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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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  • Recognize the clinical and laboratory manifestations of metabolic acidosis.

  • Differentiate among different causes of metabolic acidosis.

  • Develop a patient-specific pharmacotherapeutic plan for treating chronic metabolic acidosis.

  • Provide medication education for patients with chronic metabolic acidosis.

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PATIENT PRESENTATION

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Chief Complaint

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“I just feel so weak all the time.”

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HPI

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Sue Rider is a 67-year-old woman with progressively declining renal function, due to hypertension, who is being seen in the nephrology clinic for management of fatigue, dyspnea, somnolence, and lethargy. She further reports that over the past few months she has experienced a decrease in appetite and occasionally feels nauseated without vomiting. She reports frequent nonadherence to her antihypertensive regimen “when I feel good.” She also reports no history of diarrhea.

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PMH

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  • HTN

  • Declining renal function due to HTN

  • Seasonal allergic rhinitis

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SH

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She is a retired schoolteacher who lives with her husband of 38 years and has three grown children. She denies alcohol use. There is no history of tobacco habituation or recreational drug use.

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FH

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History of CAD in her mother’s family

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ROS

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As per HPI

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Meds

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  • Amlodipine 5 mg PO daily

  • Metoprolol succinate 25 mg PO daily

  • Metolazone 2.5 mg PO daily, taken intermittently for lower extremity edema (reports that she has not taken any for the past few months)

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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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Pleasant African-American woman in NAD

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VS
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BP 145/85 mm Hg, P 78 bpm, RR 22, T 37.2°C; Wt 75 kg, Ht 5′4″

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HEENT
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No hemorrhages or exudates on funduscopic examination

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Neck/Lymph Nodes
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JVP was 5 cm; carotid pulses were 2+ bilaterally; no thyromegaly or lymphadenopathy

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Lungs
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CTA and P

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CV
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Unable to palpate PMI; regular rate and rhythm; normal S1 and S2; no murmurs

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Abd
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Obese, soft, nontender; normoactive bowel sounds; no organomegaly

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MS/Ext
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Minimal sternal and quadriceps tenderness

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Neuro
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No focal cranial nerve deficits; strength 5/5 in all extremities. DTRs are 1+ brachioradialis, 2+ biceps, 2+ quadriceps, 1+ ankle jerks, toes downgoing bilaterally.

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Labs

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Table Graphic Jump Location
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Na 131 mEq/L Hgb 12.2 g/dL AST 13 ...

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