Guidelines Conduct a thorough search for qualitative literature. Identify the

Martin is a 72-year-old man who presents with a rash. The patient states that he noted some shoulder pain beginning about 10 days ago, and he had not suffered an injury, that he could recall. He says that after about a week of left shoulder pain, he noted itchiness, redness, and then a rash showed up. He states that it still itches a little; his shoulder pain is better but is still aching. He says he has full range of motion of the shoulder, but it pretty much aches all the time. He rates it as a 5 on a scale of 0 to 10. The patient has used Absorbine, Jr on the rash, but says it did not help. He has been putting Neosporin on it for the last 24 hours but says that he thinks rash is just continuing to worsen. He denies any kind of skin problems in the past, and he has never had anything like this before. No one else at home has a rash. He denies a change in laundry detergent, soap, cologne or diet alterations. He says it is hard to sleep because of the itchy feeling. He says he has no allergies. He does not smoke or drink. He has not had any change in medications in the last 9-12 months. Lisinopril 40 mg daily; ASA 81 mg daily; Norvasc 10 mg daily; Hydralazine 25 mg QID; Lipitor 40 md daily; Bumex 1 mg daily; Multivitamin [1] daily; Vitamin D3 5000 IU [2] daily [this was started about 9 months ago] No previous surgeries; PMH—HTN, High Cholesterol; Vitamin D Deficiency; Chronic Kidney Disease [stage III] ROS: CV—no CP, SOB or edema Resp—no cough or wheezing, no PND or orthopnea General—eats and sleeps well; no recent change in weight MSK—no chronic joint pain or aches, just the new onset left shoulder pain Exam: 98-80-16 140/80 6 feet tall 200 pounds 72-year-old male who appears his stated age; well groomed; oriented to person, place and time; good historian. Heart is regular in rate and rhythm; 2/6 systolic murmur at LLSB; no JVD or bruits; scant pretibial edema; no sacral edema Lungs—clear to auscultation; no increased work of breathing Skin—color is pink, warm and dry. Normal male pattern baldness; hair and nails are clean and show not evidence of scale, mycosis or infestations. Skin to the legs and posterior aspect of back is dry, but free of lesions; there are no lesions to the neck or face. On the left upper quadrant of the anterior chest, there is erythema, and slight warmth. You see linear vesicles in various stages of formation, none of these cross the sternum—the are no such lesions on the right side of the anterior chest. Labs today—CBC mild anemia—Hbg. 11.5 Hct. 31% normal MCV; TC 200, trigs 160 mg/dL; HDL 45; LDL 105 mg /dL; CMP—glucose 89; sodium 135; potassium 5.7; BUN 20; creatinine 2.3; phosphorus and liver function tests unremarkable would you consult the nephrologist to change his medications? Bumex is not longer used in the US, would like to change it to HCTZ and discontinue hydralazine and change Lipitor 40 mg day to Simvastatin 40mg/day since his cholesterol and triglycerides are still elevated.

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