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LEARNING OBJECTIVES

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

  • 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.

PATIENT PRESENTATION

Chief Complaint

“I just feel so weak all the time.”

HPI

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.

PMH

  • HTN

  • Declining renal function due to HTN

  • Seasonal allergic rhinitis

SH

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.

FH

History of CAD in her mother’s family

ROS

As per HPI

Meds

  • 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)

ALL

NKDA

Physical Examination

Gen

Pleasant African-American woman in NAD

VS

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

HEENT

No hemorrhages or exudates on funduscopic examination

Neck/Lymph Nodes

JVP was 5 cm; carotid pulses were 2+ bilaterally; no thyromegaly or lymphadenopathy

Lungs

CTA and P

CV

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

Abd

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

MS/Ext

Minimal sternal and quadriceps tenderness

Neuro

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.

Labs

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