INTERVAL HISTORY: CHF symptoms worsened since yesterday.
Now has some resting dyspnea. HTN remains poorly controlled with
systolic pressure running in the 160s. Also, I’m concerned about his
CKD, which has worsened, most likely due to cardio-renal syndrome.
REVIEW OF SYSTEMS: Positive for orthopnea and one episode of
PND. Negative for flank pain, obstructive symptoms or documented
exposure to nephrotoxins.
PHYSICAL EXAMINATION:
GENERAL: Mild respiratory distress at rest
VITAL SIGNS: BP 168/84, HR 58, temperature 98.1.
LUNGS: Worsening bibasilar crackles
CARDIOVASCULAR: RRR, no MRGs.
EXTREMITIES: Show worsening lower extremity edema.
LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12.
IMPRESSION:
1. Severe exacerbation of CHF
2. Poorly controlled HTN
3. Worsening ARF from cardio-renal syndrome
PLAN:
1. Increase BUMEX to 2 mg IV Q6.
2. Give 500 mg IV DIURIL times one.
3. Re-check usual labs in a.m.
Total time: 20minutes.
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