Diagnostic Tests for Proximal Renal Tubular Acidosis
Proximal Renal Tubular Acidosis Tests: Book Excerpts
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ANEMIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The most important thing to do initially is to examine a blood smear for red cell morphology. If the anemia is microcytic, one would consider iron deficiency or chronic blood loss. If it is microcytic, consideration should be given to pernicious anemia or folate deficiency. Further workup should include a chemistry panel, stool for occult blood, liver function tests, reticulocyte count, serum iron and iron-binding capacity, serum B
12
and folic acid, serum haptoglobin, and platelet count. If these studies are inconclusive, a hematologist should be consulted. A hematologist will perform a bone marrow examination for a more definitive diagnosis. Perhaps a liver-spleen scan, CT scan of the abdomen, or therapeutic trial of iron, B
12
, or folic acid is indicated.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
FATIGUE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
All patients should have routine laboratory studies, including CBC, sedimentation rate, chemistry panel, VDRL test, and a urinalysis including analysis for myoglobin. CPK, LDH, AST, and urine creatine and creatinine should be done to rule out muscle disease. A thyroid profile should be done to rule out hyperthyroidism. Further endocrine workup including serum cortisol will help differentiate Addison's disease and hypopituitarism. Because fatigue is associated with aldosteronism, a 24-hr urine aldosterone determination should be done.
Tests for chronic infectious disease, such as febrile agglutinins, brucellin antibody titer, heterophile antibody titer or Monospot test, sputum for AFB, and various skin tests for tuberculosis and fungi, can be done. HIV testing may be appropriate if there is a history of high-risk sexual behavior. Serial blood cultures also would be of value if there is significant fever. Tests for chronic organ failure such as BUN, creatinine, serum electrolytes, and liver function tests should be done. A workup of anemia including a workup of malabsorption syndrome may be necessary. Consequently, stool analysis for fat content as well as
d
-xylose absorption testing may be done.
A search for neoplasm will include chest x-rays, x-rays of the skull and long bones, a bone scan, an upper GI series, and small bowel follow-through as well as a barium enema and intravenous pyelogram. A muscle biopsy will help differentiate certain collagen diseases, muscular dystrophy, and trichinosis. An ANA test and serum complement to screen for collagen disease should be done. A Tensilon test may be necessary to differentiate myasthenia gravis. If a neurologic disease is suspected, referral to a neurologist would be in order. Consider EMG also. If sleep apnea is a possibility, overnight polysomnography is indicated.
If all the tests prove negative, referral to a psychiatrist would be appropriate. On the other hand, it may be appropriate to refer the patient to a psychiatrist earlier in the course of the workup. The diagnosis of chronic fatigue syndrome is sometimes made when all the diagnostic tests are negative, but whether it is truly a disease is questionable.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ACIDOSIS (DECREASED PH):
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
This should include a CBC, chemistry panel, electrolytes, arterial blood gas analysis, serum and urine ketones, lactic acid, pulmonary function tests, EKG, and consultation with a pulmonologist or nephrologist.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Fatigue:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Obtain a careful history to identify the patient’s fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern, a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that’s unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are other findings associated with psychological disorders.
Ask about related symptoms and recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and appetite or weight changes. Carefully review the patient’s medical and psychiatric history for chronic disorders that commonly produce fatigue. Ask about a family history of such disorders.
Obtain a thorough drug history, noting the use of any drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient’s risk for carbon monoxide poisoning, and inquire as to whether the patient has a carbon monoxide detector.
Observe the patient’s general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Tunnel vision [Gun barrel vision, tubular vision]:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when he first noticed a loss of peripheral vision, and have him describe the progression of vision loss. Ask him to describe in detail exactly what and how far he can see peripherally. Explore the patient’s personal and family history for ocular problems, especially progressive blindness that began at an early age.
To rule out malingering, observe the patient as he walks. A patient with severely limited peripheral vision typically bumps into objects (and may even have bruises), whereas the malingerer manages to avoid them.
If your examination findings suggest tunnel vision, refer the patient to an ophthalmologist for further evaluation.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Fatigue:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Obtain a careful history to identify the patient’s fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern, a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that’s unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are findings associated with psychological disorders.
Ask about related symptoms and any recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and any appetite or weight changes. Carefully review the patient’s medical and psychiatric history for any chronic disorders that commonly produce fatigue, and ask about a family history of such disorders.
Obtain a thorough drug history, noting use of any narcotic or drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient’s risk of carbon monoxide poisoning, and ask whether the patient has a carbon monoxide detector.
Observe the patient’s general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Tunnel vision [Gun barrel vision, tubular vision]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed a loss of peripheral vision, and have him describe the progression of vision loss. Ask him to describe in detail exactly what and how far he can see peripherally. Explore the patient’s personal and family history for ocular problems, especially progressive blindness that began at an early age.
To rule out malingering, observe the patient as he walks. A patient with severely limited peripheral vision typically bumps into objects (and may even have bruises), whereas a malingerer manages to avoid them.
If your examination findings suggest tunnel vision, refer the patient to an ophthalmologist for further evaluation.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Fatigue:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A thorough physical examination should be done to investigate findings of underlying disease. This is also an important prerequisite to satisfy the patient’s concern regarding the possibility of an organic cause if a psychiatric diagnosis is made. Particular attention should be given to the presence of pallor, cardiac arrhythmia, dyspnea, fever or other indication of infection; weight loss; lymphadenopathy; evidence of inflammatory arthritis, occult blood loss, organomegaly, or abdominal masses; neurologic signs of impaired coordination; hypertension; edema; generalized pruritus; obesity; peripheral neuropathy; goiter; dry hair or skin; hemoptysis; or pregnancy. Conduct a mental status examination to identify abnormalities in mood, intellectual function, memory, and personality. Pay special attention to assessment of symptoms of depression or anxiety, suicidal ideation, and psychomotor retardation.
Testing.
If diagnostic or patient concerns remain following the history and physical examination, a minimum battery of laboratory screening tests should be performed in the evaluation of fatigue. This should include a complete blood count with leukocyte differential, serum levels of alanine aminotransferase, total protein, albumin, globulin, alkaline phosphatase, calcium, phosphorus, glucose, blood urea nitrogen, creatinine, electrolytes, thyroid-stimulating hormone, erythrocyte sedimentation rate, and urinalysis. The choice of any further investigations should be guided by clinical assessment of the patient to confirm or exclude other causative possibilities; for example, obtain a chest x-ray study in the case of exposure to tuberculosis or a magnetic resonance imaging study of the brain if multiple sclerosis is suspected. In such cases, further investigation should be conducted according to accepted clinical standards. In particular, the use of other screening tests to diagnose CFS is not recommended in the clinical setting, but should be reserved for investigation in the setting of protocol-based research (4).
Diagnostic assessment
A. Organic and psychogenic causes. If the evaluation through history, physical examination, and laboratory studies reveals an organic or psychogenic cause, the diagnosis of “fatigue” should be replaced with a more precise etiologic diagnosis. The most common biomedical causes of fatigue are psychogenic (57%), usually depression or anxiety, and organic causes (37%) with infection representing the largest subgroup followed by cardiovascular and endocrine abnormalities. Cases of cancer and connective tissue disease first presenting as fatigue are rare at 1% each (5). In the case that environmental factors are identified that contribute to fatigue, a trial of behavior modification may eliminate the complaint. Prolonged fatigue is defined as self-reported, persistent fatigue lasting 1 month or longer.
B. Chronic fatigue syndrome. A diagnosis of CFS is made by two criteria:
(a) severe chronic fatigue of 6 months or longer duration with other known medical conditions excluded by clinical diagnosis; and (b) concurrent presence of four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain, multiple joint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep and postexertional malaise lasting more than 24 hours. The conditions must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue (4). For fatigue of undetermined cause present for 6 or more months that does not meet criteria for CFS, a diagnosis of idiopathic chronic fatigue is made.
References
1. Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ, Powell JB. Chronic fatigue in primary care: prevalence, patient characteristics, and outcome. JAMA 1988;
260(7):929–934.
2. Komaroff AL, Buchwal DS. Chronic fatigue syndrome: an update. Annu Rev Med 1998;49:1–13.
3. Godwin M, Delva D, Miller K, et al. Investigating fatigue of less than six month’s duration. Guidelines for family physicians. Can Fam Physician 1999;45:373–379.
4. Fukuda K, Strauss S, Hickie I, Sharpe MC, Dobbins JG, Komaroff AL, and the International Chronic Fatigue Syndrome Study Group. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;
121:953–959.
5. Valdini AF. Fatigue of unknown etiology—a review. Fam Pract 1985;2(1):48–53.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Anemia:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Symptoms include dyspnea on exertion, fatigue, headache, palpitations, difficulty concentrating, and tinnitus. When blood loss occurs gradually, oxygen delivery can be maintained at rest to a hemoglobin as low as 5 g/dL.
Tachycardia and a systolic flow murmur occur when hemoglobin is less than 7.5 g/dL. Pallor is found in the conjunctivae and notably in the palmar creases with hand extension (they normally flush). Press the base of the nail to observe blanching and flushing, comparing with the color of your own nailbeds. Always test for orthostatic blood pressure changes to assess acuteness of blood loss. Check stools for occult blood. Splenomegaly is found in hemolysis, pernicious anemia, liver diseases, infection, and thalassemia. In chronic anemia, there will be bounding pulses with a wide pulse pressure and a midsystolic
murmur.
Heavy menses are recognized by clots and gushing of blood with tampon removal. A family history of anemia suggests hemoglobinopathy (e.g., sickle cell anemia or thalassemia). Drug or toxin exposure suggests aplastic anemia, myelodysplasia, or G6PD hemolysis. Glossitis is seen with iron, folate, or vitamin B12 deficiency. Lymphadenopathy is seen with marrow infiltration or infection.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Fatigue:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Organic fatigue is characterized by physical weakness or exhaustion, which is exacerbated by activity and partially relieved by sleep, short duration (,2 months), unintentional weight loss of greater than 10%, and an ill appearance. Most organic causes have associated signs and symptoms, specific and few in number.
Psychological fatigue is characterized by a primary inertia to initiation of physical activity, which when undertaken, can be performed. The patient is tired all the time, but fatigue is not exacerbated by exertion or relieved by rest. A protracted course, multiple and nonspecific associated symptoms, relation to stressful life events, and an anxious or depressed appearance are other clues. The sick role response to prior minor illness can indicate likely response to the current illness.
A medical or psychiatric diagnosis can be found in over two-thirds of patients with more than one month of fatigue. Psychiatric diagnoses, especially depression, panic disorder, or somatization disorder are the most common.
A diagnostic approach that involves careful history-taking and physical examination, assiduous avoidance of early closure, and a clear orientation to the reality of the patient’s perceptions whatever the cause (i.e., never implying “It’s all in your head”), is most rewarding. The differential is wide, and identification of the unusual organic causes among the many psychophysiological ones takes great skill.
| Sign | Sensitivity | Specificity | Likelihood Ratio |
| Hypothyroidism |
| Coarse skin | 29 | 95 | 5.6 |
| Cool dry skin | 16 | 97 | 4.7 |
| Periorbital puffiness | 53 | 81 | 2.8 |
| Enlarged thyroid | 46 | 84 | 2.8 |
| Lateral eyebrow hair loss | 29 | 85 | 1.9 |
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Fatigue:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin your physical assessment by observing the patient’s general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation. Then, take your patient’s vital signs and perform a complete physical examination.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Fatigue:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
When childcomplains of fatigue, history and physical exam are often diagnostic.CBC can screen for anemia.Monospot test can confirm diagnosisof infectious mononucleosis, but if result is negative, Epstein-Barrvirus IgG and IgM antibodies can be performed.Psychosocial history is most importantdiagnostic tool for psychologic problems.If diagnosis remains uncertain, initialscreening investigations for chronic disease include sedimentationrate; stool guaiac; serum electrolytes, glucose, creatinine, aminotransferases;blood urea nitrogen; UA; chest radiography; and intermediate-strengthtuberculin skin test.Other investigations depend on suspecteddiagnosis and results of these tests.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Pallor (Anemia):
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Completehistory and physical exam including family history should be performed. Ageof child, severity of illness, type of onset (acute or chronic),and presence of associated physical findings (e.g., jaundice, hepatosplenomegaly,splenomegaly, purpura, and visible bleeding) are important diagnosticfeatures in patients who have anemia.This information combined with CBCand differential, MCV, analysis of blood smear, and reticulocytecount usually permits specific diagnosis to be reached.Other useful tests are Coombs testand Hgb electrophoresis. In some cases, bone marrow exam may berequired. Age
Most commoncauses of anemia in neonates are blood loss (placenta previa, abruptio placenta,fetomaternal transfusion, twin-to-twin transfusion, birth trauma,GI bleeding, repeated phlebotomy) and hemolysis (ABO incompatibility,Rh incompatibility, disseminated intravascular coagulation, hereditaryspherocytosis, G6PD deficiency).Hemolysis is most common cause of anemiain infants 1–3 mos of age, whereas iron deficiency anemiais most common cause in infants 6–24 mos of age. At 2–6yrs of age, infection, drug intake, and neoplasia are frequent causesof anemia. Chronic disease is common cause in school-aged children. Mostcommon cause of anemia in adolescence is iron deficiency due toinadequate diet and rapid growth. Severity of Illness
Most important first step is to assess severityof illness. For anyone with hypovolemia from blood loss or cardiacfailure from severe anemia, immediate treatment is mandatory.
Type of Onset
Whetheronset of illness is acute or chronic is important in diagnosis.Physical exam determines whether child is acutely ill.When child is stable, thorough investigationof cause of anemia can be conducted. Degree of pallor and thus degreeof anemia can be roughly assessed by examining mucosal surfacesand palmar creases. Individuals with slow or insidious onset maypresent with pallor, gradual change in activity, tachycardia, splenomegaly,hepatomegaly, or lymphadenopathy.Most likely mechanisms that produceslow chronic course are decrease in red cell production or chronicblood loss. Associated Physical Findings
Purpuraor easy bruising signifies involvement of other types of blood cellsin addition to red cells.Fever, lymphadenopathy, and hepatosplenomegalysuggest infection or neoplasia.Jaundice suggests active hemolysisdue to hemolytic disorder. Lab Tests
Complete Blood Count
CBC, including platelet count, provides crucialinformation about all blood cell lines (e.g., presence of pancytopeniasuggests leukemia or aplastic anemia).
Mean Corpuscular Volume
Measurement of MCV, which varies with ageand gender, is useful in the classification of anemias [seeDallman and Simes (1979) for normal values of mean corpuscular volume].Low MCV signifies microcytic anemia, whereas high MCV (101–160fL) signifies macrocytic anemia. Table45.2 lists common causes of anemia based on values ofMCV.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Fatigue:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Obtain a careful history to identify the patient's fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern, a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that's unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are other findings associated with psychological disorders.
Ask about related symptoms and recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and appetite or weight changes. Carefully review the patient's medical and psychiatric history for chronic disorders that commonly produce fatigue. Ask about a family history of such disorders.
Obtain a thorough drug history, noting the use of any drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient's risk of carbon monoxide poisoning, and inquire as to whether the patient has a carbon monoxide detector in the home.
Observe the patient's general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Tunnel vision [Gun barrel vision, tubular vision]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed a loss of peripheral vision, and have him describe the progression of vision loss. Ask him to describe in detail exactly what and how far he can see peripherally. Explore the patient's personal and family history for ocular problems, especially progressive blindness that began at an early age.
To rule out malingering, observe the patient as he walks. A patient with severely limited peripheral vision typically bumps into objects (and may even have bruises), whereas the malingerer manages to avoid them.
If your examination findings suggest tunnel vision, refer the patient to an ophthalmologist for further evaluation.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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