When working in the pre hospital environment a clinician is limited by what additional testing can be performed. While pre hospital blood testing is available to APPs this patient did not meet the criteria. It is expected that in-hospital management would involve multiple blood tests with a specific focus on kidney function however literature is conflicting as to how this is best achieved. The Glomerular filtration rate (GFR) has long been regarded the best predictor of kidney health (Hsu and Bansal, 2011, Idrees et al, 2016) however research has demonstrated it to be outperformed by other renal tests in predicting overall mortality, kidney function and cardiovascular disease mortality (Hsu and Bansal, 2011). Equally estimated GFR has been demonstrated to significantly over and under predict true GFR levels making reliable results challenging (Idrees et al, 2016). Hsu and Bansal (2011) ultimately concluded that anticipating complications and assisting management decisions represented greater importance than accurately determining a single parameter. To that effect a blood panel focusing on Urea and Electrolytes is a pertinent starting point. Measurement of the creatinine clearance rate and urea creates a comprehensive picture of kidney function while establishing sodium and potassium levels not only gives further evidence of kidney function but additionally alerts the clinician to the threat of hyponatraemia and hyperkalaemia.
Despite a working diagnosis of kidney disease it is important to not neglect other possible diagnoses. I would therefore expect a D dimer test to be performed. The D dimer test has been shown to be of the highest negative predictive value for patients with a low pre-test risk score, a category the patient falls into with a Wells score of -2 (Gurram and Pulivarthi, 2014). Additionally a chest x ray should be taken to establish the presence, or absence of, pulmonary oedema not appreciable via auscultation.