Patient Name: Pat Hernandez DOB: 05/05/19XX
Address: 555 River Rd., Columbus, OH 43210 Phone: 614-555-5555
Medication Allergies: NKDA
Pat is a pleasant 62-year-old who was admitted to the hospital 5 days ago after presenting with a several day history of worsening lower extremity edema, SOB, and cough. The patient was found to be in acute exacerbation of chronic systolic heart failure with acute kidney injury (AKI). The patient’s home ARB and potassium were stopped due to AKI/hyperkalemia upon presentation. Metformin was also held during admission. While receiving IV diuresis, the pt became hypotensive and bradycardic. Cardiology was consulted and recommended holding the home BB while continuing gentle diuresis. After normalization of fluid status, the BB was restarted at half of the home dose per recommendation from cardiology, which the pt tolerated well. AKI resolved with SCr trending near baseline currently. At discharge, the pt has been instructed to hold Diovan and continue adjustments to the doses of Coreg and Lasix made during admission. Pt will continue to take potassium supplement as an outpatient due to increased dose of Lasix. The pt will follow up with PCP in 1 week to monitor blood pressure, fluid status, and electrolytes. Due to multiple changes, the patient will receive counseling from our pharmacist on med changes prior to discharge.
HTN, HF with ejection fraction of 30%, T2DM
BP 102/60 mmHg, HR 64 bpm, Wt 109 kg, K 4.8 mEq/L, Na 142 mEq/L, SCr 1.03 mg/dL, BUN 9 mg/dL, Cl 100 mEq/L, CO2 24 mEq/L
Patient Medication Instructions
STOP taking the following medications
CHANGE the way that you take the following medications
Carvedilol (COREG) 6.25 mg, Take one-half tablet by mouth twice daily.
Furosemide (LASIX) 40 mg, Take two tablets by mouth once daily every morning.
CONTINUE these medications, which have NOT changed
Aspirin 81 mg, Take one tablet by mouth once daily.
Atorvastatin (LIPITOR) 80 mg, Take one tablet by mouth once daily.
Metformin ER (GLUCOPHAGE XR) 500 mg, Take two tablets by mouth twice daily.
Potassium chloride (KLOR-CON) 20 mEq, Take one tablet by mouth once daily.