Patient is a 79 year old male presenting with a complaint of lower extremity edema, leg ulcers, and acute kidney injury. Patient was admitted on 01/31/2017

Patient is a 79 year old male presenting with a complaint of lower extremity edema, leg ulcers, and acute kidney injury.  Patient was admitted on 01/31/2017.

HPI

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For some time patient was doing well and then lost control of salt restriction and presented to the physician’s office two weeks ago with a 25 pound weight gain, severe peripheral edema and 2 ulcers of RLE.  He was treated initially with doxycycline and subsequently with ciprofloxacin.  He has had twice a week wound care in the physician’s office and at a wound care clinic at Sibley.  Despite increasing diuretics, he has not lost about 5 pounds water weight but has become pre-renal with BUN now up to 129.  Patient has been admitted for diuresis and further management of RLE ulcers and residual cellulitis.  Patient had a fall at home and has pain in his right foot.

PMH

Patient has a past medical history of congestive heart failure, hypertension, heart attack, heart failure, atrial fibrillation, asthma, hyperlipidemia, status post biventricular cardiac pacemaker insertion, cardiac defibrillator in place, right inguinal hernia repair, patella tendon rupture, anemia, thrombocytopenia, acute kidney injury.

Medications/ Allergies

Allergies: Patient is allergic to grass pollen.

Home medications patient is taking are:

• Allopurinol (Zyloprim) 300 mg tablet by mouth daily
• Budesonide-formoterol (Symbicort) 160-4.5mcg/actuation inhaler, 2 puffs daily.
• Carvedilol (Coreg) 6.25mg tablet by mouth 2 times daily with meals.
• Gabapentin (Neurontin) 300mg capsule by mouth 2 times daily.
• Simvastatin (Zocor) 40 mg tablet by mouth daily
• Warfarin (Coumadin) 5 mg tablet by mouth every other day, alternating with 7.5 mg every other day
• Warfarin (Coumadin) 7.5 mg tablet by mouth every other day, alternating with 10 mg every other day.

Current medications

• Acetaminophen (Tylenol) tablet 650 mg PRN orally.
• Albumin human (Albuminar) 25% injection 25g injection, 3 times daily.
• Bisacodyl (Dulcolax) suppository 10 mg rectal, daily PRN
• Ceftaroline (Teflaro) 300 mg in sodium chloride 0.9% 250ml IVPB Intravenues every 12 hours
• Gabapentin (Neurontin) capsule 300 mg orally, 2 times daily
• Ipratropium-albuterol (Duo-Neb) nebulizer solution 3 ml, nebulization every 6 hours PRN for wheezing, shortness of breath.
• Iron sucrose (venofer) 20 mg/ml injection 100mg Intravenous daily
• Mupirocin (Bactroban) 2 % ointment topical daily
• Ondansetron (Zofran ODT) disintegrating tablet 4 mg oral every 6 hours PRN
• Ondansetron (Zofran) 4 mg/2 ml injection 4 mg intravenous every 6 hours PRN
• Oxycodone (oxyIR) half tablet 2.5 mg oral every 4 hours PRN
• Oxycodone (Roxicodone) immediate release tablet 5 mg oral every 4 hours PRN
• Polyethylene glycol (miralax) packet 17 g oral daily.
• Potassium chloride (K-Dur) ER tablet 20 mg oral daily.
• Sennosides (Senokot) per tablet 2 tablet oral nightly PRN
• Spironolactone (Aldactone) tablet 25 mg oral daily
• Tramadol (ultram)Tablet 50 mg oral 4 times daily

LABS AND DIAGNOSTIC TESTS

• RBC: 01
• Hemoglobin: 5
• Hematocrit: 3
• Platelet: 92000
• Sodium: 133
• Chloride: 92
• BUN: 119
• Creatinine: 76
• Phosphorus: 7
• Bilirubin: 7
• Prothrombin Time: 7
• INR, protime: 38

DIAGNOSTIC TEST

• Chest Ap: Cardiomegaly without acute infiltrates
• Bacteria yeast culture, blood: Blood, peripheral no growth to date

ROS

Patient had a small scar at the back of his head.  Patient stated “ he has a fall 10 days ago and hit his head.  He had had 3 falls in the last month from using a cane.  Patient complains of weakness but denies dizziness when getting up from bed.  Patient also states, walking is hard for him but he tries to from the bed to the chair.  Patient denies shortness of breath.

pE

Upon assessment patient is alert and oriented to person, place, and time.  Patient had a scar at the back of his head due to a fall. Face is symmetric and pupils are equal, round, and reactive to light and accommodation.  Patient mucous membrane was moist and oropharynx is clear.  Lung sounds were clear on auscultation.  No abnormal heart murmur heard on auscultation.  Vital signs are as follows: O2 sat 97% on room air, BP 100/60, pulse 63, Temp 97.8, RR 20.

GI:  abdomen is soft and distended.  Denies pain upon palpating.  Clear normal bowel sounds.

MS:  Ecchymosis of right shoulder which extends to the right arm.  Edema on both lower extremities and thighs.

GU:  Patient voided 2 hours ago