0900: The client reports fatigue for the past 3 months and mild ankle swelling. He also reports a metallic taste in his mouth and occasional constipation. The client has a history of diabetes mellitus (type two) and hypertension. Current medications include metformin, lisinopril, and HCTZ.

0900

• Complete Blood Count
• Basic Metabolic Panel
• HgbA1C

0900: The client reports fatigue for the past 3 months and mild ankle swelling. He also reports a metallic taste in his mouth and occasional constipation. The client has a history of diabetes mellitus (type two) and hypertension. Current medications include metformin, lisinopril, and HCTZ.

0930: Provider at the bedside. The client meets the criteria for Stage 3b chronic kidney disease based on reduced GFR and persistent proteinuria.

0900: The client reports fatigue for the past 3 months and mild ankle swelling. He also reports a metallic taste in his mouth and occasional constipation. The client has a history of diabetes mellitus (type two) and hypertension. Current medications include metformin, lisinopril, and HCTZ.

0930: Provider at the bedside. Client meets the criteria for Stage 3b chronic kidney disease based on reduced GFR and persistent proteinuria.

1300: Client verbalized understanding of recent diagnosis of Stage 3 chronic kidney disease. Provided education on CKD progression, fluid and electrolyte balance, blood pressure and glucose control, and avoidance of nephrotoxic medications. Discussed signs and symptoms of worsening kidney function and reinforced the importance of dietary changes. Client was alert and engaged in discussion. Client is motivated to learn and receptive to information provided. Plan to discharge and follow up in 1-2 weeks.

Week 2

0800: Client returned 2 weeks after the initial CKD diagnosis and treatment. Updated medication list and lab results received. Client states they are feeling “a little better.”