NRNP 6550: Advanced Care of Adults in Acute Settings II i-Human: Ken Fowler V5, Exams of Nursing

Download NRNP 6550: Advanced Care of Adults in Acute Settings II i-Human: Ken Fowler V5 and more Exams Nursing in PDF only on Docsity! NRNP_6550___iHuman_Ken_Fowler Week #7: Week #7 - Conditions of the Renal and Genitourinary Systems NRNP 6550: Advanced Care of Adults in Acute Settings II i-Human: Ken Fowler V5 FILL OUT THIS TEMPLET AS YOU GO THROUGH THE I-HUMAN PATIENT MODULE SO YOU KNOW WHAT YOU ARE DOING AS YOU GO. 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: 1) Observations: warm and sweaty 2) 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. 6) When do you fatigue start? Just the last few days. 7) Do you have a problem with fatigue/tiredness? Yup 8) 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 16)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. 18) 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 21)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 31)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. 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 72) Do you ever feel/have a problem with Lightheadedness? 73) 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 78)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 80)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. 83) 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. 89) 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. 91) Are you eating just before going to bed? No 92) Describe activities shortly before bedtime. Nothing usual to tell you. 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 21%. 93) Are you having trouble concentrating or making decisions well? If so how often? No, I don't have that problem 94)Have you had the pain in your abdomen before? Why you asking me that? I don't have pain there 95) Do you have any problem remembering things? No 96) Does your nausea and or vomiting come and go? No. 97)How quickly does your nausea and/or vomiting come on? Pretty quickly. I mean when I had to throw up I run for the bathroom. 98) Do you are waking frequently from sleep? Not usually 99) Do you feel more fatigued tired in the morning? No. 100) How quickly does your fatigue/tiredness come on? Within a day. Questions asked after Clinical feedback: 1) What happened? Not sure why you want to know? I think told you about my PCP telling me to come in because of the lab results? 2) Have you had nausea and or vomiting like this before? No never. I just don't feel very well. 3) Have you been vomiting anything that looks like blood or coffee grounds? No. That will be horrible. 4) Do you have any pain or other symptoms associated with your nausea or vomiting? I pulled my back last week lifting a box out of my basement. The pain is finally getting better period but that doesn't have anything to do with my vomiting. Oh, I have been getting lightheaded if I stand up too quickly. 5) Do you have frothy urine? Not that I have noticed. 6) Do you have any pain in your abdomen? I don't really have any belly pain, but my stomach muscles seem a bit sore, probably from all the vomiting I have been doing. 7) Have you lost weight? I don't really know. CLINICAL FEEDBACK: Hx Performance: You missed asking eight of the 33 key questions. Missed questions: Patient Orientation - What happened? 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, 108/60 Ortho BP (standing) 94/46 RR: 20 HR: 100 (normal) A/Ox4 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  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: 1) Vitals: Temperature (provided) 2) Vitals: BP 3) Vitals: Respiration 4) Vitals: Pulse 5) Vitals: Mental Status 6) Chest Wall & Lungs: auscultate lungs 7) Heart: auscultate heart 8) Vitals: orthostatic blood pressure 9) Skin, Hair, Nails: inspect skin overall 10) Skin, Hair, Nails: test capillary refill - fingers 11) HEENT: inspect eyes 12) HEENT: inspect mouth/pharynx 13) Neck: measure JVP (jugular venous pressure) 14) Chest Wall & Lungs: visual inspection - anterior & posterior chest 15) Chest Wall & Lungs: palpate - anterior & posterior chest 16) Heart: palpate for PMI (Point of Maximal Impact) 17) Abdomen: visual inspection abdomen 18) Abdomen: palpate abdomen 19) Abdomen: percuss abdomen 20) Extremities: visual inspection extremities 21) Musculoskeletal: test strength You also performed/saw results of additional exams that were not required, but are never inappropriate. 1) Vitals: SpO2 (provided) 2) Vitals: Skin (provided) 3) Vitals: SpCO (provided) 4) Vitals: eTCO2 (provided) Missing: Oops. You missed 1 key exam. It is: 1) Chest Wall & Lungs: percuss - anterior & posterior chest (Thorax normal/symmetrical to percussion) Percussion of the thorax differentiates abnormal processes on the basis of the following: Dullness to percussion: e.g., lung consolidation Hyperresonance; e.g. hyperexpansion Tympany; e.g., displaced stomach Incorrect: You performed 19 exams not required by expert.: 1) HEENT: examine pupils 2) Neck: auscultate carotid arteries 3) Abdomen: auscultate abdomen 4) Abdomen: auscultate abdominal/femoral arteries 5) Skin, Hair, Nails: inspect hair color, distribution, thickness 6) Skin, Hair, Nails: test capillary refill - toes 7) Skin, Hair, Nails: Quincke's test 8) Skin, Hair, Nails: inspect nails 9) HEENT: smell breath 10)Neck: inspect neck 11)Heart: dynamic auscultation 12)Musculoskeletal: percuss back and spine 13)Neurological: assess cranial nerves 14)Neurological: assess gait & stance 15)Neurological: look for involuntary movements 16)Musculoskeletal: test stability 17)Neurological: reflexes - plantar/Babinski (L5/S1) 18)Neurological: reflexes - deep tendon 19)Genitourinary: genitourinary male exam --------------------------------------------------------------------------------------------------------------------- ASSESSMENT: Organize Key findings: My key findings: o Nausea and vomiting (x3 days) o Fatigue (x3 days) o Lightheadedness o Decreased appetite (x3 days) o Decrease steering output o Back injury with acute back pain (week ago) o Unable to hold in medications o renal failure o Today: Cr 3.2 mg/dL; Last month Cr 1.1 mg/dl; 400 microalbuminuria. o Dehydration (dry mucous membranes) o chronic renal failure o orthostatic hypotension o dehydration o heart failure/congestive heart failure o urinary tract infection (UTI) o renal artery thrombosis/stenosis o chronic kidney disease o nephrolithiasis/kidney calculi o Acute glomerulonephritis Expert’s feedback: Correct: o WTF!!!!!!!! Missing: 1) Medication related (side effect): this differential diagnosis should be included because NSAIDS inhibit the cyclooxygenase (COX) enzymes. This results in a reduction of prostaglandin (PG) synthesis which can lead to reversible renal ischemia, Eddie Klein in glomerular hydraulic pressure and AKI. ACE inhibitors and their attics are thought to make the incidence of AKI frequent. 2) Uremia (intrarenal azotemia): Differential diagnosis should be included because intrarenal azotemia is intrinsic disease of the kidney. This may be due to: renal failure, TTP, glomerulonephritis, ATN, AIN 3) Uremia (prerenal azotemia): this differential diagnosis should be included because prerenal azotemia is a result of decreased renal perfusion. The BUN to creatinine ratio is > 20 and it is also defined as an increase in creatinine of >3.0 mg/dL over 48 hours or 1.5 X baseline within seven days. The causes of hypo perfusion can be: hemorrhage, sepsis, heart failure, invalid to the kidneys, shock, dehydration, add renal insufficiency, medications. 4) Urinary obstruction: this differential diagnosis should be included because signs and symptoms of urinary track obstruction (e.g. BPH) may include: feeling or having a full bladder, delayed urination, weak urine flow, abdominal pain, dysuria, oliguria, anuria, hypertension. Incorrect: o All the fucking diagnosis I mentioned. Rank Differential diagnosis: o o 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: 1) medication related (side-effect) - 12 lead electrocardiogram (ECG) - comprehensive metabolic panel (CMP) - basic metabolic panel (BMP) 2) Uremia (intrarenal azotemia) - 12 lead electrocardiogram (ECG) - comprehensive metabolic panel (CMP) - basic metabolic panel (BMP) 3) 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 4) urinary obstruction - CT abdomen/pelvis without contrast - renal ultrasound - urinalysis (UA) Expert’s feedback: Correct: - BMP - Renal US - Sodium Urine RT RENAL LONG L/M ERC) rd Carer] LT RENAL LONG L/M F 3 avi-s GEGEE 160m a] et Bt eae Urinalysis: Nam e Value Unit s Reference Range Color Dark Interpreted by physician Clarity Clear clear Odor Strong slightly nutty pH 4.8 4.5-8 Protein 1 mg/dL 0-8 Specific gravity 1.018 1.002-1.030 Osmolarity 450 mOsm/L >400 Leukocyte esterase Negative negative Nitrites Negative 0 Ketones Negative negative Bilirubin Negative negative Blood (heme) Negative negative Urobilinogen 0.5 EU/dL 0.2-1.0 Crystals None Interpreted by physician Casts 1 hyaline casts/l pf 0-4 Glucose, urine Negative negative White blood cells (WBCs) 3 hpf 0-5 Red blood cells (RBCs) 0 hpf 0-5 Red blood cell casts None none SQEP None lpf <5 Bacteria Negative negative on spun specimen Creatinine 7 5-19 Occult blood Negative negative Sodium (Na+) Urine: Name Value Units Reference Range Sodium (Na+), urine 7 mEq/24 hr 40-220 Eosinophils urine Name Result Eosinophils, urine negativ e Pelvic Ultrasound: Normal bladder size, no masses seen, --------------------------------------------------------------------------------------------------------------------- DIAGNOSIS: What is the correct diagnosis for this patient? (select the main Dx) o Uremia (prerenal azotemia) Expert’s feedback: o Uremia (prerenal azotemia) o Medication related (side-effect) ------------------------------------------------------------------------------------------------------------------- Clinical Exercises: 1) Which of the following findings are consistent with a patient with prerenal volume depletion? Answer: Urine sodium concentration 15 mEq/L and urine osmolarity 500 mOsol/kg 2) a 74 year old man with long standing histories of diabetes, CD, and PVD, is seen in the clinic for evaluation of a new rash involving his lower extremities. He underwent a go to catheterization one month prior and had a drug eluting stent placed. At this time, labs are