Student practice case PATIENT PRESENTATION Chief Complaint ‘My kidney doctor told me to come in’ History of Present Illness RW is a 66 year old white…

Question Student practice casePATIENT PRESENTATION Chief Complaint”My kidney doctor told me to come in” History of Present IllnessRW is a 66 year old white male who presents to the emergency department after receiving a call from his nephrologist reporting critical lab values and encouraged him to come to the ED for further work up and need for vascular access for Peritoneal Dialysis (PD)/Hemodialysis (HD). He reports he has had discussions with his nephrologist in the past for need for PD or HD soon because of his worsening CKD. RW has agreed to try PD first (for his long-term renal replacement mode) since he does have some residual renal function and does have some urine output on his own. From talking with him, he is aware of the need to do an HD bridge in the hospital until PD vascular access has been secured, and then he will go back to PD at home. RW is otherwise alert and oriented to person, place, and time.  Past Medical HistoryCKD, HTN, CAD (history of 2 cardiac stents to LAD and LCX seven years ago), gout, hyperlipidemia, COPD, restless leg syndrome Family History Mother- DM2, HTN, CAD (MI at 70 yoa); Father- Noncontributory; Children- 2 with non-contributory diseases; Brother- HTN, DM2 Social History: Tobacco/Alcohol/Substance useSmoking- quit 7 years ago after heart stents placed (smoked 1 PPD x 30 years), EtOH- social use-2 cans beer/week. No illicit drug use  Allergies: NKDA Current Medications: Aspirin 81mg PO QDAllopurinol 100mg PO TIDAmlodipine 10mg PO QDAtorvastatin 10mg PO QDCalcium Acetate 667mg PO TIDFenofibrate 135mg PO QDMetoprolol tartrate 75mg PO BIDPramipexole 0.25mg PO QHSAnoro Elipta (umeclidinium 62.5 mcg/vilanterol 25mcg) Inhale 1 puff QD  Review of Systems: General: Alert, oriented, appears his age HEENT: WNL, PEERLACardiovascular: denies any chest pain and is not currently short of breath, no murmurs or JVD, no carotid bruitsRespiratory: denies any cough or sputumGI: denies any diarrhea or constipationGU: denies any problems passing urine. Denies any kidney stones or kidney infectionsMusculoskeletal: Pt does have gout, but do not visually observe tophi or joint swelling, pain in legs at night due to restless leg syndrome, edema in lower extremities  Physical Findings:General: Well appearing, nontoxic.   HEENT: Head is atraumatic, oromucosa moist; Eyes no scleral icterusNeck: Soft, supple, no masses, trachea midlineChest/lungs: clear to auscultation bilaterallyHeart: RRR, no murmurs or gallopAbdomen: soft, no guarding or rigidity, non-tenderExtremities: no clubbing, cyanosis. 2+ edema lower extremities. No rashes.Musculoskeletal: no deformities noted, range of motion of extremity joints intact; hx of gout but no current complaints in joints/extremities, no visual tophiNeurological: awake, alert and oriented x 3 Vital Signs   Clinic Visit (3 mos ago) Clinic Visit (today) ED Wt kg 69 74 74 Temp 36.9 37 37 HR 85 82 80 RR 20 18 20 BP 136/84 144/84 148/86 SPO2 98% on room air Height 67 inPain reported as 0/10 Laboratory and Other Diagnostic Tests   Clinic Visit (3 mos ago) Clinic Visit (today) WBC [4-12 k/uL] 8.4 7 Hgb [12-16 g/dL] 9.8 7.4 Hct [36-48%] 30.5 23 Plt [140-440 k/uL] 341 219   Clinic Visit (3 mos ago) Clinic Visit (today) Glucose [70-110 mg/dL] 85 107 BUN [6-24 mg/dL] 110 166 Cr [0.6-1.3 mg/dL] 7.4 13.1 Na [134-145 mmol/L] 140 141 K [3.7-5.1 mmol/L] 4.2 5.1 Cl [96-110 mmol/L] 105 111 CO2 [22-32 mmol/L] 20 14 Calcium [8.5-10.5 mg/dL] 9 9.2 Albumin [3.5-5 g/dL] 3.1 3.2 PO4 [2.5-4.9 mg/dL] 5 9.4 Mg [1.8-2.6 mg/dL] 2.2 2 AST [10-40 u/L] 37 20 ALT [30-65 u/L] 36 29 GFR if not African American CKD-EPI [>60/ml/min1.73m2] 6.9 3.5 GFR if African American CKD-EPI [>60/ml/min1.73m2] 8 4 Iron [37-170 mcg/dL] 58 23   Ferritin [30-300 ng/mL for males, 6-115 ng/mL for females] 183 134 Transferrin saturation % [15-50] 21 20 25(OH)D [30-74 ng/mL] 22   Intact PTH [10-60 pg/mL] 400 661  Lipid panel 3 mos ago: TC 172, TG 90, HDL 50, LDL 104 Ins/Outs: -Not evaluated at outpt clinic visits, however pt reports he does have urine output and urinates ~3-4 times/day Assessment 1.  CKD patient presenting to ED with elevated BUN/SCr, PO4, K and need for vascular surgery to place PD catheter for PD access. Will bridge with temporary HD for 1-2 sessions to manage lab abnormalities initially. Once stabilized, plan for PD catheter for home PD therapy  Quiz Questions:Student Q1: What components of the “AEIOU” acronym did patient RW have that influenced the nephrologist to want to start PD/HD?  Student Q2: RW has a GFR of 3.5 ml/min/1.73m2. What category/stage of CKD does RW have?  Student Q3: What risk factors led RW to develop CKD?  Student Q4: There are CKD related lab values that look abnormal that commonly coincide with complications due to CKD. Which complications of CKD do you believe that RW is experiencing based on lab values?  Student Q5: How often should Hgb be evaluated for RW?  Student Q6: The MD would like to address RW’s anemia. RW is not on ESA therapy or IV/PO iron. He does have IV access while in the hospital having temporary HD sessions to bridge him to PD. What iron preparation and dose would be appropriate to start?   Student Q7: RW has labs of PO4=9.4, Ca=9.2, Albumin 3.2. Using his corrected calcium*, what is his Ca X PO4 product mg2/dL2)? *Corrected Calcium eqn= [(4 – albumin) x 0.8 mg/dL) + Serum Ca]  Student Q8: Relative to RW’s hyperphosphatemia and taking into account his most recent Ca x PO4 product result, what changes, if any, should be made to RW’s PO4 binding meds (calcium acetate)?  Student Q9: Which of the following medication regimens would be most appropriate to start to directly address RW’s secondary hyperparathyroidism and Vitamin D insufficiency complications?  Student Q10: What are advantages/disadvantages of switching to long term PD in this patient? Health ScienceScienceNursingPHA MISCShare Question