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Tamara Binge Case Study

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Tamara Binge Case Study

Introduction

Tamara is a 53-year-old Aboriginal female with hypertension for 2 years. 7 She has
achieved optimal control of bold pressure with medication, exercise, and a healthy diet; however,
recently, she has been ill. This paper will analyze her care state, highlight the provisional
diagnosis based on her history and presentation, evaluation tests to confirm the diagnosis,
treatment plan, and education. 
Provisional Diagnosis
Based on Tamara's presentation, family, and personal history, the provisional diagnosis is
Chronic kidney disease (CKD). Tamara's presentation is consistent with Chronic kidney disease
symptoms. She has fatigue, edema of the lower limbs, skin itchiness, loss of appetite, and nausea
(Vaidya & Aeddula, 2019). Further, she complains of waking up at night more than often to
urinate; nocturia. According to Gulur, Mevcha, & Drake (2011), nocturia can result from chronic
kidney disease or fluid and solute shifts in the compartments. When they lie down in patients
with peripheral edema, the fluid shifts to the vascular system, leading to the kidneys excreting it.
Hence, during sleep, there is increased urine production.
Besides, there is presence of risk factors for susceptibility, initiation, and progression of
chronic kidney disease. According to Kakitapalli, Ampolu, Madasu, & Sai Kumar (2020), CKD's
risk factors include ethnic background, family history of kidney disease, and age, hypertension,
and smoking. From Tamara's history, she has a positive family history of a first-degree relative
with kidney disease; her father has the disease. Her mother is suspected of having died from
kidney disease. She is Aboriginal, which is a risk factor for CKD (RACGP, 2018). Also, she has
a 2-year history of hypertension and has a smoking history.
 Further tests, assessments, and examinations
An accurate diagnosis for CKD requires various tests to establish the chronicity and state
of the kidney functions.
Laboratory test Important measurements
Complete blood count Hemoglobin level, leukocyte counts, and
hematocrit level
Urine tests Albumin and protein levels
Basal metabolic panel Kidney function, electrolyte levels, and blood

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glucose levels
Urine dipstick analysis Abnormal sediments

  In CKD, anemia occurs, which causes fatigue. Leukocyte levels in CKD reduce,
implicating the immune functions and response and explaining slow healing and recovery from
the flu (Chen, Knicely, & Grams, 2019).
The basal metabolic panel measures are crucial in confirming the diagnosis. Two vital
measures for kidney functions are serum creatinine and blood urea nitrogen. Depending on the
laboratory reference range, the normal blood urea nitrogen range is 7-20mg/dl, and the normal
serum creatinine range is 45 to 90 μmol/L. Electrolytes measured include potassium, sodium,
chloride, and calcium. Depending on the laboratory reference range, the levels should lie within
the normal range. To confirm CKD, the blood urea nitrogen levels are greater than 140mg/dl,
and serum creatine is greater than 13.5mg/dl (Fraser & Blakeman, 2016). The serum calcium
levels are low, while potassium levels are elevated. Serum creatinine levels are useful in
glomerular rate estimation, a more accurate assessment of kidney function. The normal
glomerular filtration rate is greater than 90mL/min/1.73 m2 (Gounden & Ishwarlal Jialal, 2019). 
Albumin levels in urine are crucial in the diagnosis and are a marker of renal impairment.
The normal range is less than 3.5-35mg/mmol, and any level above confirms renal impairment
(RACGP, 2018). The normal range of protein urine is 150mg/day; abnormal levels indicating
chronic renal disease are greater than 300mg/day (Gounden & Ishwarlal Jialal, 2019). Urine
dipstick analysis is crucial, as the presence of abnormal sediments such as hematuria or red blood
cells casts is a marker for kidney damage (Naiker, Assounga, & Meyers, 2015). Besides, a renal
ultrasound is necessary to demonstrate the morphology of kidneys and rule out other diseases. In
CKD, the kidneys are small with a reduced cortical thickness (Gounden & Ishwarlal Jialal,
2019).
Treatment plan
The treatment plan that is effective if the CKD is in stages I to 3 involves implementing
interventions and therapies that delay CKD progression and manage and alleviate symptoms.  
First, in delaying the progression of CKD, the measure includes optimal blood pressure control
with antihypertensive. Secondly, dietary salt restriction. Her daily intake should not exceed
6g/day (RACGP, 2018). Salt restriction controls blood pressure and albumin excretion.
Glomerular filtration rate decline has been established to slow with low protein diet intake

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(Vassalotti et al., 2016). Other measures include addressing hyperlipidemia with statins,
avoidance of any drugs that cause nephrotoxicity, such as non-steroidal anti-inflammatory drugs,
and the use of nephroprotective medications to boost kidney functions (Vassalotti et al., 2016).
Statins are recommended to reduce cardiovascular events in patients at risk of developing heart
disease with CKD (RACGP, 2018). Lastly, alleviating symptoms involve treating pathological
manifestations such as anemia, electrolyte derangements, and volume overload (Vassalotti et al.,
2016). Currently, her medications include captopril and angiotensin-converting enzyme inhibitor
and hydrochlorothiazide, a thiazide diuretic. The recommended treatment regime is an
angiotensin-converting enzyme inhibitor and diuretics. A loop diuretic, frusemide, can be added
to control volume overload (Vassalotti et al., 2016).
Continued assessment and evaluations are necessary. A follow-up plan will involve:
 Regular blood pressure checks.
 Blood tests for serum creatinine and blood urea nitrogen.
 Urine analysis for albuminuria and proteinuria.
 Dose adjustment depending on the glomerular filtration rate and blood pressure levels.
Dose adjustment is necessary to avert further injury (Vassalotti et al., 2016).
These interventions are possible in the primary care setting. A referral will be done in the
following instances according to Australian guidelines (1) Stage 4 CKD, (2) GFR decline that is
sustained within 12 months, (3) persistent macroalbuminuria despite optimal treatment and
sustained high blood pressure despite optimal dosage s of at least 3 antihypertensive drugs
(RACGP, 2018).
Patient education
Lifestyle modifications are crucial in halting the progression of CKD. For Tamara, the
teachings will include encouraging consumption of a healthy diet rich in dietary fiber, fruits, and
vegetables. Salt and protein intake restriction. Dietary salt restriction helps in blood pressure
control. Depending on the level of potassium, dietary rustication may be needed. Another
important teaching for Tamara is on the various types of nephrotoxins drugs she should avoid.
Drugs such as non-steroidal anti-inflammatory drugs cause kidney injury and might implicate
their condition. Lastly, educate the client on the prescribed medications, including their benefits
in managing her condition and potential adverse effects, emphasizing medication compliance and
adherence.

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References

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Chen, T. K., Knicely, D. H., & Grams, M. E. (2019). Chronic Kidney Disease Diagnosis and
Management. JAMA, 322(13), 1294. https://doi.org/10.1001/jama.2019.14745
Fraser, S., & Blakeman, T. (2016). Chronic kidney disease: identification and management in
primary care. Pragmatic and Observational Research, Volume 7, 21–32.
https://doi.org/10.2147/por.s97310
Gounden, V., & Ishwarlal Jialal. (2019, April 3). Renal Function Tests. Retrieved from Nih.gov
website: https://www.ncbi.nlm.nih.gov/books/NBK507821/
Gulur, D. M., Mevcha, A. M., & Drake, M. J. (2011). Nocturia as a manifestation of systemic
disease. BJU International, 107(5), 702–713. https://doi.org/10.1111/j.1464-
410x.2010.09763.x
Kakitapalli, Y., Ampolu, J., Madasu, S. D., & Sai Kumar, M. L. S. (2020). Detailed Review of
Chronic Kidney Disease. Kidney Diseases, 6(2), 85–91.
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Naiker, I. P., Assounga, A. G., & Meyers, A. M. (2015). Diagnostic approach to chronic kidney
disease. South African Medical Journal, 105(3), 237–239. https://doi.org/DOI:
10.7196/samj.9414
RACGP. (2018). RACGP - Chapter 13: Chronic kidney disease prevention and management.
Retrieved January 26, 2021, from Racgp.org.au website:
https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-
guidelines/view-all-racgp-guidelines/national-guide/chapter-13-chronic-kidney-disease-
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Vaidya, S. R., & Aeddula, N. R. (2019, June 6). Chronic Renal Failure. Retrieved from Nih.gov
website: https://www.ncbi.nlm.nih.gov/books/NBK535404/
Vassalotti, J. A., Centor, R., Turner, B. J., Greer, R. C., Choi, M., & Sequist, T. D. (2016).
Practical Approach to Detection and Management of Chronic Kidney Disease for the
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