19 Sep Update the supporting evidence for the assessment problems and include a plan and rationale for EACH problem in the plan. Using the Global AKI Guidelines? A

Name: Denise Fields	DOB: 5/9/1985	Date: 11/20/23

Chief Compliant

“I’m here to follow up on the results of my labs”

History of Present Illness

A 38-year-old woman with type 2 diabetes mellitus (T2DM), hypertension (HTN), and dyslipidemia returns to her primary care physician (PCP) for a follow-up visit. At her routine physical examination 3 months ago, her annual nephropathy screening revealed a urine albumin-to-creatinine ratio (UACR) of 659 mg/g, which was elevated from the previous year’s screening that showed a mildly increased UACR of 145 mg/g and an SCr of 1.2 mg/dL. A second spot urine test from 1 week ago showed a persistently elevated UACR of 673 mg/g. She has returned to the office today to review her lab results and presents with no complaints. She brought with her a list of her medications and self-monitoring blood glucose readings.

Past Medical History

Medical Conditions: T2DM x 8 years, HTN x 6 years, Dyslipidemia x 5 years, seasonal allergies

Medications

Metformin 1000 mg PO twice daily

Semaglutide 0.5 mg mh injected subcutaneously once weekly

Hydrochlorothiazide 25 mg PO once daily

Atorvastatin 20 mg PO once daily

Mometasone 100 mcg two sprays in each nostril once daily prn allergies

Cetirizine 10 mg PO once daily prn allergies

Naproxen 220 mg PO twice daily prn headaches

Multivitamin PO once daily

Allergies

Seasonal: grass and pollen

Drug: NKDA

Family History

Mother: alive at age 62, has HTN and dyslipidemia

Father: passed at age 50 secondary to myocardial infarctions, had T2DM and CVD

Brother: alive at age 31, has T2DM

Social History

Education: high school graduate

Employment status: full time administrative assistant

Marital Status: married to husband, no children

Smoking Status: current 1 PPD smoker, decreased from last year (2 PPD)

Illicit Drugs: denies

ETOH: occasional consumption on weekends or when out with friends (1-2 beverages/week)

Review of Systems

Eyes: no vision changes

Cardiovascular: no chest pain or palpitations

Respiratory: no shortness of breath

Gastrointestinal: no polydipsia or polyphagia

Genitourinary: no polyuria

Musculoskeletal: no edema

Neurological: occasional headaches, generally associated with menstruation, no dizziness, fatigue, or sensory loss

Physical Examination

Constitutional: no acute distress

Neck/lymph nodes: supple without adenopathy or thyromegaly

HEENT: PEERLA, EOMI, negative for diabetic retinopathy; no retinal edema or vitreous hemorrhage; TMs intact; oral mucosa moist with no lesions

Cardiovascular: heart sounds normal, no murmurs, no bruits

Respiratory: clear, breath sounds normal

Gastrointestinal: soft NT/ND

Genitourinary: rectal exam deferred; recent PAP smear negative

Musculoskeletal: no CCE, normal ROM

Neurological: A&O x 3, CNs intact, normal DTRs

Skin: warm, dry, no rashes

Vitals 1

Height: 5 ft. 6 in. Weight: 191 lbs. BMI: 30.8 Systolic1: 148 Diastolic1: 84 Systolic2: 146 Diastolic2: 82 Pulse: 82 Resp:18 Temp: 37.5C O2SAT: 98%

Lab Reports (collected 1 week ago)

BMP LAB REPORT

Test Name	Patient Results	Reference Range	Unit
SODIUM	140	135 – 145	MEQ/L
POTASSIUM	3.9	3.5 – 5	MEQ/L
CHLORIDE	107	98 – 106	MEQ/L
CO2	26	22 -28	MEQ/L
BUN	29	8 – 20	MG/DL
CREATININE	1.6	0.6 – 1.2	MG/DL
GLUCOSE	196	65 – 99	MG/DL
CALCIUM	9.4	8.6 – 10.2	MG/DL
PHOSPHORUS	2.7	2.8 – 4.5	MG/DL

ESTIMATED GLOMERULAR FILTRATION RATE LAB REPORT

Test Name	Patient Results	Reference Range	Unit
eGFR	46.4	> 90	mL/min/1.73m2

CBC LAB REPORT

Test Name	Patient Results	Reference Range	Unit
WBC	9,500	4,000-10,000	cells/μL
HGB	12.2	12-17	g/dL
HCT	36.1%	36-51	%
MVC	79	79-97	fL
PLATELETS	148,000	150,000-400,000	cells/μL

HbA1C LAB REPORT

Test Name	Patient Results	Reference Range	Unit
HBA1C	8.2	<5.7	%

PREGNANCY TEST LAB REPORT

Test Name	Patient Results	Reference Range	Unit
HCG, qualitative	NEGATIVE	NEGATIVE

LIPID PANEL LAB REPORT

Test Name	Patient Results	Reference Range	Unit
TOTAL CHOLESTEROL	212	100 – 199	MG/DL
LDL, DIRECT	149	0 – 99	MG/DL
HDL	42	>39	MG/DL
TRIGLYCERIDES	149	0 – 149	MG/DL

UA LAB REPORT

Test Name	Patient Results	Reference Range	Unit
pH	5.2	5 – 7.5
SPECIFIC GRAVITY	1.020	1.001-1.029
URINE COLOR	YELLOW	YELLOW
APPEARANCE	CLEAR	CLEAR
PROTEIN	325	< 20	mg/dL
GLUCOSE	1+ GLUCOSE	NEGATIVE
KETONES	NEGATIVE	NEGATIVE
BLOOD	NEGATIVE	NEGATIVE
LEUKOCYTE ESTERASE	NEGATIVE	NEGATIVE
NITRITE	NEGATIVE	NEGATIVE
BILIRUBIN	NEGATIVE	NEGATIVE
UROBILINOGEN	0.2	0.2 – 1	mg/dL
WBC	3-4	0 – 5	hpf
RBC	0	0 – 2	hpf
EPITHELIAL CELLS	0	0 – 10	hpf
CASTS	NONE SEEN	NONE SEEN
BACTERIA	NONE SEEN	NONE SEEN

MICROALBUMIN TO CREATINE RATIO LAB REPORT

Test Name	Patient Results	Reference Range	Unit
MACR	673	< 30	MG/G

URIC ACID LAB REPORT

Test Name	Patient Results	Reference Range	Unit
URIC ACID	6.2	2.3 – 7	MG/DL

ALBUMIN LAB REPORT

Test Name	Patient Results	Reference Range	Unit
ALBUMIN	3.4	3.5 – 5.5	G/DL

Assessment

1. CKD with albuminuria (G3bA3) with inappropriate medication dosing

Supporting Evidence:

Subjective: patient does not report any complaints

Objective: worsening of SCr to 1.6 from 1.2 a year ago, eGFR of 42 mL/min (stage 3 CKD), MACR/UACR 673 up from 659 3 months ago and 145 1 year ago, CrCl = 53 mL/min

(ActualBW = 87 kg, IBW = 59.3 kg, AdjBW = 70.4 kg)

Non-pharmacologic options:

A. remove nephrotoxic agents

B. Dietary recommendations

– diet high in vegetables, fruit, whole grain, fiber, plant based proteins, unsaturated fats and nuts; low in processed meats, refined carbohydrates, and sweetened beverages

– dietary protein should be 0.8g/kg daily

– restrict sodium to < 2000 mg/day

C. Weight reduction

D. Physical exercise

E. Smoking cessation

Pharmacologic options:

A. Blood pressure management: the patient is currently above goal of < 130/80 on HCTZ therapy

Hydrochlorothiazide (current therapy)

Pros: currently tolerating therapy, efficacy with CrCl > 25-30 mL/min, first line therapy for HTN

Cons: electrolyte disturbances

ACE inhibitor (lisinopril)

Pros: slows the progression of kidney disease, first line in patients with CKD and diabetes with albuminuria

Cons: may increase SCr if not stable (AKI risk), cough, hyperkalemia, angioedema risk

ARB (losartan)

Pros: slows the progression of kidney disease,