Subjective
MN is a 75 y/o African-American female who presents with complaints of shortness of breath, nausea, reduced urine output, fatigue and swellings in the legs as well as the ankles. The patient states that her symptoms began three days prior to her visit to the clinic and has had a decreased urine volume. Initially, the patients attributed the symptoms, especially nausea and fatigue to the side effects of the medications that she used in managing hypertension and diabetes. However, she states that the symptoms have gradually worsened and that was the reason for visiting the clinic.
Past medical history: The patient has h/o hypertension and diabetes that were diagnosed a few years ago and has osteoporosis as well.
Current medications: Lisinopril, Metformin, Ibuprofen, calcium carbonate and Enbrel.
According to Beers Criteria, the use of Metformin and Iisinopril is appropriate for type II diabetes and hypertension respectively. However, based on the patient’s age the use of Ibuprofen is inappropriate, since it may lead to internal bleeding (Radcliff et al., 2015).
Family history: MN’s mother is alive but was diagnosed with hypertension nine years ago that she manages though medications while her father died seven years ago as a result of diabetes.
Allergies: The patient has no known allergies.
Social History: A mother of three daughters and currently lives with her youngest daughter. She formerly worked as a teacher, drinks once in a while and socializes with friends especially from her book club.
Review of systems: Swellings on her feet and decreased appetite.
Objective
General: The patient is calm, well dressed and cooperative.
Vital signs: BP-160/100, T-99.3 RR-26, Wt-217lbs, Ht-5’7’’
HEENT: WNL (Within Normal Limits)
Pulmonary: Presence of minor crackles and wheezing
CV: No murmurs or gallops
Abdomen: Soft and non-tender with no distention.
Musculoskeletal: Presence of edema in the legs
Differential diagnosis
-Acute Renal Failure
-Hypertension
-Chronic Kidney disease
Based on the subjective information offered by the patient as well as the onset and the symptoms progression, the likelihood of CKD (Chronic Kidney Disease) could be ruled out. As stipulated by Lameire et al. (2013), Chronic Kidney disease does not present acute symptoms but they usually occur in a period of about three months and subsequently result to steady loss of the kidney function. Hence, Acute Renal Failure could be considered as the primary diagnosis, since the symptoms began a few days ago could not be traced over a three month period. Moreover, the use of hypertensive medications especially the ACE inhibitors such as lisinopril is usually associated with renal failure, hence increasing the likelihood of acute renal failure.
Plan
It is necessary to carry out diagnostic tests in order to verify the diagnosis. Some of the relevant diagnostic tests include; urine tests, imaging tests as well as blood test that would help in revealing elevations in the creatinine and urea level so as to assess the patient’s kidney functioning (Chawla et al., 2014). With regard to medication treatment, the patient needs to be started on furosemide (80 mg IV) and discontinue the use of ibuprofen as well as lisinopril. The patient should be monitored regularly for vital signs and the current hypertensive medications should be replaced with alternative drugs. On the other hand, the patient and her daughter who is her care giver need to be educated on the relevant lifestyle and dietary approaches such as consumption of low potassium diet and limiting the amount of phosphorous intake in order to improve her recovery (Lameire et al., 2013).
Reflection
Although, the evaluation for this patient was quite successful, there are some things that require improvements in order to correctly diagnose and offer appropriate treatment to patients in future. In regard to this, adequately preparing for the assessment is essential in future in order to ask relevant questions that could help in coming up with a correct diagnosis, since the success of this evaluation can largely be attributed to the patient’s honesty that may be unlikely in future. More importantly, I would collaborate with team members in order to seek information especially in situations where the complications may present overlapping symptoms and share information with the other members in order to come up with effective decisions.
References
Chawla, L. S., Eggers, P. W., Star, R. A., & Kimmel, P. L. (2014). Acute kidney injury and chronic kidney disease as interconnected syndromes. New England Journal of Medicine, 371(1), 58-66.
Lameire, N. H., Bagga, A., Cruz, D., De Maeseneer, J., Endre, Z., Kellum, J. A., & Vanholder, R. (2013). Acute kidney injury: an increasing global concern. The Lancet, 382(9887), 170-179.
Radcliff, S., Yue, J., Rocco, G., Aiello, S. E., Ickowicz, E., Hurd, Z., & Beers, M. H. (2015). American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, 63(11), 2227-2246.
