John Jenkins Male Explained for Students (Easy Guide)
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Original Question
HPI: John Jenkins is a 45 yr old male who presents to the clinic with his grandmother Jana Jenkins. She is an 89 yr old female who is concerned about her kidneys. She states she was recently hospitalized due to acute kidney injury (AKI) that was felt to be related to use of trimethoprim/sulfamethoxazole for a urinary tract infection. The medication was stopped, she was given IV fluids, and she recollects that her kidney function improved but she is not sure how much. She states that she is worried about her kidneys now because she has never had problems with them before and she REALLY does NOT want to have to do dialysis. She states that she is hoping you can help her keep her kidneys healthy. Past Medical History HTN GERD DMII AKI Past Surgical History Hysterectomy at age 35 Current Medications Lisinopril 20 mg daily Famotidine 20 mg daily Metformin 500 mg BID Allergies NKDA ROS Constitutional: – fevers, chills HEENT: No changes in vision, no ear drainage, no sore throat. Cardiovascular: No chest pain, palpitations. No edema. Respiratory: No shortness of breath or cough. GI: No n/v/abd pain. GU: No dysuria, difficulty voiding. No hematuria. Integumentary: No rashes, wounds. Neuro: – HA, dizziness. MS: No red or swollen joints. Endocrine: No polyuria, polydipsia, polyphagia. O: Physical Exam VS: T 97.9 P 68 R 16 BP 130/70 O2 sat 98% RA General: Healthy appearing 89 yo woman, appears younger than her stated age. Reliable historian. HEENT: Nose without drainage. Mouth with moist mucous membranes. Normal dentition. Posterior oropharynx pink and moist. Cardiovascular: S1S2 normal. No murmurs, rubs, or gallops. Respiratory: Lungs clear to auscultation. Respirations even and unlabored. Skin: No rashes on exposed skin. Neuro: No focal deficits. MS: No red or swollen joints. Enlarged DIP and PIP joints bilaterally. Extremities: No edema, DP 2+ bilaterally. Labs/Diagnostics 01/2022 Creatinine 1.2 Baseline 0.9 – 1.0 eGFR 48 K+ 4.2 At this time, Jana does not meet criteria for CKD as her decreased GFR has not been present for over 3 months consistently. Would you stop her lisinopril and metformin at this time? Why or Why not?
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