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Discussion

Priority Dx for Case Study

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Hi all, I am graduate student struggling with the priority dx for a case study. I REALLY want to say pt is stage 4 CKD secondary to uncontrolled DM and HTN but don't know if I can definitively say that based on the info given. There is no recent hx as pt has not been seen in 3 years so it's not like she has been followed and information compared over a time period. I guess my argument for the CKD is that pt had previously been diagnosed with 2 major causes CKD and both have been unmanaged for decades so it is realistic to say that these chronic conditions have lead renal insufficiency.

Pt was diagnosed with htn and dm type 2 in the 80's and was not med compliant due to the way the medications made her feel. This is pt's first visit with physician in 3 years. Labs from that visit are as follows: currently has GFR of 18, protein of +4, BUN 40, Creatinine 3.1, A1C of 9, glucose, phosphate of 5, elevated triglycerides in 900s and cholesterol 500s, obese, bp 175/130, R 22, HR 75. The cbc is wnl, all other labs wnl. Pt is 60 y.o AA woman, sedentary lifestyle, former smoker of 20 years, quit 5 years ago, and no alcohol use. Pt also has hx of long term NSAID for headaches and body aches which I know could be caused by the HTN but the NSAIDS could be contributing to nephropathy. We were given no other info, no head to toe assessment, no previous labs. I just wanted to see if anyone had any input as I have thought this out but am still iffy as to what takes priority - Kidneys or BP?

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    My vote is kidneys for the primary problem. Impaired kidney function can impair the RAAS system which can lead to an elevated BP and I think the impaired kidney function would be more likely to kill the patient vs the high blood pressure. You could phrase the patient problem as AKI/ CKD? as patients with stable CKD can go into an AKI when they get sick. I would also relate the the NSAID use as a related to for this problem.

    I would probably make her uncontrolled diabetes your secondary problem then HTN for order of priorities, but that is just me

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    I might consider the HTN as the priority diagnosis, as it is very high and could result in MI or stroke at any time. That is the first thing I would deal with if that patient came to see me.

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    • Experts

    I was thinking about that as well but then was wondering since she has had HTN for over 20 years a higher bp is probably more of her baseline? There are also things that could explain the high reading - anxiety over not being seen by a physician for over 2 years, maybe she walked to the appointment, or even wrong size cuff could cause a higher than normal reading. I think I would have her sit quietly for 5-10 minutes and then reassess. It seems like the lab values given are leading me to focus on renal function and then diabetes. Thank you so much for your input. It is much appreciated and I haven't ruled it out yet - just need to dig a bit deeper:)

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    • Experts

    Thanks so much for the response. The more I looked at it, the more it seems like the information given (specifically labs and nsaid use) is pushing me to focus on renal issues and then diabetes. Since she has had HTN for a few decades without any major issues, her baseline is probably a bit higher than the norm and her body has adjusted at the expense of her kidneys. I'll keep looking around though. I'm not completely confident with my reasoning quite yet:)

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    Ya... When I read the scenario, my first impression wasn't that she would stroke out. If you did some dialysis/ gentle diuresis, you would decrease her circulating volume and would likely help her bp as well

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    The hypertension has caused the kindey failure. There is no priority. Both must be managed at the same time.

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