Chief complaint (CC)
The patient complains of abnormal renal function, severe backache, swollen legs, hypertension, and shortness of breath. The backache pains are persistent for the past three years, and the pain alternate with shortness of breath.
History of the present illness (HPI)
The patient is a Hispanic American female aged 40 years. This is the first visit for the patient to a chronic disease department. The chronic kidney disease (CKD) seems to be in stage IV due to late identification and lack of management. Stage IV of CKD is exemplified by severe impairment of the kidneys, and an estimated glomerular filtration rate ranges from 15 to 29 ml/min/1.73m2 (Levey et al., 2010). Additionally, the severe backache pains first appeared three years ago were extended to the lower abdomen. Each time the patient experiences back pain she takes Tylenol, for every 4 to 6 hours, which has antipyretic and analgesic properties.
The patient is uneasy because she is developing shortness of breath, anemia, swollen legs, and abnormality in renal function. The patient had received education on the possible outcome of abnormal renal failure, shortness of breath and hypertension. After the education session, the patient found it worth to make the first visit to the chronic disease department for further medication.
Last menstrual period (LMP)
A female patient is aged 40 years, and she is the potential of getting pregnant, although her last menstrual period was seven months ago after treatment with erythropoietin. The patient menstrual periods are irregular, and she experiences severe abdominal pain before commencing of menses. During the past pregnancy and childbirth, the patient developed hypertension complications that have relation to chronic kidney disease.
The patient shows allergic reactions in non-steroidal anti-inflammatory drugs (NSAIDS) due to overuse of the painkillers. Major antibiotics and NSAIDS cause interstitial nephritis that increases the risk of kidney failure (Levey et al., 2010). Some of the NSAID that show allergic reactions are acetaminophen, ibuprofen, and naproxen. Some of the antibiotics that increase the allergic reactions are vancomycin and β-lactam penicillin. The patient has attended one session of dialysis where she developed skin changes associated with itching and discoloration. Skin-itching reduced after stopping dialysis sessions. The skin-itching is associated with blood tubing, phosphorus salts, and heparin used during dialysis (Levey et al., 2010).
Past medical history
The patient has a history of type 1 diabetes mellitus, cardiovascular disease, obesity, and hypertension for the past three years. Urine tests indicated renal complications and decreased glomerular filtration rate. The patient has undergone diabetes, hypertension, and peripheral vascular disease screening in relation to renal complications. The results indicated high possibilities of developing chronic kidney disease. Blood tests indicated a high level of creatinine and sodium salts. Additionally, there were proteins in the urine; the cardinal indicator of kidney impairment. The patient underwent hemodialysis due to iron deficiency anemia, which resulted in inflammation, and bone marrow suppression (Levey et al., 2010).
The father of the patient died at the age of 65 due to ailments relating to chronic kidney disease and diabetes. The mother is not susceptible to chronic kidney disease, but shows frequent signs of edema, muscle cramps, and slight headaches. Hypertension and diabetes are common in the family lineage of the father, hence increasing the risk of kidney disease to the offspring. Genes highly determine individual’s health because they are inherited from parents (Stevens & Levin, 2013).
According to Cash and Glass (2010), understanding family history is essential in determining preventive measures toward CKD related diseases such as hypertension and diabetes. The males in the father’s family have a higher susceptible to kidney diseases than female. Every generation there is a predominant male susceptibility hence making this a unique case. There is a high probability that the CKD is an autosomal recessive disease and only prevails in individuals that possess a pair of recessive alleles (Stevens & Levin, 2013).
The patient has undergone minor surgical procedures in order to remove renal tissues for renal biopsy. The importance of renal biopsy is to identify glomerulopathy due to frequent complaints about the abnormal renal function and type-1 diabetes (Stevens & Levin, 2013). The patient also underwent surgery during the dialysis process. Surgery increases the risk of developing hypertension, diabetes mellitus and cardiovascular diseases (Stevens & Levin, 2013).
The patient is fond of consuming high levels of stimulants such as caffeine, tobacco, and cardiovascular drugs. She lives a sedentary lifestyle with minimal exercises hence contributing toward obesity. The patient consumes much soda, alcohol and sometimes skips doctor’s appointments. She insists on taking elevators and does not limit on sugary foods.
The patient registered for a gymnasium twice a week in order to reduce her body weight. The patient decreased the intake of foods with high cholesterol for management of diabetes and cardiovascular disorders. She underwent immunization and received appropriate counseling on ways to avoid opportunistic infections such as pneumonia, hepatitis B, and influenza (Stevens & Levin, 2013). The patient undertakes a physical examination on a weekly basis, especially to identify the development of cancerous cells. She is reducing the intake of cigarettes in order to decrease the risks of contracting cardiovascular related diseases. The patient undergoes a variety of exercises due to her old age and the high risk of developing cardiovascular diseases.
The patient follows the traditional practice of consuming large quantities of food in order to reduce the risk of chronic kidney disease. The patient does not have any cultural belief that may hinder diagnosis or examination of the chronic disease. The patient families are Christians and believe that doctors treat and God heals. The spiritual concept makes the patient adhere to the doctor’s instructions and receives support from all the family members.
The patient is receiving topical creams to clear her rashes, ergocalciferol 800mg per day, levothyroxine 75 micrograms daily, aspirin 85mg per day, calcium carbonate 1000g daily and fluotetine 20mg twice per day. The patient also takes folic acid and vitamin B as supplements for normal renal functions. In order to reduce complications in diabetes and cardiovascular diseases, the patient has a high intake of oral nutritional supplements. The patient has severe complications due previous surgeries hence the need of consuming angiotensin-converting enzyme inhibitors and angiotensin II antagonists.
The patient is elderly, energetic and stressful. She has a height of 1.72meters and a weight of 88kg. The blood pressure is 137/85 mm Hg, 15 units per minute in respiratory rate, and a body temperature of 370C. The patient shows signs of uremia and other similar symptoms. The vital signs of the patient show she is at risk of hypertension and a rise in body temperature. The patient shows the difficulties in metabolizing and eliminating waste products from the body due to increased risk of renal failure. There is high retention of fluids, hence causing swollen legs. Although the patient is obese, there exist signs of poor nutritional health, brittle bones, and nerve damage.
The patient is a female, with a physical malaise of ill health. The patient’s pupils are reactive to light and equal. The auditory canals are clear and lack lesions. The patient does not suffer from lymphadenopathy and has moist mucus.
The cardiovascular system is rhythmic and has elevated levels of heart rate. The first heart sound and the subsequent sound are normal with adventitious and gallop rhythms.
The patient has excessive fluids, pleural effusion, pulmonary edema, and shortness of breath.
- The first diagnosis involves treating hypertensive chronic kidney disease. The diseases in this category receive the code I12 to code N18 according to the 2014 ICD-10-CM guidelines. The patient receives medications for hypertension in combination with management of renal failure (Cash & Glass, 2010).
- The second diagnosis involves managing hypertensive heart and chronic kidney disease. The diseases and secondary infections under the category of hypertensive heart and chronic kidney disease receive the code range of I13 to I50 (Cash & Glass, 2010).
- Different stages of chronic kidney disease, from mild to severe CKD, receive different treatments and diagnosis. Mild CKD stages get coded as N18.1 while severe CKD get coded as N18.6 (Cash & Glass, 2010).
- Diagnoses of complications that arise due to kidney transplant receive the code Z94.0. Kidney transplant complications are failure or rejection due to the differences in major histocompatibility complex in the immune system (Cash & Glass, 2010).
- Prescription. The patient will continue to use oral Tylenol after every 4 to 6 hours. Peritoneal administration of angiotensin-converting enzyme inhibitors will take place twice daily. In order to lower the cholesterol levels, the patient will consume oral statins once daily (Cash & Glass, 2010).
- Diagnostic testing. Major diagnostic tests the patient should undergo are blood tests, urine tests, imaging tests, biopsy, and dialysis.
- Program oriented education. The patient continuously attends healthy living education sessions in order to acquire knowledge that will be helpful in reduction of complications that may arise due to chronic kidney disease.
- Health promotion/maintenance needs. The patient should frequently consume supplements that will compensate iron deficiency in the blood. Appropriate counseling of the patient is essential to quit smoking and intake of stimulants in order to reduce risks of developing kidney complications.
- Cultural and lifespan considerations. The cultural setup is very supportive of management of CKD. The patient should eat traditional foods that are highly nutritious in iron and protein. The moral support of the community contributes to the healing process of the patient.
- Referrals. Referral indicators in the patient are proteinuria, hematuria, hypertension, and cardiovascular risks.
- Follow-up plans. Monitoring and follow-up will take place at least six months after the date of pre-visit and diagnosis. The follow-up will adhere to the current procedural terminology (CPT) from the American medical association. The code for evaluation and management of chronic kidney infection will be 99241 for consultations, 99363 for case management, and 50010 for the urinary system examination (Levey et al., 2010).
Cash, J. C., & Glass, C. A. (2010). Family practice guidelines (2nd ed.). New York, NY: Springer Publishing Company.
Levey, A. S., de Jong, P. E., Coresh, J., El Nahas, M., Astor, B. C., Matsushita, K.,… & Eckardt, K. U. (2010). The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report. Kidney international, 80(1), 17-28.
Stevens, P. E., & Levin, A. (2013). Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Annals of internal medicine, 158(11), 825-830.