solved

CASE 1

Martin James is a 73-year-old man who originally presented to the hospital with symptoms of heart failure that culminated in aortic and mitral valve replacement surgery. His surgery was complicated by a 1-hour hypotensive episode, with BP as low as 70/50. Three days post-operation, purulent drainage was noted from the surgical site, and he was subsequently diagnosed with mediastinitis. At that time, the patient was also found to have a Serratia bacteremia (blood cultures × 4 positive for Serratia marcescens, sensitive to gentamicin, piperacillin, ceftazidime, and ciprofloxacin; resistance was noted to ampicillin). Therapy was initiated with gentamicin and piperacillin. Thus far, he has completed day 25 of a 6-week course of antibiotics. A gradual increase in his BUN and serum creatinine concentration from baseline and signs of volume overload have been noted over the past 7 days (see Table below)

Martin has Type 1 DM, CKD, Gout, Osteoarthritis, HTN, and Atrial fibrillation. He has undergone Aortic and mitral valve replacement surgery 28 days ago. His father had Type 1 DM. He denies smoking or alcohol; he is a retired coal miner (11 years ago).

Current Medications: Gentamicin 180 mg IVPB Q 48 h (See Table below for previous dosages) Ceftazidime 1 g IVPB Q 12 h × 25 days Enalapril 5 mg po once daily Colace 100 mg po BID Furosemide 80 mg po Q 12 h × 2 days Digoxin 0.25 mg po once daily Allopurinol 100 mg po once daily Ranitidine 150 mg po Q 12 h Meperidine 25 mg IM Q 4-6 h PRN pain (started 3 days ago) Ibuprofen 400 mg po Q 4-6 h PRN pain (started today for joint pain) Sliding scale insulin

Allergies: Bactrim (experienced rash about 10 years ago; subsided when drug discontinued)
ROS: Currently complains of trouble breathing, weakness, general malaise, and pain in joints in hands. No fever or chills.
Physical Examination
Gen: Confused-appearing man in mild distress
VS: BP 152/90, P 80, RR 26, T 37.7°C; Current Wt 87 kg (admission Wt 73 kg), Ht 5’10”
Skin: Normal skin turgor
HEENT: PERRLA, EOMI, poor dentition
Neck/Lymph Nodes: (+) JVD
Chest: Basilar crackles, inspiratory wheezes
CV: S1, S2 normal, no S3, irregular rhythm
Abd: Soft, nontender, (+) BS, (-) HSM
Genit/Rect: (-) Masses
MS/Ext: 2+ Ankle/sacral edema
Neuro:A & O to person and place, but not to time
Lab Examination (Current)
UA: Color, yellow; character, hazy; glucose (-); ketones (-); SG 1.010; pH 5.0; protein 30 mg/dL; coarse granular casts 5-10/lpf; WBC 0-3/hpf; RBC 0-2/hpf; no bacteria; nitrite (-); osmolality 325 mOsm; urinary sodium 45 mEq/L; creatinine 33 mg/dL, FENA = 3.2%.
Repeat Blood Cultures Today Negative.
Fluid Intake/Output and Daily Weights
Question:
List down ACTIVE problems present. Rank them from the most urgent to the list urgent problem

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."