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Instructions: Respond by extending, refuting/correcting, or adding additional nuance. Response must be in current APA format, must be grammatically correct and must be at least 200 words.

Clinical Manifestations of Acute Kidney Injury
The possible types of Acute Kidney Injury as per M.r J.R clinical manifestation are perenal injury and intrinsic injury. In perenal injury, the kidney may normally be functioning, but renal perfusion linked to vomiting or diarrhea results in a decreased arterial filtration rate. Some symptoms of perenal injury include nausea, fatigue, and vomiting. And as from the presented case, M.r J.R has shown these symptoms. Besides, there are clinical manifestations of gastroenteritis and possible renal injury. These are possible signs of perenal injury type of Acute Kidney Injury. 
The intrinsic injury happens when there is injury to the kidney, resulting to loss in kidney function. A common type of intrinsic injury is acute tubular necrosis, with the usual cause such as nephrotoxic (toxic agents to the tubular cells) (Rahman, Shad & Smith, 2012). Some of these toxic agents may include medicine. They are more severe when the patient has an existing condition that increases risk of having acute kidney disease. As from the presented case, M.r J.R has been using pain-relieving medicines such Pepto-Bismol, which can be harmful if overused with existing kidney disease. Toxic medicines may limit the normal homeostatic responses to volume depletion, thus resulting in the decline of renal functions. This type of acute kidney has symptoms such as nausea and fatigue, which were presented by M.r J.R. A clinical manifestation of possible renal injury is linked to this type of acute kidney injury.
Risk Factors 
There are various risk factors for acute kidney injury. From the given case, Mr. J.R might have the following risk factors.

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Age: Mr. J.R is 73 years old, and people older than 65 years are susceptible to developing acute kidney injury; this is due to the functional deterioration of the kidney due to the aging process and a reduced renal reverse (American nurse, 2015).
Sepsis: Sepsis can be a risk factor in Mr. J.R’s case, mainly because he has infections such as diarrhea and inflammatory response during this process can lead to the adaptive response of the tubular epithelial cells, which reduces functions of the cells to minimize energy demand, and can result in reduced kidney function.
Toxic medications can also be a risk factor for kidney disease since they limit the normal homeostatic responses to volume depletion, resulting in the decline of renal functions.

Complications On Hematologic System (Coagulopathy and Anemia) and the Pathophysiologic Mechanisms Involved
In this case, hematologic system functions will reduce significantly. This is because damaged kidneys generate fewer erythropoietin (EPO), a hormone responsible for indicating bone marrow to create red blood cells. With reduced EPO, the body will make fewer red blood cells signifying less oxygen is supplied to other body tissues. Besides, chronic kidney disease can lead to low levels of nutrients such as vitamin B12 and folate to make red blood cells (Nih.gov, 2014). The case of fewer red blood cells leads to anemia. Besides, chronic kidney disease can lead to venous thromboembolism, making it easier for the body to form blood clots; this is mainly seen with kidney problems causing welling or higher levels of proteins in the urine.
Ms. P.C. Case Study Questions
Clinical Manifestations and Microscopic Examination of the Vaginal Discharge
The most possible diagnosis for Ms. P.C is a pelvic inflammatory disease. This disease mainly happens when sexually transmitted bacteria extends from the vagina and affects the uterus, fallopian tube, or ovaries. Ms. P.C has presented clinical manifestations such as abdominal pain, nausea, emesis, and vaginal discharge, which is thick, greenish-yellow in color, and very smelly; these are all symptoms of pelvic inflammatory disease (Higuera, 2019). Besides, the positive high white blood cells count in her microscopic examination of the vaginal discharge is a positive sign for pelvic inflammatory disease.
Microorganism Involved
The microorganism involved is bacteria. Greenish-yellow in color, smelly vaginal discharge, and abnormal white blood cells, as seen in the case of Ms. P.C, are signs of bacterial infection (Higuera, 2019). This bacteria travels from vagina to womb or fallopian tubes, causing an infection. Several types of bacteria can cause pelvic inflammatory disease; however, the common types are gonorrhea or chlamydia infections. They are mainly acquired during unprotected sex (Higuera, 2019). Besides, someone can get bacteria when they gets into the reproductive region when the usual barrier, which is formed by the cervix, is disrupted; this happens mostly during menstruation (Mayo clinic, 2019). As from the Ms. P.C case, she admits to having unprotected sex once in a while, and her LMP also ended three days ago. These can be one of the causes of the bacteria. 
Criteria to Recommend Hospitalization

Treatment of pelvic inflammatory disease is essential since it helps relieve acute symptoms, exterminate the current infection, or minimize the disease’s long-term effect. This as well helps in the reduction of the transmission of the infection to a sexual partner. A patient can be urgently admitted to the hospital if they have severe symptoms such as the ones shown by Ms. P.C., such as nausea and vomiting. Another factor is when the patient has signs of pelvic peritonitis.
The criteria I will use to recommend hospitalization to Ms. P.C include administering antibiotics. The first treatment line is to prescribe antibiotics immediately to Ms. P.C after receiving the lab test. The recommended antibiotics are penicillin, cefoxitin, metronidazole, ceftriaxone, and doxycycline (Das, Ronda & Trent, 2016). They help in stopping the growth of the bacteria or kills it. The patient should then be checked after three days of taking the antibiotics to monitor and ensure the treatment is working. It is also imperative to advise the patient to continue taking the antibiotics to finish the dose even if the condition improves. If the oral antibiotics do not work or in the cases of severe symptoms, the patient will continue in the hospital, where the intravenous medication will be recommended (Das, Ronda & Trent, 2016). Surgery can also be considered when the patient shows signs of scarring on the fallopian tubes. One or both of the fallopian tubes can be removed. Treating Ms. P.C’s sexual partner will also be recommended to avoid the bacteria’s reinfection. While out of the hospital, Ms. P.C will be advised to refrain from any sexual activities until the treatment is completed. 
References
Rahman, M., Shad, F., & Smith, M. (2012). Acute kidney injury: A guide to diagnosis and management. American Family Physician, 86(7), 631-639.
American nurse. (2015, July 13). American nurse: The official Journal of the American Nurses Association (ANA). American Nurse. https://www.myamericannurse.com/acute-kidney-injury/
Das, B. B., Ronda, J., & Trent, M. (2016). Pelvic inflammatory disease: improving awareness, prevention, and treatment. Infection and Drug Resistance, 9, 191–197. https://doi.org/10.2147/IDR.S91260
Higuera, V. (2019). Pelvic inflammatory disease (PID). Healthline. https://www.healthline.com/health/pelvic-inflammatory-disease-pid#risks
Mayo clinic. (2019, October 18). Iron deficiency anemia – Diagnosis and treatment – Mayo Clinic. Mayo Clinic – Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/diagnosis-treatment/drc-20355040
Nih.gov. (2014, July 16). Anemia in chronic kidney disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/anemia (Links to an external site.)

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