74 y.o Male NKDA Full code BMI: 35.4

74 y.o
Male
NKDA
Full code
BMI: 35.4

Medical Dx:

Left hip fracture
UTI- E.Coli

HTN, Anemia, Diabetes, CKD stage III, Narcolepsy

22g IV
Neurovascular checks Q4h
Carb controlled, renal, and heart healthy diet
Pressure injury to R. buttock,
R elbow laceration, lesion/blister to LLE, incision to L hip

Imaging

Hip Xray 6/21/18: Slightly angulated fracture to L femoral neck
Hip Xray 6/21/18: Reduction and pinning of a femoral neck fracture of the left hip. 3 cannulated screws.

CT pelvis 6/21/18: Slightly angulated comminuted fracture to L femoral neck. NO pelvic fx. Multiple renal cysts.

EKG 6/20/18: Normal sinus rhythm. Left axis deviation. Right bundle branch block. Ventricular rate 83 bpm.

Labs

CBC 6/21/18: WBC 14.0 H, RBC 3.23 L, Hgb 10.4 L, Hct 31.6 L, RDW 15.8 H, Neutrophils 84.7 H, Lymphs 7.5 L, Neutrophils absolute 11.89 H.
CBC 6/22/18: WBC 9.3 Normal, RBC 2.89 L, Hgb 9.2 L, Hct 28.8 L, RDW 15.7 H, Neutrophils 77.1 H, Lymphs 13.3 L, Neutrophils absolute 7.17 H
CBC 6/23/18: RBC 2.84 L, Hgb 9.1 L, Hct 28.3 L, RDW 15.8 H, Neutrophils 75.4 H, Lymphs 12.7 L, Immature gran 0.8 H, Immature gran absolute 0.07 H
CBC 6/24/18: RBC 2.93 L, Hgb 9.4 L, Hct 28.3 L, RDW 15.3 H, Neutrophils 77.7 H, Lymphs 10.9 L

Increased WBC and neutrophils r/t UTI.
Decreased RBC, Hgb, Hct r/t
MDX of anemia, CKD, and post op hip fx

BMP 6/20/18: CO2 18 L, Anion gap 19 H, BUN 60 H, Creatinine 3.07 H, Glucose 233 H, Magnesium 1.5 L,
Lipase 7 L, eGFR 24 L, eGFR 20 L
BMP 6/21/18: CO2 20 L, Anion gap 17 Normal, BUN 58 H, Creatinine 2.95 H, Glucose 259 H, Calcium 8.0 L, eGFR 25 L, eGFR 21 L
BMP 6/22/18: Chloride 109 H, CO2 19 L, BUN 53 H, Creatinine 3.00 H, Glucose 245 H, Calcium 7.8 L, eGFR 25 L, eGFR 21 L
BMP 6/23/18: Chloride 109 H, CO2 19 L, BUN 51 H, Creatinine 3.21 H, Glucose 145 H, Calcium 8.1 L, eGFR 23 L, eGFR 19 L
BMP 6/24/18:BUN 44 H, Creatinine 2.78 H, Glucose 221 H, Calcium 8.4 L, eGFR 27 L, eGFR 22 L

Increased BUN, Creatinine,low Ca+, and
low eGFR reflect MDX CKD stage III.
Elevated glucose r/t MDX diabetes.

Urinalysis 6/21/18: Nitrate, Positive
Protein 100 H
Blood Small
WBC 5-10 H
RBC 2-5 H
Bacteria Many

Urine culture 6/21/18: POSITIVE for E. Coli

Meds

Allopurinol 300mg PO Daily
Antigout

Calcitriol 0.5 mcg PO Daily
Hypocalcemia and hip fx

Ceftriaxone 1g in 100 mL NS IVPB Q24h
UTI

Diltiazem hcl coated beads 1 cap PO Daily
HTN

Enoxaparin 30mg/0.3mL SC Daily
Prophylactic post op

Furosemide 80 mg PO Daily
HTN

Hydralazine 50mg PO BID
HTN

Insulin aspart 8 units SC TID with meals + 2-9 units sliding scale SC QID with meals and HS
Diabetes

Insulin glargine 30units SC QHS
Diabetes

Rosuvasatin 10mg PO Daily
High cholesterol

Possible NDX:

Acute pain r/t surgical hip fx repair

Risk for infection r/t surgical procedure, CKD, + DM,

Risk for fluid and electrolye
imbalance r/t CKD and diuretic therapy

Impaired skin integrity r/t surgical procedure, DM, + CKD