Discussion w3 650

Instructions for Discussion Replies to 3 DQS

DO NOT JUST REPEAT SAME INFORMATION, DO NOT JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED TO ADD NEW INFORMATION TO DISCUSSION.

1- Each reply should be at least 200 words.

2- Minimum One Peer reviewed/scholarly reference ( NO MAYO CLINIC/ AHA)

3- APA 6th edition style needs to be followed.

4- Each response should have reference at the end of each reply

5- Reference should be within last 4 years

Q1

Utilizing DxR Clinician was not the most user friendly, nor the video tutorials helpful as well. However, after reading the case report at the end of the activity, I did learn a lot from this. Originally I had tried to go through the activity and when the patient said that they were having back pain combined with abdominal pain I had thought of getting an ultrasound as the first test but had to set up my differential diagnosis list first to see if it would fit.

Some negatives that helped focus my assessment towards the renal system were that the patient denied any changes in diet, exercise, activity or habits. The patient also denies any extreme or strenuous activity recently which helps rule out musculoskeletal involvement.

I was originally going with the differential diagnosis of nephrolithiasis versus pyelonephritis until I had realized that the patient also smoked and was on birth control. At this point in the investigation, I had also asked about recent hospitalizations and the patient stated she was recently admitted for asthma. Interestingly enough the patient divulged that she always ends up being dehydrated after an asthma-related hospitalization. At this point in the scenario, I was thinking about nephrolithiasis, pyelonephritis, and thrombus embolism.

A lot of information on this case study can be obtained through assessment of the patient’s abdomen including palpation and percussion while utilizing radiological interventions as a confirmation to rule in the final diagnosis or diagnoses.

Lately, in our classes, we have talked about utilizing the right test for the patient, going from least invasive to most invasive. I had thought of initially ordering an ultrasound on this patient’s abdomen for multiple reasons. An ultrasound can still detect calculi, thrombosis, and structural deformities, and any other abnormalities that may be preset (Shafi, Anjum, & Shafi, 2017). An ultrasound is also less expensive and does not carry the risk of exposing the patient to radiation (Shafi, Anjum, & Shafi, 2017). Even though a CT scan is more sensitive and gives a better picture of the abdomen, there is no difference in outcomes when choosing an ultrasound or CT in a patient with possible nephrolithiasis (Shafi, Anjum, & Shafi, 2017).

If there was any indication of an abnormality or defect, a CT Scan would be warranted at this point to have the best view of the possible disease process occurring (Shafi, Anjum, & Shafi, 2017).

Differentiation between nephrolithiasis and pyelonephritis can be obtained during the assessment portion of the exam (Hudson & Mortimore, 2020). Pyelonephritis usually presents as the patient feeling “sick” with possible fever and nausea but is not absolutely specific to pyelonephritis (Hudson & Mortimore, 2020). Costovertebral Tenderness indicates an inflammatory process that is occurring in the kidneys and is usually typically selective to pyelonephritis (Hudson & Mortimore, 2020) This would indicate an inflammatory process from an infection when combined with fever and nausea (Hudson & Mortimore, 2020).

References:

Hudson, C., & Mortimore, G. (2020). The diagnosis and management of a patient with acute pyelonephritis. British Journal of Nursing, 29(3), 144–150. https://doi-org.lopes.idm.oclc.org/10.12968/bjon.2020.29.3.144

Shafi, S. T., Anjum, R., & Shafi, T. (2017). Clinical predictors of an abnormal ultrasound in patients presenting with suspected nephrolithiasis. Pakistan Journal of Medical Sciences, 33(3), 545–548. https://doi-org.lopes.idm.oclc.org/10.12669/pjms.333.12651

Q-2

1. I used Urinalysis, CBC, BUN, Creatinine, Kidney Ultrasound, pelvic ultrasound, and transvaginal ultrasound.
   1. The Urinalysis showed positive blood, trace bacteria, positive nitrates, RBCs 5-8, and WBC’s. The culture showed 100,000 CFU pan-sensitive E. Coli. The BUN and creatinine were elevated.
   2. The CBC showed elevated WBC of 22.6, elevated neutrophil count showing inflammation and bacterial infection
   3. The ultrasounds were normal.
   4. The ultrasounds ruled out any Kidney stones, pelvic abscess (history of STI) and any pregnancy.
2. I would diagnose with UTI based on the Urinalysis and culture and the increase in WBC’s and elevated BUN and creatinine. The others were ruled out with ultrasound as there were no stones, abscess’s, or pregnancy shown on ultrasound. The pain wasn’t muscular.  The treatment would be antibiotics and increasing fluid intake. The CT showed left kidney enlargment which could indicate pyelonephritis.
3. The Consult indicated: Abnormal findings include evidence of thrombus in the left renal vein and the left gonadal vein. There is limited excretion of contrast into the collecting system. Filling defects in the renal pelvis probably represent clot. Small cyst in the lower pole of the left kidney. No calculi noted. Enlarged left kidney. Poor/delayed function.

Wiothout the CT the clot couldn’t be ruled out and that wasn’t even one of my diagnoses. I tried to start with the least invasive to most invasive. She is at risk for clots taking birth control and being recently hospitalized for her asthma. Her BUN and creatinine were also affected by this as well. The congestion caused by thrombosis can cause flank pain, hematuria, and decreased urine output (Mazhar & Aeddula, 2020).

Mazhar HR, Aeddula NR. Renal Vein Thrombosis. [Updated 2020 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536971/

Q-3

Crystal Bates is a 23-year-old female report left lower back pain that began yesterday after supper last night while watching TV. She reports that her “pain is awful, making it hard to breathe” and feels like she has to go to the bathroom all the time. Her pain is constant and describes it as “burning, knife-like”. The pain is better when using a heating pad, but burned herself using it. She reports she was just discharged from the hospital two days ago for an asthma attack.

The patient is in moderate distress, experiencing severe pain.

Height: 67″  Weight: 160 lbs  BMI 25

VS: BP 120/80 mmHg, HR 90, Temp 100.0F, R 20,

Abdomen: Normoactive bowel sounds in all 4 quadrants, no bruits or friction rubs noted, tympany. The spleen cannot be palpated, the liver edge is palpable and is smooth and non-tender, no masses palpated, mild tenderness on deep palpation of the LUQ, and moderate tenderness of the LLQ.

CVA tenderness noted of the left lower back, no discomfort on the right

The patient reports left lower back pain and the physical examination showed abdominal tenderness of the LUQ/LLQ, CVA elicited left renal tenderness, and the patient had a temp of 100.0F. Recognizing the presenting symptoms of flank pain, fever, and CVA tenderness helped me develop a differential diagnosis including acute pyelonephritis, renal calculi/nephrolithiasis/urolithiasis, and PID. Therefore, a CBC/BMP, urinalysis, urine culture, and ultrasound of the abdomen/kidney was ordered. An ultrasound is a method of choice for renal diagnosis because of its advantages. It avoids both ionizing radiation and the nephrotoxic intravascular contrast utilized in CT scans (Hudson & Mortimore, 2020).

The CBC showed leukocytosis: WBC 22.6 k/mm3 and elevated neutrophil, band 12% and lymphocytes 68%. The BUN and creatinine were also elevated.

The urinalysis showed proteinuria, hematuria, RBC’s and WBC’s, and a trace of bacteria. Clinical guidelines recommend urinary dipstick tests to differentially diagnose acute pyelonephritis from conditions with similar symptoms. Leukocytes are the predominant inflammatory cell in the immune response to bacterial pyelonephritis (Hudson & Mortimore, 2020).

Urine cultures showed positive for greater than 100,000 CFU of pan-sensitive E. coli.

Ultrasound results showed normal right renal, left renal is enlarged, pelvis appeared normal, and no evidence of calculi. This ruled out renal calculi.

A CT scan should be considered if the patient does not improve after 48-72 hours with antibiotics.

References

Hudson, C., & Mortimore, G. (2020). The diagnosis and management of a patient with acute pyelonephritis. British Journal of Nursing, 29(3), 144–150. doi:10.12968/bjon.2020.29.3.144