Question: A 65-year-old woman with diabetes and chronic kidney disease (CKD) stage 4 presents to the clinic with complaints of excessive fatigue and dyspnea on exertion, which are new for her.

Case Study:

Patient Presentation: A 65-year-old woman with diabetes and chronic kidney disease (CKD) stage 4 presents to the clinic with complaints of excessive fatigue and dyspnea on exertion, which are new for her. She has a history of congestive heart failure with reduced ejection fraction and worsening renal function in the past year. Her CHF and CKD have been adequately managed and no evidence of worsening heart failure, acute illness, or deteriorating renal function is found. She has no history of bleeding or other causes of anemia. She reports taking her medications regularly, which include lisinopril, carvedilol, furosemide, spironolactone, metformin, and iron supplements. She has no known drug allergies. She has been hospitalized twice in the past year for acute decompensated heart failure, requiring intravenous diuretics and inotropic support. Her last hospitalization was six months ago. Her family history is significant for diabetes and hypertension in both parents, who died of myocardial infarction in their 70s. She has two siblings who are alive and well. She is a retired nurse who lives alone in a senior apartment complex. She does not smoke or drink alcohol. She has no history of illicit drug use. She has a regular nephrologist and cardiologist who follow her closely. She underwent coronary artery bypass grafting 10 years ago and had a pacemaker implanted for sick sinus syndrome five years ago. She denies any chest pain, palpitations, syncope, or edema. She follows a low-sodium and low-potassium diet and weighs herself daily. She has no pets or recent travel history.
Physical Examination: General Appearance: The patient is a 65-year-old female who appears chronologically appropriate for her age. She is alert and oriented to time, place, and person, but appears fatigued.
Vital Signs: Temperature 98.7°F, pulse rate 102 beats per minute, respirations 28 breaths per minute, and blood pressure 138/72 mmHg. Height: 5 foot 6 inches. Weight: 165 pounds. BMI: 26.6.
HEENT: Head is atraumatic. Eyes are anicteric, and there is mild conjunctival pallor. No scleral icterus. Ears are clear bilaterally. Nasal passages are patent and clear. Oral cavities show moist mucous membranes without any lesions or petechiae.
Neck: Supple with no cervical lymphadenopathy or thyromegaly. Jugular venous distention is observed. Carotid pulses are equal bilaterally with no bruits.
Cardiovascular: Apical pulse is 102. Heart rhythm is regular, S1, S2, & S3 no S4. Pedal pulses are palpable +1 bilaterally and radial pulses +2 bilaterally.
Pulmonary: Respiratory rate is mildly elevated. Breath sounds are clear to auscultation bilaterally, except for some fine rales in the bases bilaterally, no rhonchi or wheezing noted. No signs of respiratory distress.
Gastrointestinal: Abdomen is soft, non-distended, and non-tender. No hepatosplenomegaly or ascites is appreciated. Normal bowel sounds are present in all four quadrants.
Extremities: There is no cyanosis, clubbing in the extremities. There is +1 pitting edema bilaterally to mid anterior LEs. Capillary refill time is less than 2 seconds in fingernails.
Skin: The patient appears slightly pale, but the skin is warm and dry to touch. No rashes, lesions, or ulcers are noted.
Neurological: Cranial nerves II-XII are grossly intact. Strength is 5/5 in all extremities. The sensation of light touch and proprioception is intact. Patellar and Achilles reflexes are 2+ and symmetrical. No signs of cerebellar dysfunction. No restlessness noted.
Investigations: A complete blood count (CBC) reveals a hemoglobin level of 9.5 g/dL and a hematocrit of 29%, which are significantly lower than her previous values of 11 to 13 g/dL and 33 to 39%, respectively. Other laboratory tests show a serum creatinine of 2.8 mg/dL, a blood urea nitrogen of 48 mg/dL, a serum ferritin of 150 ng/mL, and a transferrin saturation of 20%.

Case Study Questions:

Create a Problem list for this patient. What is the priority diagnosis?
Based on the information provided, what are the key features that support your diagnosis?
What are the possible differential diagnoses diagnosis list and rationales for excluding or including the diagnosis for the patient's condition based on her history and physical examination findings?
What additional laboratory tests or diagnostic procedures would you consider ordering for this patient?
What treatment would you prescribe for this patient? Be detailed in your plan for this patient and include traditional and complimentary options for this patient. Write out any prescriptions exactly as you would write them on a prescription pad or call in the prescription to a pharmacy. If you have additional orders write those out as well.
Provide your recommendations for follow-up.
What educational topics would you provide for this patient
Describe your plan for monitoring the patient’s lab or diagnostic procedures ordered.