Question

1. What are priority assessments for chronic kidney disease (include physical assessment and labs)? What abnormal results would you anticipate?

Answer 1

Priority assessments:

Physical:

1. confusion, loss of orientation of time, place and person, increase sleepiness, non -responsiveness to verbal stimulus.
   • These symptoms can be seen in uremic encephalopathy.
2. Chest pain:
   • chest pain can occurs due to pleuritis (inflammation of pleural) or pleural effusion.
   • Chest pain can also be due to ischemic heart disease (common comorbidity in patients suffering from chronic renal disease.)
3. Breathlessness:
   • This symptom can develop due to pulmonary edema due to fluid overload.
   • This could be due to pleural effusion and pleural inflammation.
   • This could also be due to pericardial effusion.
4. Weight gain:
   • Weight gain can be due to edema.
   • A patient of chronic kidney disease is unable to maintain fluid balance in the body. This can lead fluid retention and edema formation.
5. Presence of petechia or ecchymosis on the body.
   • This may be due to bleeding tendency.
6. Pathological bone fractures - these fractures develop with trivial trauma.
   • These condition is suggestive of vitamin-D deficiency and osteoporosis.
7. Fever
   • Chronic kidney disease leads to immunosuppression.
   • These patients are at the risk of developing mild to severe recurrent infections.
   • Infections leads to fever development.
8. Weakness and easy fatiguability:
   • This is due to loss of appetite and anemia.
   • Patient with chronic renal disease lose proteins in their urine.
   • This leads to protein energy malnutrition and also lose immunoglobulins ( they protect the body from infections)
   • The kidney release a hormone called erythropoietin
   • Reduce appetite and anemia result in reduced excercise capacity and fatigue.
9. High blood pressure:
   • Patient with chronic renal disease tend to have high blood pressure.
   • This should be managed with anti-hypertensive drugs.
10. Low blood pressure:
    • Some patients can have low blood pressure as well.
    • This could be due to massive pericardial effusion leading to cardiac tamponade.
    • This could also be due to tubulointerstitial involvement.
11. On chest auscultation:
    • Presence of pleural rub - this can occur due to pleural effusion.
    • Absense of breath sounds - this can occur due to pleural effusion. Pleural effusion in chronic kidney disease can be bilateral.
    • Muffled heart sounds - this could be due to pericardial effusion.

Labs:

1. total urine volume - if the urine output reduces the patient needs to be taken up for dialysis.
2. Hemoglobin count - anemia
   1. these patients may require parenteral erythropoietin therapy.
3. Increase white blood count - this could be due to infections.
   1. Appropriate antibiotic theraphy needs to be given. Avoid nephrotoxic drugs and alter the drug dose as per the creatinine clearance.
4. Serum electrolytes - High level of potassium (hyperkalemia)
   1. Hyperkalemia can lead to cardiac arrhythmia.
   2. This needs to be correct urgently
   3. It may also require dialysis.
5. Chest xray :
   1. there might be presence of pleural fluid ( Either unilateral or bilateral)
   2. There might be cardiomegaly ( due to pericardial effusion)
   3. Lung parenchymal opacities like bat-wing appearance ( due to volume overload)