Assessment and Plan
62F with a history of type 2 diabetes, CHF, and a fractured left tibia, presenting with chest pain, numbness in the legs, and symptoms concerning for a UTI, currently managed with medication adjustments and diagnostic monitoring.
# Fractured left tibia – ortho consulted
Oxycodone dose changed to 7mg from 5mg PRN
Patient needs a cast
# Acute kidney injury
Serum creatinine: 1.0 (03/02/2022) up from 0.7 (03/01/2022)
Diagnosed on 2/27 with Cr 1.0
# DM type 2 complicated by obesity
Hold metformin for now until able to tolerate oral intake.
Blood glucose range >180 (since 02/28/2022)
Continue aspart insulin sliding scale
# Anemia: microcytic, due to mixed iron deficiency anemia and anemia of chronic disease
Hemoglobin: 14.3
Mean corpuscular volume: 83
NEW REGARD DIAGNOSES
# Congestive heart failure: HFpEF
Weight: 84.5 kg (up from 83.9 kg on 11/11/24; baseline estimated at 82 kg).
Continue empagliflozin 25 mg PO daily.
