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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify medication-related problems in a patient with end-stage kidney disease maintained on chronic hemodialysis.

  • State the desired therapeutic outcomes of each problem.

  • List therapeutic alternatives for managing each problem.

  • Develop a plan for managing each problem that includes plans for monitoring patient response to interventions.

  • Outline a plan for helping the patient understand and effectively implement medication-related interventions.

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PATIENT PRESENTATION

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Chief Complaint

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“I feel tired, nauseated, and constipated.”

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HPI

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Jane Lopez is a 42-year-old woman who presents to the outpatient dialysis center for her routine HD treatment. She has ESRD secondary to hypertension and has been on HD for 4 years. She has a failed AV fistula and graft and is currently dialyzed via central venous catheter. She has an upcoming appointment with the vascular surgeon to reevaluate her HD access. She also frequently leaves HD 30–60 minutes early against medical advice.

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PMH

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  • ESRD secondary to HTN

  • Anuria

  • HTN

  • Anemia

  • Secondary hyperparathyroidism

  • H/O gestational diabetes 12 years ago

  • GERD

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PSH

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  • Cesarean section 12 years ago

  • Tubal ligation 10 years ago

  • AV fistula creation 5 years ago (failed)

  • AV graft creation 3 years ago (failed)

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FH

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Father died of MI at age 60. Mother deceased due to breast cancer. No siblings. Has a 12-year-old son in good health.

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SH

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Married, lives with husband and a 12-year-old son. Occasional social alcohol use. Smokes 1/2 ppd (decreased from one ppd × 10 years). Denies caffeine consumption.

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ROS

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Complains of feeling tired and weak over the past several weeks. Reports some swelling in feet and lower legs. Also reports constipation, nausea, and heartburn.

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Meds

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  • Furosemide 80 mg PO daily

  • Metoprolol tartrate 50 mg PO BID

  • Lisinopril 20 mg PO daily

  • Calcium acetate 667 mg three caps PO TID with meals

  • Nephro-Vite PO daily

  • Omeprazole 20 mg PO daily

  • Ferrous sulfate 325 mg PO TID

  • Docusate 100 mg PO daily PRN

  • Calcium carbonate PO PRN heartburn

  • Epoetin alfa 10,000 units IV three times weekly with dialysis (dose stable for 3 months)

  • Iron sucrose 50 mg IV once weekly at dialysis

  • Paricalcitol 6 mcg IV three times weekly with dialysis

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All

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NKDA

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Physical Examination

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Gen
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The patient is a WDWN Hispanic woman in NAD who appears her stated age

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VS
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  • BP 175/88 mm Hg (predialysis); 149/89 mm Hg (postdialysis)

  • Wt 88.6 kg (predialysis); 84.0 kg (postdialysis)

  • P 91 bpm, RR 16, T 36.5°C; Ht 5′4″

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Skin
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