MC is a 56 year-old female who presents to the ED with hematemesis and fluid ove

MC is a 56 year-old female who presents to the ED with hematemesis and fluid overload. Additional Complaints: – vomiting – nausea – GI bleeding PE Vital Signs : BP 132/70, Pulse(141),Temp 97.9F, Resp 19, Ht 5’10”( 1.778m), Wt: 312Lbs 11.2oz (141.8kg), pregnancy test: negative SpO2: 97% BMI: 44.87 Kg/m2 General: Awake female, no apparent distress HEENT: Mucous membranes are moist Resp: Diminished throughout negative for wheezing, rhonchi, or crackles Cardio/Vasc: S1/S2 heard, no mumurs, bilateral lower extremity and abdominal edema 3+pitting GI: Tender, Bowel sounds are present. colostomy bag is intact and draining MSK: Moving all 4 extremities Skin: Normal coloration, warm and dry. supra pubic cath in place and draining Neuro: No dysarteria Psych: Awake, alert, oriented X4, appropriate affect PMH: HTN, Hyperlipidemia, COPD,CAD and drug eluting stent, combined HF, Depression. Neuropathy, OSA, paraplegia cauda equina syndrome with chronic suprapubic catheter and colostomy, classIII obesity, CKD stage IIIa, DMT2 insulin dependence and hypothyroidism. Recents Labs: Na: 143 K: 5.2 Cl: 92 CO2: 7 BUN: 25 Creatinine: 3.39 Glu: 140 WBC: 27.1 HgB:8.9 HCT: 29.1 PLT: 285 Problem List: – Principal Problem Acute on chronic combined systolic ( congestive) and diastolic (congestive) HF( HCC) – Active problems UTI associated with cystostomy catheter (HCl), Microcytic anemia, Morbid obesity with BMI of 50, Diabetes, Azotemia, CKD Medication List: – Start taking these meds: metoprolol succinate (Toprol XL) 25mg Tab spironolactone( Aldactone) 25 mgTab – Continue these medications with have not changed aspirin 81 mg chewable Tab atorvastatin (Lipitor) 80mg Tab furosemide( Lasix) 80mg Tab ticagrelor (Brilinta) 90mg Tab – Stop taking these medications metoprolol tartrate (Lopressor) 25mg Tab nifedipine (Adalat) 30mg Tab Assessment: -AKI progressing to CKD stage 4 – Cardiorenal syndrome with azotemia, baseline creatinine 2.5-3, 1 session of hemodialyse, chronic protenuria and micro hematuria – Acute on chronic HF with newly reduced EF: LVEF, 25 TO 30%, weight management daily, 1.5Lof fluid restriction, salt restriction -Metropol XL 50 mg daily -cardiomyopathy, hold off on further GDMT due to marginal BP and AKI -no ACEI/ARB/ARNi/MRA given renal dysfunction -hold home nifedipine due to marginal BP -continue to hold Brilinta after tunnel catheter placement Plan: -Fluid and electrolyte management per nephrology -GDMT for HFref with Toprol -no ACEI/ARB/ARNi/MRA -statin for hyperlipidemia -Brilinta on hold in anticipation of tunneled dialysis catheter placement – strict intake and output daily weights -soduim and fluid restriction -No anticoagulant for PAF given her recent GI bleeding with severe anemia requiring,blood transfusion NB: The patient died in 8/18 ( also so take that in consideration)