Complicated Adult Case Study (Internal Medicine)

Sample H&P for Complicated Patient

6/21/2020 FNP Student H&P 11:00 Note the date, time, and fact that this is a FNP-S student note are clearly labeled.

CC: Mr. Jones is a 72yo white, retired farmer, who presented to the ER because “I fainted 3 times in the last 2 days.” CC is specific, gives key pt demographics, and duration of cc. If he’d had a h/o CAD or CVA, you could include that here.

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HPI: Mr. Jones was in his usual state of health, which allows him to lead a fairly active life, until 2 days PTA when he was in the kitchen making a sandwich. At that time he felt “dizzy” and found himself on the floor. He described the dizziness as “feeling like he was going to pass out.” He doesn’t remember what happened but thinks he lost consciousness for only a few seconds to minutes. No one was home at the time to witness it. He had a headache after the episode, which he relates to hitting his head. (It has eased off with Tylenol.) Prior to losing consciousness, he did not experience a headache, chest pain, palpitations, or shortness of breath. He was not incontinent. Other than the headache, he felt fine and ate his sandwich once he “came to.”

He had a very similar episode the next day while he was sitting down watching TV. He felt like he was going to faint and then became aware that he had missed part of his show. The 3rd fainting spell occurred this morning as he was getting out of bed. He fell back onto the bed so did not hurt himself. He told his wife what happened and she insisted that he come to the ER.

The chronology is very clear and descriptions are specific. The information is presented as a story. The question ‘why seek help now’ is clearly addressed. (‘Usual state of health’ alone can be misleading if a patient is usually in poor health. Notice the brief elaboration.)

He has not started any new medicines or engaged in any new activities lately. He has not been sick including no N/V/D. He has never had chest pains or been told he has heart disease. He has had vertigo in the past but that was very different from his current “dizziness”. He has not had any change in vision, slurred speech, weakness, numbness, or tingling in the last week.

Pertinent positives and negatives are in a separate paragraph, CAN be one large paragraph

He still likes to ride his tractor and do light farming but is afraid to since these episodes started. He is also afraid to drive as it could happen then and cause an accident.

The effect of the problem on the patient’s life is addressed.


  1. COPD- smoked 2 ppd for 40 years, quit 1987.
  2. HTN- usually runs 130s/80s, per patient
  3. Pneumonia- hospitalized for 3 days in 1996 (received pneumovax then)
  4. Osteoarthritis of hips, knees, and hands
  5. Gout
  6. BPH
  7. Diverticulitis 1988- last colonoscopy 2000 w/ 2 polyps
  8. Appendectomy 1965
  9. Right inguinal hernia repair 1982

Operations can be listed separately under Past Surgical History (PSH)


  1. lisinopril 20 mg po daily, for HTN
  2. ASA 325 mg po daily, for cardioprotection
  3. Allopurinol 300mg po daily, for gout prevention
  4. Atrovent 2puffs 4 times a day, for COPD
  5. Motrin 200mg po 2-3 times a day as needed for arthritis
  6. Aleve 1-2 tabs po 2-3 times a day as needed for arthritis
  7. Tylenol arthritis 1-2 tabs po 3-4 times a day as needed for arthritis
  8. Saw palmetto 2 tabs po daily, for prostate

You are strongly encouraged to include the reason for each medication. It is also interesting to learn why patients think they are taking certain medications.

Allergies– sulfa (rash)
Adverse drug reactions- codeine (N/V)

Drug reactions are clearly separated from the true allergies.


Father killed in WWII
Mother-HTN and DM, died age 75 of heart attack Sister- 75 and healthy
Brother – 70 with heart problems and emphysema Brother- died at 68 of heart attack
Son- 47, healthy

The health of all 1st degree relatives is addressed.

SHx- Married 50 years this Oct; retired corn and tobacco farmer but still maintains about 3 acres of grazing pasture and a small vegetable garden himself; High School grad; served 1 year in Korea (Army). One son and 3 grandchildren who live nearby. He keeps 2 horses for them but doesn’t ride himself anymore. Tobacco- as above, ETOH- 2 beers/day for about 20 years but now only an occasional beer every month; no other drugs; monogamous w/ wife.

The SHx provides a clear sense of what the patient’s lifestyle is like, including activity level and support system. Habits are detailed but there is no redundancy, e.g. tobacco history was already addressed in the HPI.

ROS– Cough- chronic, mostly in the morning, productive of a small amount of white phlegm
low back pain- chronic and worse at the end of the day
nocturia- gets up 3-4 times a night, worse over past year

Given your stage of training, we want you to include everything you ask in the ROS, including the negatives. This is perfectly acceptable. This guideline is meant to reflect what an experienced clinician does in practice, so you can apply it to all stages of your career. Found in bates; but if you don’t ask about it; don’t chart it. Should be complete ROS from bates – specific to the patient you are seeing.

PE- Thin, alert, elderly white man with a purple-red nodule above the left eye who is sitting up on the stretcher breathing comfortably and appears neither acutely nor chronically ill.

General description is specific.

Vitals- T 97.8 BP 105/40, supine, 100/40; standing P 56, regular, supine; 52 standing R 22, unlabored, O2 sat- 93% (RA)

Pertinent details of the vitals are included.

Head- 3cm, tender, round, purple-red nodule above left eyebrow, skin intact, no surrounding erythema; Eyes- PERRL; fundi- limited exam secondary to hazy, brown opacities obscuring retina
Ears- both ear canals impacted w/cerumen

Nose- nares patent w/o edema or D/C
Mouth/throat- edentulous, moist mucosa w/o lesions Neck- supple, thyroid nonpalpable, no LAD
Back- spine straight w/o point tenderness, lumbar paraspinal muscles tight w/ diffuse tenderness
Lungs- hyperresonant, diminished BS throughout, I:E ratio 1:3, no wheezes or crackles CV- carotids 2+ w/o bruits, JVP 5 cm, heart bradycardic, regular S1, S2 w/ II/VI holosystolic murmur at apex radiates to axilla; rad pulses 2+, fem pulses 1+w/ rt bruit, DP 1+ left, nonpalp right
Abd- scaphoid, normoactive bowel sounds, soft, NT; liver 7 cm by percussion, spleen nonpalp, no masses or bruits
Rectal- normal sphincter tone, brown heme neg stool, large, firm prostate w/o nodules or asymmetry (per ER resident)

Sometimes certain parts of the exam that are sensitive like GU and pelvic have already been performed by the time you see the patient and the patient declines to have them repeated. In this situation, you still include any findings but note that you did not personally perform that portion of the exam. You should still ALWAYS try to perform these parts of the exam yourself with a chaperone.

Ext- clubbing, no edema, hair loss on feet to mid calf but warm w/o cyanosis, Heberden’s nodes on 2nd-5th digits of both hands, knees enlarged w/o effusion, warmth, or erythema but crepitations bilaterally, hips NT w/ FROM
Neuro- MMSE 29/30 (forgot one object), CN 2-12 intact except diminished hearing to finger rub bilaterally, BC>AC on Rinne test, sensation intact to pinprick, vibration, and light touch in all 4 ext, strength 5/5 bilaterally delts, biceps, triceps, wrist ext, hand grip, hand intr, psoas, quads, tib ant, EHL, gastroc; muscle bulk and tone normal; no pronator drift, fine motor normal, Romberg absent; coordination: FTN and HTS normal, gait slightly broad based but steady; DTRs 2+ bicep, tricep, brachrad and 1+ patella, Achilles absent; Babinski absent;

Skin- leathery w/ marked wrinkles on face and neck, multiple brown papules 1⁄2-1 cm w/ regular boarders that appear “stuck on” scattered on back, scaly erythematous macules scattered on forearms, dorsum of hands, and one on right temple and one behind left ear

Descriptions in the PE are consistently specific, vague terms are avoided.

You know exactly what the examiner did and did not perform.

(as you are the examiner)

Lab data /Diagnostic studies

Hgb- 12.5 (13.5 in 1999)
WBC- 5.0 (P50%, L40%, M10%)

glc- 168

(creat 1.0 in 1999, CO2 32 in 1999)

Ca- 8.2, Mg 2.0, PO4 3.2 U/A- trace glucose and protein, no RBC’s or WBC’s, nit. neg.

Pertinent old lab data is included.

Plts- 425,000 MCV- 70

CXR- hyperinflated lung fields with rounded opacity in RUL, decreased alveolar markings apices> bases, no cardiomegaly (formal radiology report pending).

ECG- sinus bradycardia, rate 56 w/ RBBB pattern, rt and left atrial abnormality, one ectopic beat, and 3mm Q’s in III and aVF

Problem list /Differentials

Student provides own interpretation.

The problem list is complete, prioritized, and specific w/o being redundant or too detailed. There is subjectivity to the specific prioritization, but the most urgent issues are at the beginning starting with the cc and the least urgent issues are at the end.

  1. Syncope
  2. Head trauma
  3. Possible lung mass
  4. ECG w/ RBBB, ectopy, and evidence of likely old MI
  5. COPD
  6. Microcytic anemia
  7. Hyperglycemia
  8. Renal insufficiency
  9. HTN
  10. Nocturia, recently increased w/ trace glucose and protein on U/A
  11. PVD
  12. LBP
  13. OA
  14. BPH
  15. Elevated CO2, chronic and likely secondary to CO2 retention from #5
  16. Polypharmacy


Mr. Jones is a 72yo man w/ 2d h/o syncope that is acute in onset, not positional, and is in the setting of an abnormal ECG, all of which is concerning for an arrhythmia.

There is a summary statement that reiterates the cc and key related features, followed by a definite commitment to an impression.

  1. Syncope from probable arrhythmia- cardiac etiology such as sick sinus syndrome or VT is compatible with history. Although he hasn’t had CP, he has many cardiac risk factors (age, sex, FHx, tobacco, and possible diabetes) and could have had an MI to precipitate this. More likely an MI would be old, given the lack of symptoms but an acute coronary syndrome (ACS) can’t be ruled out at this point. A neurologic process like vertebro-basilar insufficiency could cause syncope and he has evidence of vascular disease on exam. However, the lack of focal neurological signs or symptoms makes this less likely. He lacks incontinence or post-ictal confusion to suggest seizure. Finally the possible lung mass and significant tobacco history raise the possibility of lung cancer and possible CNS met. But again, lack of focal symptoms or headache preceding the fall makes this less likely. Orthostasis is a common cause of syncope in the elderly but his history and PE aren’t compatible, despite being on Hytrin.

Notice how the differential diagnosis is woven into the discussion of the assessment. Critical features of the history, PE, and lab data are noted. The amount of space devoted to the explanation of the various differentials is proportional to their relative likelihood. Unlikely diagnoses are only mentioned. Very rare possibilities are not addressed.

Check troponin, admit to tele bed, consult cardiology for possible EP study, ECHO to assess for LV dysfunction and wall motion abnormalities to suggest prior infarct (and nidus for arrhythmia), fasting lipids in AM for risk factor modification

  1. Head trauma – risk of subdural but no focal findings or headache now, consider CT or MRI if change in neuro status or cardiac w/u for syncope unrevealing
  2. Possible lung mass concerning for malignancy given the extensive smoking history and clubbing. Consider CT scan.
  3. Microcytic anemia w/ thrombocytosis suggestive of Fe deficiency anemia. Stool heme neg but GI bleed would still be most likely source particularly given multiple NSAIDS. Check Fe panel, hemocult stools, monitor Hgb, and avoid NSAIDS. If stable can w/u as outpatient. If Hgb decreases, consider EGD to eval for PUD
  4. Hyperglycemia- concerning for diabetes given recent increase in nocturia, monitor glucose, and add insulin if needed for glucose control, consider checking HgbA1c if persistently elevated glucose
  5. Renal insufficiency- unclear chronicity but new since 1999; likely multifactorial given HTN, possible diabetes and NSAIDS. Once patient weighed will calculate estimate of creat cl and renally dose drugs, maintain good BP control and cont. ACEI but will d/c NSAIDS as above
  6. COPD- clinically stable, continue Atrovent MDI
  7. HTN- well-controlled, cont. lisinopril
  8. Nocturia- likely secondary to BPH and may be exacerbated by hyperglycemia.
  9. Prostatitis possible but no tenderness on exam. No symptoms to suggest UTI. Will check U/A for glucose and signs of infection. Check postvoid residual. Cont. Hytrin for now as has tolerated in past (also may be helping maintain good BP control)
  10. BPH- possibly worsening, will make sure no urinary retention, cont. meds (except saw palmetto as nonformulary)
  11. Chronic CO2 elevation- likely compensatory secondary to chronic CO2 retention and respiratory acidosis from COPD, not acute problem but will be careful giving high levels of O2 if hypoxia develops and consider ABG.
  12. Polypharmacy- will educate about OTC’s and redundancies of NSAIDS
  13. DVT risk- he’s on bedrest so will prophylax w/ heparin 5000U SQ bid
  14. F/E/N- (fluids/electrolytes/nutrition)- he appears euvolemic so no IVF and low fat diet, consider diabetic diet if fasting glucose elevated.

The plan is listed immediately after each problem. But, it is equally correct to list all your assessments in one section and then have a separate section devoted entirely to the plan. It is a matter of personal choice. Often you will be unsure of the plan but you still should try to come up with a plan. In these cases, use the word ‘consider’. This allows you to demonstrate your thought processes without having something potentially erroneous or misleading in the medical record.

#13 and 14 are commonly included in A/P for completeness sake and so these important issues are not overlooked. Sometimes ‘status’ (DNR vs. full code) is added to the problem list. This can be misleading and look as though it is factoring into your care of the patient in a way you probably don’t intend. It should generally be avoided unless code status really is an active issue.

This plan section also includes pharm/non-pharm interventions, treatment, follow up, and your evidence based article


Patient particulars

Initials: S.K

Age: 76years

Gender: Female

Ethnicity: African American

Subjective Data

Chief complaint: difficulties in breathing

History of presenting complaint: S.K is a 76years old American female accompanied by her husband due to difficulties in breathing for three months. It has been on the gradual onset and was initially during exertion and progressed to difficulties in breathing when sleeping such that she cannot sleep throughout the night without support from the pillows. The patient reports chest pain on and off. The pain is in the central region, sharp, and radiates to the left jaw. The patient also complained of dyspnea at exertion and rest, syncope, lower limb swelling, facial puffiness, weight gain, coughing especially at night, and awareness of the heartbeat.

Past medical history: the patient has had hypertension from the age of 56years. She has had type two diabetes mellitus since the age of 48 years. She has a history of pre-eclampsia and gestational diabetes mellitus during her third and fourth pregnancies. She has had chronic bronchitis since the age of 5 years. The patient states that she had community-acquired pneumonia at the age of 60years and was hospitalized for ten days for treatment. However, she denies a history of intubation and blood transfusion.

Surgical history: the patient has a history of tonsillectomy at the age of 16years due to recurrent tonsillitis. She has a positive history of orthopedic surgery-open reduction and internal fixation of the fracture left femur.

Current medication: nifedipine 10mg PO daily, HCTZ 50mg PO once daily, metformin 500mg PO twice daily, prednisolone 40mg PO PRN, and Ventolin inhaler 200mcg 2puffs PRN.

Allergies: the patient is allergic to cotrimoxazole because she develops a rash and generalized skin itchiness. She is allergic to animal fur, hay, dust, and cold weather. These worsen the symptoms of bronchitis like coughing, sneezing, and wheezing. She relives these symptoms by taking antihistamines like cetirizine. She denies food and latex allergy.

Immunization: her childhood immunization schedule is up to date. She goes for booster vaccines on influenza, pneumococcal, tetanus, meningococcal, and covid 19. Her last tetanus vaccine was three months ago. Her last covid 19 booster vaccine was six months ago. She is yet to receive her influenza and pneumococcal vaccine.

Health maintenance: the patient goes for an annual mammogram and pap smear test. Her last mammogram two weeks ago shows billiards 1. Her last pap smear test was six months ago showing undifferentiated squamous cells. Her last optical check-up was three months ago showing a right eye cataract. Her last dental exam was six months ago and there were normal findings. She has a fire detector in her house. She uses seat belts when in the vehicle. She has support rails in her bathroom and a walking aid.

Social history: the patient is married and has six children, two sons, and four daughters. Her children liver far apart and are married with children. She lives with her husband and their domestic manager. She is a retired lecturer for 16years. Since retirement, she has been doing a large-scale vegetable farming business on her farm. She is a staunch catholic Christian and enjoys singing in the church choir and attending mass. She enjoys the company of her husband in the evening when relaxing in the backyard smoking tobacco and taking a glass of whisky at least three times a week. She takes fried fish and potatoes for lunch and steamed vegetables for dinner. She denies the use of cannabis, heroin, and cocaine.

Family history: the patient is the third born in a family of four. Her mother passed on at the age of 89years due to a heart attack, she was obese, had hypertension, and had hyperlipidemia. Her father passed on at the age of 70years due to lunch cancer, he was a chain smoker and developed the chronic obstructive pulmonary disease. Her elder brother is 87years old and living with diabetes mellitus, chronic kidney disease, and hypertension. Her 84years old sister has hypertension and stage three cervical cancer. Her 70years old sister has hyperlipidemia, hypertension, obesity, and asthma. Her sons have hypertension and asthma. Her 48years old daughter has breast cancer stage three. Her 50years old daughter has hypertension, diabetes mellitus, and acute kidney injury.

Sexual and reproductive history: the patient’s menarche was at the age of 17years. She has a regular 28days cycle with four days of moderate flow. She denies a history of dysmenorrhea and pre-menstrual syndrome. She is 20 years post-menopause. She has six children all born at term via spontaneous vertex delivery. She reports pre-eclampsia, eclampsia, and gestational diabetes during her fourth, fifth, and sixth pregnancies. She has postpartum depression and puerperal sepsis after the delivery of her first child. She denies childhood diseases in her children during the infancy period. Her first sexual encounter was at the age of 22 years. She is heterosexual and engages in vaginal and anal sex. She uses a condom during anal sex. She denies contraception use in her life because it is against her religion. She has had one partner in her life and denies a history of sexually transmitted infections.

Review of systems

General: the patient complained of fatigue and body weakness that is on and off. She denies fever, weight changes, malaise, and night sweats.

HEENT: the patient complains of a headache that is diffuse and throbbing. He denies blurring of vision, eye pain, loss of hearing, runny nose, throat pain, palatal itchiness, and neck pain.

Respiratory system: the patient presents with a cough every morning. The cough is of acute onset and productive with thick phlegm. It is occasionally associated with shortness of breath and chest tightness, especially at night such that he is unable to sleep. However, he denies wheezing and night sweats.

Gastrointestinal system: the patient denies vomiting, abdominal pain, nausea, diarrhea, reflux, heartburn, and constipation.

Genitourinary system: the patent complaints of increased urinary frequency especially at night. She has mild lower abdominal pain, vaginal itchiness, and dysuria. She denies anuria, flank pain, and hematuria.

Musculoskeletal system: The patient complains of lower back pain that is worse at the end of the day, joint pain, stiffness of the joints, and numbness. She denies muscle spasms and weakness.

Psychiatric: The patient reports extreme mood changes from sadness to happiness. She denies insomnia, anxiety, hallucinations, delirium, anxiety, and suicidal ideation.

Neurologic system: The patient denies dizziness, changes in her gait and posture, resting tremors, body weakness, facial droop, tingling sensation, and numbness.

Skin: the patient denies facial acne, increased facial and body hair distribution, skin breakout, brittle nails, and hair fall.

Endocrine: she denies heat and cold intolerance, striae, irritability, and night sweats.

Hematologic system: she denies bleeding tendencies, frequent infections, and anemia.


Objective Data

General examination: the patient is an elderly lady who is calm, alert, and oriented sitting upright in a wheelchair. She has no pallor, jaundice, cyanosis, lymphadenopathy, and finger clubbing.

Vitals: her blood pressure is 186/98mmHg, pulse rate of 56beats per minute, the temperature at 36.3 degrees Celsius, respiratory rate of 28breathes per cycle, oxygen circulation at 98% room air, and height at 160cm. weight of 60kgs, and BMI of 31.25kg/m2. Her fasting blood sugar level today was at 10mmol/l.

HEENT: The head is round, cephalic, and a-traumatic. The eyes have equal hair distribution at the eyelids and eyebrows. The surrounding skin is intact with no surrounding erythema. The pupils are bilaterally expanding and reacting to light and accommodation. The conjunctiva is pink and the sclera is white. There is a cataract in the right eye. The ear canal is shiny without trauma or impacted wax. The nasal nares are patent with no discharge. The nasal mucosa is moist with no post nasal drainage. The mouth has a moist mucosa without lesions and mass. There is no throat swelling and erythema at the tonsillar and pharynges. The neck is soft, round, and supple.

Cardiovascular system: the heart sounds S1 and S2 are present with a pansystolic murmur and mitral valve regurgitation. The patient has bradycardia with regular irregular heart sounds. The patient has rales, gallop rhythm, and displaced PMI. There is jugular venous distension at 6cm at 45degrees. The carotid pulse is present without bruits. The peripheral pulses are present, with a regularly irregular rhythm, weak and collapsing. The radial pulse and femoral pulse are present without bruits. The patient has bilateral pitting edema up to the ankle joint.

Respiratory system: the chest wall has normal skin color without mass and scars. There is a symmetrical chest expansion with breathing. The patient has a fast and labored breathing rate at rest. The vocal fremitus is symmetrical both posterior and anterior. There is a hyper-resonant percussion note over the lung fields. There is a broncho-vesicular breath sound with transmitted sounds over the lung fields. There are no rhonchi, crackles, stridor, or wheezing.

Musculoskeletal system: the back spine is straight with no point of tenderness. The lumbar paraspinal muscles are tight with no diffuse tenderness. The lower back has pitting and non-tender edema.

Abdominal examination: the abdomen is round, scaphoid, with uniform skin color, and flank fullness. There are no scars, mass, and therapeutic marks. The bowel sounds are normally active in all four quadrants. There is a tympanic percussion note. The liver span is 10cm below the coastal margin. The spleen and the kidneys are not palpable. The shifting dullness and fluid thrills are present.

Genital-urinary system: the suprapubic region is distended with no tenderness. The pubic hairs are white with equal distribution. The external genitalia is clean with no discharge and abrasions. The vaginal walls are erythematous and dry. There is no Bartholin’s cyst.

Musculoskeletal system: the patient presents with finger clubbing and edema of the lower limbs up to the ankle joint. The knee joints are swollen with increased local temperature. She has non-tender pitting edema in the lower back. She has enlarged joints of the fingers and the toes without effusion.

Neurological examination: the cranial nerves are intact. The cerebella function test is diminished because the patient has a bending gait and jerky movements. The pronator drift, finger-to-nose test, and rapid alternating action are poor because of muscle weakness and loss of coordination. On motor examination, the patient has the sensation of the pinprick intact in all the limbs. The strength is 4/5 in the biceps, triceps, and bilateral lower limb. The bulk is normal and the tone is increased in all the limbs.

Mental state examination: the patient is well kept. She is alert and oriented to time, place, and person. She is in a sad mood and has flat effects. Her speech is clear and coherent. She is easy to interview and freely opens up during the interview. She maintains eye contact and does not fidget. Her judgment and insight are intact. She denies suicidal ideation, hallucinations, and delirium.

Skin: her skin is leathery with marked wrinkles on his face and neck. She has normal hair distribution at the head and body.


The patient presents with difficulties in breathing, dyspnea on exertion, chest pain, lower limb swelling, facial puffiness, coughing at night, and syncope. She presents with, musculoskeletal and urinary symptoms. She has hypertension, diabetes, Mellitus, chronic bronchitis, and obesity. She has a family history of stroke, chronic obstructive pulmonary disease, diabetes mellitus, asthma, breast cancer, and cervical cancer. On examination, the patient has distended jugular veins, bradycardia, heart murmurs, lower limb swelling, and high fasting blood sugar.

Differential diagnosis

  1. Coronary heart disease

Coronary heart disease is a heart disease characterized by the accumulation of fat in the blood vessels and the coronary artery. It begins with plaque formation that causes vascular remodeling, then acute and luminal obstruction and diminished oxygen supply. It presents with shortness of breath, palpitations, dizziness, chest pain, jaw pain, leg swelling, weight gain, tachypnea, murmurs, gallop, and high blood pressure. Risk factors for coronary artery disease are hypertension, diabetes mellitus, obesity, and hyperlipidemia (Malakar, et al, 2019). This is the actual diagnosis because the patient presents with similar symptoms.

  1. Chronic kidney disease

Chronic kidney disease is the damage to the kidneys resulting in a low glomerular filtration rate of less than 15. CKD is more prevalent in patients more than 65years old. The presenting symptoms are peripheral edema, hypertension, pulmonary edema, fatigue, reduced exercise capacity, impaired cognitive function, and the development of cardiovascular disease (Kalantar-Zadeh, et al, 2021). Chronic kidney disease is a result of untreated high blood pressure and diabetes mellitus. Renal function test, hemoglobin levels, erythrocyte sedimentation rate, and glomerular filtration rate determines help in confirming the diagnosis.

  1. Metabolic syndrome

Metabolic syndrome is a cluster of diseases like hypertension, hyperlipidemia, diabetes mellitus, and obesity. These diseases cause the occurrence of cardiovascular events, kidney injury, and osteoarthritis. Metabolic syndrome is diagnosed in a patient with fasting blood glucose above 100, blood pressure above 135/85mmHg, BMI more than 30, and triglycerides above 150 (Dabke, et al, 2019). The metabolic syndrome causes heart failure by causing ventricular hypertrophy and accumulation of plague in the blood vessels. This progressive arterial risk cause renal and microvascular dysfunction.


Diagnostic tests

  1. Complete blood count with differentials to check the hemoglobin levels and rule out anemia.
  2. The chemistry panel checks the potassium and other electrolytes functions
  3. Thyroid function test to rule out hyperthyroidism
  4. Blood glucose hemoglobin to check the sugar control
  5. Cardiac troponin to rule out acute coronary syndrome
  6. C-reactive protein to rule out inflammatory diseases
  7. Echocardiography to check the structural function of the heart
  8. Chest X-ray to rule out COPD and chronic bronchitis
  9. Lipid function test to rule out hyperlipidemia
  10. Renal function test and glomerular filtration rate to rule out CKD

Pharmacological treatment

  1. Nifedipine 20mg PO daily for hypertension
  2. Lasix 40mg PO daily for diuresis to reduce edema
  3. Enalapril 5mg PO BID for blood pressure
  4. Sitagliptin-metformin 1tablet PO twice daily
  5. Tylenol 1g PO daily for pain
  6. Atorvastatin 80mg PO daily to reduce the accumulation of cholesterol
  7. Digoxin 0.25mg PO daily to improve the heart contraction
  8. Ventolin inhaler to prevent exacerbation of bronchitis
  9. Albuterol 90mcg/spray MDI 2puffs Q4H PRN

The patient is obese and has high blood pressure, bradycardia, and high glucose level. She has heart disease due to the complication of these diseases. Therefore, changing the treatment would help improve the quality of life by achieving the therapeutic goal. Sitagliptin-metformin is a combination of two drugs that would help control blood sugar and protect the kidneys from damage (Dawra, et al, 2019). Enalapril is an angiotensin-converting enzyme that lowers blood pressure and protects against the loss of electrolytes in the kidneys.

Non-pharmacological treatment

Lifestyle modification: stop smoking, engage in physical exercise to lose weight, reduce intake of junk foods and Then patient follow-up to prevent complications such as kidney disease, heart failure, and liver disease.


Dabke, K., Hendrick, G., & Devkota, S. (2019). The gut microbiome and metabolic syndrome. The Journal of clinical investigation129(10), 4050-4057.

Dawra, V. K., Cutler, D. L., Zhou, S., Krishna, R., Shi, H., Liang, Y., … & Sahasrabudhe, V. (2019). Assessment of the drug interaction potential of ertugliflozin with sitagliptin, metformin, glimepiride, or simvastatin in healthy subjects. Clinical pharmacology in drug development8(3), 314-325.

Kalantar-Zadeh, K., Jafar, T. H., Nitsch, D., Neuen, B. L., & Perkovic, V. (2021). Chronic kidney isease. The lancet398(10302), 786-802.

Malakar, A. K., Choudhury, D., Halder, B., Paul, P., Uddin, A., & Chakraborty, S. (2019). A review on coronary artery disease, its risk factors, and therapeutics. Journal of cellular physiology234(10), 16812-16823.


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