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A/P: Pt recently has had worsening urinary retention which likely precipitated this UTI. UA + for infection, urine cultures drawn from 12/21 NGTD and today's cultures pending. Blood cx x2 drawn. Was given 1 dose rocephin in ER.
-Starting cefepime, renally dosing. Urine culture from '14 showed ceftriaxone resistant organism.
2: Sepsis
A/P: SIRS criteria met: tachycardia and leukocytopenia.
Sepsis bundle: lactates, no IVF, blood and urine cx pending x2
3: Urinary retention
A/P: Foley catheter in place. Initially was scheduled to see Urologist Dr. Shirrell tomorrow morning at 8:30AM. Will need to consult Urology tomorrow morning.
4: ESRD s/p renal transplant and now back on HD T/TH/Sa
A/P: Renal Dr. Lucia consulted. Has K 5.8, will likely have HD today. Cr 2.62, signs of LE edema. Has not taken his immunosuppressive treatment in the last 2 days. On HD schedule T/Th/Sa.
-Na and K restricted diet
-On prednisone 5mg daily, renal holding cellcept
-No IVF
5: Hypotension with hx HTN
A/P: Will CTM, holding beta-blocker.
6: CAD s/p CABG
A/P: Continue statin, will hold beta blocker. Last had rt and lt heart catheter in 2014. Cardiac diet.
Has medtronic ICD pacemaker/defibrillator.
7: GERD
A/P: PPI
8: CHFrEF combined with EF 45% and DD
A/P: On atenolol at home. Holding beta blocker for hypotension for now. Last echo showed EF of 45%, does not appear to be in acute exacerbation. Will monitor, daily weights, I/Os. Na restrict.
9: Aortic and mitral mechanical valve repair
A/P: On warfarin. PT/INR pending, last from 12/21 within therapeutic range (2.5-3.5).
-Pharmacy to dose adjust
10: Gout
A/P: Not on home meds for this. Not an acute flare.
11: Leukocytopenia
A/P: WBC 1.3. Monitor on CBCs.
12: Ashraf 4188
A/P: FEN/GI/PPX: Cardiac/diabetic diet with Na and K restricitons, no IVF, warfarin
CODE A
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