Olivia Engle

Endocrinology Standardized Case Study

FNP 4

June 5, 2022

Assessment:

1. Chronic Kidney Disease: Chronic kidney disease is defined as the loss of functioning nephrons in
the kidney eventually leading to renal failure. Chronic kidney disease can be staged in five
different stages with stage one being decreased renal reserve and stage five being end stage or
kidney failure (Dunphy et. al, 2019). There can be multiple causes of kidney disease including
diabetic nephropathy, hypertensive nephropathy, and glomerulonephritis. Diagnosis of CKD is
based on the patient’s glomerular filtration rate (GFR) and presence of proteinuria (Dunphy et.
al, 2019). Because this patient has existing diabetes that is not controlled (evidenced by HgA1C
of 8.2%) and a BMI greater than 30, chronic kidney disease is a likely diagnosis. A GFR should be
taken to help further stage the patient’s disease.
2. Metabolic Syndrome: Metabolic syndrome is a group of risk factors that put the patient at
greater risk for cardiovascular disease, stroke, diabetes, and overall mortality. Diagnostic criteria
for metabolic syndrome include three or more of the following: central obesity, elevated fasting
triglycerides, low HDL, elevated blood pressure, and elevated fasting blood glucose levels
(Dunphy et. al, 2019). The patient in this study has a BMI greater than 32, but an unknown waist
circumference. He has a blood pressure of 140/94 and is being treated for hyperglycemia. To
properly diagnose metabolic syndrome, lipid levels would need to be taken. Metabolic
syndrome may also be associated with microalbuminuria such as the patient in this study (Li et.
al, 2016).
3. Essential Hypertension: essential hypertension occurs when the patient has high blood pressure
with no identifiable etiology. The pathophysiology is not fully understood, though there are
many factors involved including genetic, environmental, diet and lifestyle factors in addition to a
dysfunction of the arterial endothelium (Dunphy et. al, 2019). Diagnosis of hypertension is based
on patient’s history and physical as well as blood pressure measurements taken in office.
Hypertension stage 1 includes a systolic blood pressure from 130-139 or diastolic from 80-89
and hypertension stage 2 includes systolic blood pressure greater than or equal to 140 and
diastolic greater than or equal to 90. One result of hypertension can be proteinuria, which the
patient in this study has. To diagnose essential hypertension, the patient must have an average
at least two seat blood pressure measurements on at least to visits that are great than 80
diastolic or 130 systolic (Dunphy et. al, 2019).
4. Secondary Hypertension: secondary hypertension is when patient’s blood pressure is elevated
due to an existing condition. Patients can be diagnosed with secondary hypertension with
assessment findings including age of onset less than 30 years or older than 50 years, blood
pressure that is higher than 180/110 at diagnosis, renal insufficiency, or target organ damage at
diagnosis (Dunphy et. al, 2019). While this patient is over 50 years old and does have indicators
of renal insufficiency, his blood pressure is not extremely elevated, and he has no other signs of
target organ damage.
Plan:

1. This patient should have labs taken including complete blood count, basic metabolic panel,
glomerular filtration rate and lipid levels. These will help to further determine the patient’s
kidney and cardiovascular function (Dunphy et. al, 2019).
2. Start patient on lisinopril to treat his high blood pressure. Starting dose of lisinopril is 10 mg by
mouth daily. Cost of generic lisinopril is around six dollars per month for the patient. Per the JNC
8 guidelines, diabetic patients with CKD, regardless of race, should be started on an ace inhibitor
or angiotensin II receptor blocker (Kovell et. al, 2015). According to Woo & Robinson (2020),
starting a diabetic patient with proteinuria on an ace inhibitor can slow the process of
nephropathy. ACEIs interact with lithium as they can increase serum levels and lead to toxicity.
Goal blood pressure for diabetic patients with CKD is no higher than 130/80 (Dunphy et al,
2019). Adverse reactions associated with ace inhibitors include hypotension and more severe
reactions of angioedema and renal failure (Woo & Robinson, 2020). Patients should be advised
to change positions slowly and avoid exercising in hot weather to avoid hypotension.
3. Because patient’s HgA1C continues to be elevated above 7% despite treatment with metformin,
in addition to microalbuminuria and elevated blood glucose levels, an additional antidiabetic
medication should be added. A SGLT2 inhibitor such as canagliflozin (Invokana) could be added
to the patient’s current regimen in addition to the current metformin dose. According to the
ADA guidelines, these types of medications are recommended for diabetic patients with
indications of possible kidney disease, such as the patient in this case study, and may even slow
progression of kidney disease (Woo & Robinson, 2020). Cost of canagliflozin is based on the
patient’s insurance, and with Medicare the patient will pay between zero and fifty dollars per
month. Out of pocket, the cost of canagliflozin is around five hundred dollars per month. The
initial dose of canagliflozin should be 100 mg once daily and can be increased to 300 mg once
daily as tolerated (Woo & Robinson, 2020). The only drug interaction for SGLT2 inhibitors are
sulfonylureas as SGLT2 inhibitors may increase the hypoglycemic affects of sulfonylureas (Woo
& Robinson, 2020). The most common adverse drug reactions related to SGLT2 inhibitors are
urinary tract infections, increased urination, and genital fungal infections. Once the patient is
stable on the Jardiance, a combination pill such as Invokamet (metformin and canagliflozin) can
be started.
4. This patient should follow up in three months to reassess his blood pressure and HgbA1C to
check for effectiveness of medications. Goals for blood pressure are no higher than 130/80 and
a HgA1C less than 7% (Dunphy et. al, 2019). If these goals are not met, then medication doses
may be increased at this time.
5. This patient should be referred to an ophthalmologist as a common complication of diabetes is
retinopathy. If the patient’s eye exam is normal, then they can follow up with the
ophthalmologist every two years (Dunphy et. al, 2019)
6. Patient should be referred to a podiatrist. Based on the patient’s foot exam, he is experiencing
some signs of neuropathy. It is recommended that diabetic patient’s see a podiatrist as least
once a year for a full examination of their feet.
Education:

1. Patient should be advised to monitor his blood glucose levels at home and this includes fasting
and post meal blood glucose levels (Woo & Robinson, 2020).
2. Patient should be educated on wearing shoes that fit properly and checking his feet every day
for open areas or wounds.
3. This patient should also be educated on lifestyle modifications. Because of his BMI that is
greater than 30, this patient should be educated on exercise and diet modifications. This patient
should be advised to get at least 60 minutes of exercise at least 3 days a week. Additionally, he
should monitor his caloric intake and should be educated on a diabetic diet. Both diet and
exercise can help to obtain better glycemic control (Davies et. al, 2018). This patient may benefit
from seeing a diabetes educator and dietician.
 References

Davies, M. J., D’Alessio, D. A., Fradkin, J., Kernan, W. N., Mathieu, C., Mingrone, G., ... & Buse, J. B.
(2018). Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the
American Diabetes Association (ADA) and the European Association for the Study of Diabetes
(EASD). Diabetes care, 41(12), 2669-2701.

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019) Primary care; The art and
science of advanced nursing (5th ed). Philadelphia: F.A. Davis Company.

Kovell, L.C., Ahmed, H.M., Misra, S., Whelton, S.P., Prokopowicz, G.P., Blumenthal, R.S., McEvoy, J.W.
(2015). US Hypertension Management Guidelines: A review of the recent past and
recommendations for the future. Journal of the American Heart Associations, 4(12).
https://doi.org/10.1161/jaha.115.002315

Li, X. H., Lin, H. Y., Wang, S. H., Guan, L. Y., & Wang, Y. B. (2016). Association of microalbuminuria with
metabolic syndrome among aged population. BioMed research international, 2016.

Woo, T.M. & Robinson, M.V. (2020). Pharmacotherapeutics for Advanced Practice Nurse
Prescribers, (5th ed.). Philadelphia, PA: F.A. Davis.