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Original Question

Greetings, Please help me with this case study. HPI: 88 year old white male patient seen at New Hope Landing ALF to establish care with a history of acute kidney injury, type 2 diabetes, hypertension, stage III CKD, bladder cancer, BPH with LUTs, and anxiety. I have requested his full medical record for thorough review to help guide his current management as well as to ensure continuity of care. His breathing is currently unlabored. His vital signs are unremarkable. He states that his bowels are stable. He states that he is passing urine and denies any obstructive symptoms. He states that his appetite is good. He reports that his blood glucose readings have been in the low 200s with blood glucose checks twice daily. His mood is anxious with a disorganized thought pattern. He states that he has insomnia. MEDICATIONS: Sertraline HCl 100 MG Oral traZODone HCl 50 MG Oral Carvedilol 25 MG Oral Tablet metFORMIN HCl 500 MG Oral Daily Multivitamin Oral Capsule Acetaminophen 325 MG Oral Temazepam 15 MG Oral Capsule Tamsulosin HCl 0.4 MG Oral Capsule Januvia 50 MG Oral Tablet 2 tablets amLODIPine Besylate 10 MG Oral Atorvastatin Calcium 40 MG Oral Tablet Clopidogrel Bisulfate 75 MG Oral Tablet Ferrous Sulfate 325 (65 Fe) MG Oral Fluticasone Propionate 50 MCG/ACT Nasal Suspension Lisinopril 40 MG Oral Tablet 1 tablet 1 tablet (600 mg) Senna-S 8.6-50 MG Oral Tablet 1 tablet Sertraline HCl 50 MG Oral Tablet 1 tablet (50 mg The only thing abnormal from the physical exams Vascular: (+) trace leg edema, no claudication, (+) varicose veins, no thromboses or emboli. Musculoskeletal: (+) arthralgia, (+) bilateral lower extremity neuropathy (+) chronic arthritis. No gout. (+) gait instability. CARDIOVASCULAR: (+) diastolic heart murmur. EYES: Visual Acuity: Abnormal Ocular symmetry Vitals: 154/83 Heart rate 64 Temp afebrile Respirations 14 Weight 177.6 pounds Height 69 inches BMI 26.2 Labs: 11/29/2019: BUN 46 creatinine 1.9 Na 136 K 5.9 Chloride 109 CO2 20 Calcium 8.1 Labs 11/24/2019: BUN 71 creatinine 2.6 Na 137 K 4.7 What are your diagnoses based on this? Why did you choose these diagnoses ? Evaluate his medications ..do you want to stop or start any medications? What labs would you order and why? What do you think of his labs? What is important to focus on his management?

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