CKD Case CC: "I am here for a routine follow-up to manage my CKD" HPI: Patient DR is a 55-year old Native American female who has
CKD secondary to uncontrolled type-2 diabetes. She lives in a nearby Indian Reservation and sees a primary physician on the Reservation
who manages her diabetes and her other primary care concerns. She was referred to our nephrology specialty clinic for the management of
her diabetic kidney disease. Our nephrology group regularly shares information with her primary care practitioner via clinic notes (Care Plans
or SOAP notes
). She has been seeing the nephrologists at our CKD clinic for the past 5-years to manage the complications of her disease.
She has history of poor adherence to her medications but claims that she has no problems paying for her medications (i.e., no insurance
problems). At the last clinic visit 11-months ago, her CKD was categorized as Stage G3b/A2. At this clinic, she was consulted on by the
nephrology
dietician who placed her on a low sodium, low potassium, and low phosphorus diet. At today's visit she states that she has some
tingling in her fingers and has noticed her appetite has declined since the last clinic visit. She denies any nausea, vomiting, or abdominal
problems. He also complains that her energy levels have been low and has worsened since the last clinic visit. Laboratory orders were sent
to our lab for CMP, CBC, Urinalysis, bone panel, and iron indices PMH: T2D, Hypertension, Obesity, Depression, AKI (5 years ago
secondary to septic shock), Amputation of three toes (right foot), Appendectomy Social History: smokes ½ pack of cigarettes daily,
consumes a six-pack of beer on most days, denies illicit drug use Family History: Father had diabetes (died at 68 years old), Mother (alive
has
hypertension) Physical exam: +2 pitting edema of both lower extremities Allergies: No known drug allergies (NKDA) Medications History:
Medication
Indication Date last taken Enalapril 40 mg PO daily Hypertension Unknown Hydrochlorothiazide 25 mg PO daily Hypertension
Unknown Sertraline 25mg PO daily Depression Unknown Metformin ER 1000 mg PO daily Type-2 diabetes Unknown Calcium Carbonate
500 mg PO TID AC Hypocalcemia Unknown Supplements and Vitamins Nephro-vite one-tab PO daily Multivitamin Unknown Vital signs:
Date: Today 06/07/2023 4/20/2022 T (o C): 36.5 36.8 37 HR (beats per min): 87 82 78 RR (bpm): 17 14 14 BP (mmHg): 151/78 148/78
148/80 Weight (kg) 113.8 116.4 116.4 Height (cm) 168 168 168 BMI (kg/m2) 40.4 41.3 41.3 Laboratory Values: Lab Value Normal Range
Today 06/07/2023 4/20/2022 CMP Na (mEq/L) 136-145 141 144 142 K (mEq/L) 3.5-5.2 6.2 5.3 5.1 Cl (mEq/L) 98-106 105 104 104 CO2
(mEq/L) 22-28 16 19 19 BUN (mg/dL) 8-20 95 41 41 SC (mg/dL) 0.7-1.3 2.8 1.5 1.5 Calculated CrCl (ml/min) n/a 18 37 37 eGFR (ml/min/
1.73m2) > 60 19 41 41 Glucose (mg/dL) 70-100 (fasting) 164 196 196 Ca (mg/dL) 8.6-10.2 9.1 7.4 8.6 AST (unit/L) 20-48 22 25 25 ALT
(unit/L) 10-35 24 34 33 Albumin (g/dL) 3.4-5.4 4.2 3.6 3.8 CBC WBC (x 103 cells/ul) 4-10 4.6 5.1 4.2 RBC (x106 cells/ ul. 4.2-5.9 4.4 4.9 4.6
Hgb (g/dL) 12-16 10.2 11.5 11.6 Hct (%) 36-47 44 44 48 Iron Indices Transferrin saturation (%) n/a 12 25 38 Ferritin (ng/mL) n/a 500 430 480
Bone Panel
Phosphorus (mg/dL) 2.8-4.5 4.1 5.3 5.2 PTH (pg/mL) 10-54 480 280 120 Vitamin D-250H (ng/mL) 30-50 21 25 24 Urinalysis:
Urine Labs Today 06/07 /2023 4/20/2022 Protein 1+ 1+ Albumin (mg/dL) 1880 2320 Creatinine (g/dL) 11.2 10.4 Albumin-to-Creatinine Ratio
(mg/g) 167.9 223.1 RBC Neg Neg WBC Neg Neg Bacteria Neg Neg provide the following answers: 1. List 5 CKD related complications in the
patient case (one problem per table) 2. For each problem list the assessment findings based on the subjective and objective clinical findings
in this patient 3. List ONE (1) pharmacological recommendation to manage the problem (must include specific medication name, dose, route
and frequency) 4.
That is the therapeutic goal or target you are hoping to achieve with this pharmacological intervention (Hint: this will be an
objective
clinical
finding) 5. What will you monitor to show assess if your intervention is adequate (must include both the specific parameter
and frequency of monitoring recommended)

Question

mav998217 mav998217

05-05-2024
Medicine

Answered

CKD Case CC: "I am here for a routine follow-up to manage my CKD" HPI: Patient DR is a 55-year old Native American female who has
CKD secondary to uncontrolled type-2 diabetes. She lives in a nearby Indian Reservation and sees a primary physician on the Reservation
who manages her diabetes and her other primary care concerns. She was referred to our nephrology specialty clinic for the management of
her diabetic kidney disease. Our nephrology group regularly shares information with her primary care practitioner via clinic notes (Care Plans
or SOAP notes
). She has been seeing the nephrologists at our CKD clinic for the past 5-years to manage the complications of her disease.
She has history of poor adherence to her medications but claims that she has no problems paying for her medications (i.e., no insurance
problems). At the last clinic visit 11-months ago, her CKD was categorized as Stage G3b/A2. At this clinic, she was consulted on by the
nephrology
dietician who placed her on a low sodium, low potassium, and low phosphorus diet. At today's visit she states that she has some
tingling in her fingers and has noticed her appetite has declined since the last clinic visit. She denies any nausea, vomiting, or abdominal
problems. He also complains that her energy levels have been low and has worsened since the last clinic visit. Laboratory orders were sent
to our lab for CMP, CBC, Urinalysis, bone panel, and iron indices PMH: T2D, Hypertension, Obesity, Depression, AKI (5 years ago
secondary to septic shock), Amputation of three toes (right foot), Appendectomy Social History: smokes ½ pack of cigarettes daily,
consumes a six-pack of beer on most days, denies illicit drug use Family History: Father had diabetes (died at 68 years old), Mother (alive
has
hypertension) Physical exam: +2 pitting edema of both lower extremities Allergies: No known drug allergies (NKDA) Medications History:
Medication
Indication Date last taken Enalapril 40 mg PO daily Hypertension Unknown Hydrochlorothiazide 25 mg PO daily Hypertension
Unknown Sertraline 25mg PO daily Depression Unknown Metformin ER 1000 mg PO daily Type-2 diabetes Unknown Calcium Carbonate
500 mg PO TID AC Hypocalcemia Unknown Supplements and Vitamins Nephro-vite one-tab PO daily Multivitamin Unknown Vital signs:
Date: Today 06/07/2023 4/20/2022 T (o C): 36.5 36.8 37 HR (beats per min): 87 82 78 RR (bpm): 17 14 14 BP (mmHg): 151/78 148/78
148/80 Weight (kg) 113.8 116.4 116.4 Height (cm) 168 168 168 BMI (kg/m2) 40.4 41.3 41.3 Laboratory Values: Lab Value Normal Range
Today 06/07/2023 4/20/2022 CMP Na (mEq/L) 136-145 141 144 142 K (mEq/L) 3.5-5.2 6.2 5.3 5.1 Cl (mEq/L) 98-106 105 104 104 CO2
(mEq/L) 22-28 16 19 19 BUN (mg/dL) 8-20 95 41 41 SC (mg/dL) 0.7-1.3 2.8 1.5 1.5 Calculated CrCl (ml/min) n/a 18 37 37 eGFR (ml/min/
1.73m2) > 60 19 41 41 Glucose (mg/dL) 70-100 (fasting) 164 196 196 Ca (mg/dL) 8.6-10.2 9.1 7.4 8.6 AST (unit/L) 20-48 22 25 25 ALT
(unit/L) 10-35 24 34 33 Albumin (g/dL) 3.4-5.4 4.2 3.6 3.8 CBC WBC (x 103 cells/ul) 4-10 4.6 5.1 4.2 RBC (x106 cells/ ul. 4.2-5.9 4.4 4.9 4.6
Hgb (g/dL) 12-16 10.2 11.5 11.6 Hct (%) 36-47 44 44 48 Iron Indices Transferrin saturation (%) n/a 12 25 38 Ferritin (ng/mL) n/a 500 430 480
Bone Panel
Phosphorus (mg/dL) 2.8-4.5 4.1 5.3 5.2 PTH (pg/mL) 10-54 480 280 120 Vitamin D-250H (ng/mL) 30-50 21 25 24 Urinalysis:
Urine Labs Today 06/07 /2023 4/20/2022 Protein 1+ 1+ Albumin (mg/dL) 1880 2320 Creatinine (g/dL) 11.2 10.4 Albumin-to-Creatinine Ratio
(mg/g) 167.9 223.1 RBC Neg Neg WBC Neg Neg Bacteria Neg Neg provide the following answers: 1. List 5 CKD related complications in the
patient case (one problem per table) 2. For each problem list the assessment findings based on the subjective and objective clinical findings
in this patient 3. List ONE (1) pharmacological recommendation to manage the problem (must include specific medication name, dose, route
and frequency) 4.
That is the therapeutic goal or target you are hoping to achieve with this pharmacological intervention (Hint: this will be an
objective
clinical
finding) 5. What will you monitor to show assess if your intervention is adequate (must include both the specific parameter
and frequency of monitoring recommended)

Answer :

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