ID: WA is a 65 yo male admitted with anascara and stage 5 CKD
(same patient as: https://shermainengorx.wordpress.com/2016/09/15/c3-2-r5-reconcile-a-patients-medications-on-admission-2mg/)
Upon discharge from the hospital, reconciled his medications and went over the following medications, side effects and overall plan, etc.:
I. Medications PTA that have been stopped:
- Hydralazine 25mg PO TID
- Metoprolol 25mg PO BID
- Digoxin 62.5mcg PO daily
Plan is for heart failure therapy to be reassessed as an out-patient by the heart function clinic and renal dialysis clinic (new start to hemodialysis in the hospital).
II. Medications PTA that have been continued with no changes:
III. Medications PTA that have been continued with changes:
- Furosemide 40mg PO daily has been increased to 80mg PO BID
IV. Medications that are new start in hospital
- Calcium carbonate 1250mg (elemental calcium: 500mg) PO TID with food
- Replavite – 1 tablet PO once daily
- Insulin glargine – 12 units SC at bedtime
Plan is for diabetic therapy to be reassess as an out-patient by the diabetic clinic. Concerns with discharging patient on regular insulin due to regimen complexicity.
V. Medication Adherence
- Emphasized importance of medication compliance even when patient is feeling asymptomatic
- OT assessed need for blister pack – discussed blister packs and the value of using them. Patient OK with discharge prescription stating blister packing.
- Advised to follow up with family physician as soon as possible and to bring medication calendar to his general physician and all new clinic visits