From Greg Gahm, MD
RW is a 102-year-old black female with primary diagnoses of Atrial Fibrillation, HTN, Cardiomegaly, PVD, generalized weakness, hypothyroidism, dyslipidemia and hyperthyroidism (yes, her most recent PCC list of diagnoses contains both hypo- and hyperthyroidism!) She has a remote history of a single DVT associated with a Pulmonary Embolus.
Despite her age and the occasional low stage pressure ulcer, she seems to be doing fairly well other than just slowing down a bit. Her most recent BP is 156/90, pulse 60 and pulse ox of 93. She requires assistance with many ADLs and has some swallowing problems requiring a diet of regular texture, thin consistency. Her BIMS is 7 and PHQ-9 is 1. She has no complaints and is not in pain.
- Metoprolol ER 75 mg qd
- Amiodarone 200 mg qd
- Aspirin 81 mg qd
- Atorvastatin 20 mg qhs
- Warfarin 2 mg qd (dose changes every month or so)
- Lidoderm patch to sacral area qd
- Omeprazole 40 mg q am (GERD)
- Protein Liquid 30 ml qd
- Tapazole 5 mg qd
- Acetaminophen 650 mg tid
- Lasix 20 mg qod
- Viscous Lidocaine Solution 15 cc po q 6 hours “as needed for pain”
- Lactulose, Dulcolax, Senna qd prn
- Maalox Max Suspension 400-400-40 30 ml q 6 prn heartburn
- TUMS q 2 hours prn heartburn
What would you recommend to the provider? How strong would your recommendation(s) be?
(Posted by HLeMaster for Dr. Greg Gahm)