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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,

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