Clinical note · #15
Office & outpatient
History
A 72 YO/F with MDD who has been diagnosed with aplastic anemia after several bone marrow biopsies in june 2018. She was immediately started on cyclosporine and prednisone. In july 2018, she had 4 days hospitalization for Cyclosporine toxicity that caused AKI. Her cyclosporine was withdrawn immediately and improvement in her renal function took 6 months after withdrawal. Histopathological data of renal biopsy in july 2020 (after cyclosporine withdrawal) showed significant interstitial fibrosis and tubular atrophy. She has been closely followed up by me for prolonged time with her clinical and biological parameters monitored regularly. The patient has been feeling well since then though her GFR has been declined significantly.
Today, she is here for her elevated blood pressure readings in morning.
Current Medications
- Folic acid
- Aciphex
- MiraLax
- Trazodone
- Prednisone (5-day course every 4 weeks)
- Bactrim double strength (1 tablet b.i.d. on Mondays, Wednesdays, and Fridays)
Allergies
No known drug allergies
Objective
Vitals: Height 167 cm, weight 66 kg, BP 122/96 mmhg, Pulse 85 bpm, Temp 98.9°F
Physical Exam: Nontoxic, noncachectic appearance
unremarkable head, eyes, ENT, lymph. Thyroids normal
No heart murmur present, no signs of hypertrophy or cardiomegaly
Unremarkable peripheral veins, lungs, abdomen
No lower extremities edema.
Assessment/Plan
A decline in the renal function is always observed in people with aging. Reduced GFR is not below the estimated rate considering her age and her recent ECG does not concerns the risk of cardiovascular events. But giving her age and previous nephrotoxicity, the lowest cyclosporine dosage and shortest exposure time affording therapeutic effect are required in order to provide best long-term renal and cardiovascular outcome. Therefore Consider resuming cyclosporine at 50% dose reduction due to prior supratherapeutic levels. Perform urine analysis for any signs of proteinurea.
Repeat CMP to assess kidney function every 15 days. Continue weekly CBCs and follow up in one month. Continue her current medication.
Diagnosis: severe aplastic anemia, cyclosporine induced reversible nephrotoxicity.
Electronically signed by Jane Smith, NP. Date: 03/15/2024. Time: 10:45.