dL following a three day history of nausea and vomiting now with dry hives, poor PO intake, fatigue, the crazy rain volume and orthostatic hypotension (108/60) and tachycardia (98 bmp). PMH it's significant for lifting a heavy object resulting in a low back pain one week prior. He self-medicated with NSAIDS (Naproxen) BID). his medications include lisinopril, metoprolol, and HCTZ. His PMH is also significant for mild chronic renal disease with a creatinine (one month ago) of 1.1 with 400 mg albuminuria. Physical exam is notable for dry mucous membranes, mild periumbilical tenderness and lack of CVA tenderness or bladder distention Select Problem Categories: My selection: Cardiovascular Gastrointestinal Genitourinary/Renal Expert’s statement problem: Gastrointestinal Genitourinary/Renal Gastrointestinal needs to be considered since he presents with nausea, vomiting, and periumbilical tenderness as a cause of his orthostatic hypotension. Genitourinary/Renal needs to be considered in light of his previous history of renal insufficiency and proteinuria and presentation of orthostatic hypotension. Comparison to expert: Correct/Incorrect/Missing: (TABLE GOES HERE PROVIDED BY i-HUMAN) Feedback: Select Differential Diagnosis: Student Differential Diagnosis: o Acute renal failure
o o o Expert’s feedback: Diagnosis ranking: Correct: o Medication related (side effect) o Uremia (intrarenal azotemia) o Uremia (prerenal azotemia) o Urinary obstruction Incorrect: o Diagnosis Must-not-Miss (MnM): Correct: o Medication related (side effect) o Uremia (prerenal azotemia) o Urinary obstruction Incorrect: o Uremia (Intrarenal): Discussion: This is unusual case in which there are two leading diagnosis. The first is medication related side effects and the second is prerenal azotemia. both medications, in particular NSAIDS, as well as hypovolemia, from a variety of causes, can cause prerenal azotemia. there is a medication side effect E leading diagnosis is that it is important to stop medication in order to reverse the azotemia. Prerenal azotemia is a must-not-miss diagnosis because if left untreated, it can progress to permanent kidney damage or intrarenal azotemia. repeat myologie data has found the incidence of NSAIDS-induced prerenal azotemia can be as high as 5% of those individuals that use this type of medication. Furthermore, the combination of NSAIDs diuretics, and ACE inhibitors are implicated as cofactors in causing and/or exacerbating an acute kidney injury in a volume depleted state.
TESTS FOR DIFFERENTIAL Dx:
- medication related (side-effect)
- 12 lead electrocardiogram (ECG)
- comprehensive metabolic panel (CMP)
- basic metabolic panel (BMP)
- Uremia (intrarenal azotemia)
- 12 lead electrocardiogram (ECG)
- comprehensive metabolic panel (CMP)
- basic metabolic panel (BMP)
- Uremia (prerenal azotemia)
- urinalysis (UA)
- sodium (Na+), urine
- creatinine, urine (24 hour)
- basic metabolic panel (BMP)
- renal ultrasound
- osmolality, urine
- echocardiogram, transesophageal (TEE)
- 12 lead electrocardiogram (ECG)
- kidney scan
- urinary obstruction
- CT abdomen/pelvis without contrast
- renal ultrasound
- urinalysis (UA) Expert’s feedback: Correct:
- BMP
- Renal US
- Sodium Urine
Platelets (thrombocytes) 282 k/dL 150-399, adults Red cell distribution width (RDW) 12.7 % 11.5-14.5, adults Neutrophils 63 % 46-78, adult Lymphocytes 24 % 18-52, adult Monocytes 8 % 3-10, adult Eosinophils 4 % 0-6, adult Basophils 1 % 0-3, adult Segmented neutrophils 59 % 36-72, adult Band Cells 4 % 0-6, adult Renal US: kidneys are normal in size, location, and echogenicity; no hydronephrosis, focal mass, or shadowing stones period
