CC: Diabetes, kidney recheck
Jana Jenkins is an 89 yr old female returning to the clinic for recheck of her kidneys. Three months ago, she was hospitalized due to acute kidney injury (AKI) that was felt to be related to use of trimethoprim/sulfamethoxazole for a urinary tract infection. The medication was stopped, she was given IV fluids, and her kidney function improved but not quite to her baseline. She states that she is still worried about her kidneys. She would like her kidney function checked today. She also notes that she needs her diabetes check up. She states she has followed her glucoses once per day and they have been 120-200 in the morning. She states she stopped taking her metformin “awhile” ago. She felt like it might hurt her kidneys and her daughter-in-law told her she shouldn’t take it. She states she has been checking her feet daily and she doesn’t have any ulcers.
Past Medical History
Past Surgical History
Hysterectomy at age 35
Lisinopril 20 mg daily
Famotidine 20 mg daily
Metformin 500 mg BID
Trimethoprim/Sulfamethoxazole – intolerance, caused acute kidney injury
Constitutional: – fevers, chills
HEENT: No changes in vision, no ear drainage, no sore throat.
Cardiovascular: No chest pain, palpitations. No edema.
Respiratory: No shortness of breath or cough.
GI: No n/v/abd pain.
GU: No dysuria, difficulty voiding. No hematuria.
Integumentary: No rashes, wounds.
Neuro: – HA, dizziness.
MS: No red or swollen joints.
Endocrine: No polyuria, polydipsia, polyphagia.
VS: T 97.6 P 72 R 18 BP 125/72 O2 sat 99% RA
General: Healthy appearing 89 yo woman, appears younger than her stated age. Reliable historian.
HEENT: Nose without drainage. Mouth with moist mucous membranes. Normal dentition. Posterior oropharynx pink and moist.
Cardiovascular: S1S2 normal. No murmurs, rubs, or gallops.
Respiratory: Lungs clear to auscultation. Respirations even and unlabored.
Skin: No rashes on exposed skin.
Neuro: No focal deficits. Protective sensation present in 7/10 right foot, 8/10 left foot – completed with monofilament.
MS: No red or swollen joints. Enlarged DIP and PIP joints bilaterally.
Extremities: No edema, DP 2+ bilaterally. Thickened bilateral great toenails. No fissures, calluses, skin cracks. Hair on bilateral feet, no Charcot deformities.
Labs/Diagnostics (done just prior to this appointment)
Baseline 0.9 – 1.0
A1C 8.2 (average glucose 189)
Unfortunately, Jana does continue to have a decreased eGFR so she may have Chronic Kidney Disease (CKD). After discussion with nephrology, you have ordered additional tests to confirm the diagnosis.
What would be the best diabetes regimen for this patient given that her A1C is elevated and she has a possible new diagnosis of CKD?
a) Restart metformin.
b) Insulin glargine, insulin aspart
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