For this assignment, discuss
what diagnostic testing you order for the evaluation of gross hematuria in a 47 year old female. Be sure to discuss the rationale for the chosen tests (what are you looking to rule in or rule out).

What pertinent questions would you ask?
What testing would you order?
Chief complaint (CC):   Gross hematuria.

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History of present illness (HPI):  47 year old woman presents with gross hematuria
Past medical history: None
Gross hematuria (ICD-10-CM-N30.40)is defined as the presence of blood in urine. Epocrates online (2018) defines gross hematuria as “urine that is visibly discolored by blood or blood clots (Epocrates online, 2018). Tilak et al (2018) defines gross hematuria as blood that is visible to the naked eye (Tilak et al., 2018). The presence of blood in urine could be significant in that it might signify the presence of more serious pathology of disease going on with the patient and might suggest the need for further testing and investigation. Urine with gross hematuria might present as reddish, dark brown or bright red color. Gross hematuria is reportedly painless. Reddish discoloration of urine might be caused by medications like ASA ,methyldopa, rifampin, or the presence of foods like beets, berries and food coloring. In women, urine can be contaminated by the presence of menstrual blood (Tilak et al., 2018).
Gross hematuria in adults can be caused by urinary tract infections (UTI), pyelonephritis, kidney stone, enlarged prostate, cancers and other malignancies, inherited disorders, kidney injuries, certain medications like anticoagulants, rifampin and penicillin, strenuous exercises, menstrual blood, food coloring and certain foods like beets, vascular aneurisms, vascular malformations, chronic renal diseases, congenital diseases, diabetes, and even hypertension. This patient is a 47 year old adult female who is still within the range of active sexual activity and menstruation as well.
Therefore some of the questions I would ask her would include but not limited to:
Does she exercise vigorously and if yes, how often does she exercise?
Is she currently menstruating? How regular is her menstrual cycle? How heavy does she bleed during her menstrual cycle?
Does she bleed after sexual intercourse?
Is she pregnant? Or could she be having a miscarriage?
What does her diet consists – Is she eating beets or artificial food coloring for instance?
What medications is she currently taking?
Family history questions would be relevant to identify congenital diseases that could be causing hematuria
Does she have a history of kidney stones?
Does she have seizures and is she on any anti-seizure medications like
What kind of work does she do? Does she work with dyes, chemicals, textiles or tyre/rubber industry?
Is she a cancer patient? Is she undergoing chemotherapy?
Is she in any kind of pain?
Is she a smoker?
Does she have any renal diseases or kidney injuries?
Does she have urinary tract infections/diseases?
Is she diabetic?
Does she have cardiac or cardiovascular diseases? Could she be hypertensive?
Could she have aneurysms?
Is she on anticoagulant medications?
Was she recently involved in a fall or trauma? Did she recently have any invasive procedure or surgery?
Does she have any psychiatric or mental health issues? And if yes, what psychiatric medications is she taking?
Did she recently undergo blood transfusion therapy?
2. What testing would you order?
Comprehensive and thorough patient history and physical examination is very important in the diagnosis of gross hematuria. Some of the tests to order for the diagnosis of gross hematuria would include:
Vital signs: to rule out fever which could affect/direct the choice and course of treatment
Urinalysis – With gross hematuria, patient is expected to have a red or dark/tea colored urine. Dip strip test could be very pertinent, The dip strip test is based on the principle of the peroxidase activity of the hemoglobin and is very sensitive that it could detect even the presence of trace red blood cells in urine. False positives could be as a result of drugs, food dyes, beets and oxalates. Dip strips is reportedly said to have a sensitivity of 100% and a 99% specificity in detecting 1-5 RBDs per high power field (HPF).

BUN, Glomerular filtration rate (GFR) and serum creatinine which will help assess the patients kidney function and the efficiency or compromise of the kidneys. It will help to rule out any renal disorders.

Urine calcium
Urine culture and sensitivity: this will help to rule out the presence of bacteremia or UTI/Cystitis. Culture and sensitivity will also help with the identification of the correct bacteria and antibiotic it is sensitive or resistant to, thus enhancing appropriate treatment with appropriate antibiotic.

PTT/INR: Coagulopathy test helps with the assessment of the hematuria and could help to rule in or out the magnitude of the hematuria (or bleeding).
Serum beta HCG test: to rule out pregnancy since pregnancy could affect the type of imaging tests that might be needed.

Some other diagnostic tests that might be required include:
Renal utrasound : which would help to rule in or rule out urolithiasis/stones and masses.

CT scan/CT urography (CTU): is said to be the most sensitive imaging test in the diagnosis of hematuria in that it identifies urolithiasis, renal masses, stenosis and abdominal aortic aneurism or might even discover incidental non-related pathology. It is important in helping rule out masses, hydronephrosis and stones as cause of hematuria.

References
Buttaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2016). Primary Care: A Collaborative Practice (5th ed.). F References
Epocrates online. (2018). Evaluation of gross hematuria Diagnostic Tests – Epocrates Online. Retrieved July 18, 2018, from https://online.epocrates.com/diseases/31623/Evaluation-of-gross-hematuria/Diagnostic-Tests
Tilak, P., Hyder, Z. Z., Moeller, A., Doran, T. J., & Patel, S. G. (2018). Evaluation and Workup of Hematuria in Adults. Physician Assistant Clinics, 3(1), 23-35. Retrieved from https://physicianassistant.theclinics.com/article/S2405-7991(17)30114-7/abstract
Florida, FL: Elsevier Publications.

 
 

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