Please read the entire case and answer this question Create an individualized, patient-centered, team-based care plan to

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Please read the entire case and answer this question
Create an individualized, patient-centered, team-based care plan
to optimize medication therapy for this patient’s AKI and other
drug therapy problems. Include specific drugs, dosage forms, doses,
schedules, and durations of therapy:
pharmacotherapy casebook chapter 54 acute kidney injury: there
is nothing acute about it
Chief Complaint
“I feel really weak.”
HPI
Everit Mitchell is a 72-year-old man who presents to the ED with
complaints of severe weakness that started this morning and recent
stomach pain for the past week. He was feeling normal until he
developed stomach pain 1 week ago that worsened with meals. Two
days ago the pain worsened to the point where he avoided eating,
and last evening he felt more tired than usual and went to bed
early. He had difficulty sleeping due to the pain, and since waking
this morning he has been in too much pain and too weak to perform
his normal ADLs. His wife brought him to the ED because his
physician is away on vacation.
PMH
HTN × 30 years
CAD × 20 years
MI × 2 with most recent 2 months ago s/p PCI with drug-eluting
stent placement
s/p CABG 20 years ago
HF × 4 years
RA × 1 year
FH
Father died of an acute MI at age 52; mother had diabetes
mellitus and died of a stroke at the age of 65.
SH
Retired and living at home with his wife. Before retirement, the
patient was employed as an accountant. No alcohol, no tobacco
use.
Meds
Aspirin 81 mg PO daily
Amlodipine 10 mg PO once daily
Furosemide 40 mg PO once daily
Metoprolol succinate 50 mg PO once daily
Enalapril 20 mg PO once daily
Prasugrel 10 mg PO daily
Naproxen 500 mg PO BID
All
NKA
ROS
In addition to weakness and stomach pain, the patient complains
of feeling cold but denies chills or fever. No changes in vision.
Denies SOB, CP, and cough. Complains of feeling lightheaded. Has
been having frequent loose black stools over the past 3 days and
abdominal pain that has become severe in the past 2 days. Has noted
a decrease in the frequency of his urination over the past 24
hours. Denies musculoskeletal pain or cramping.
Physical Examination
Gen
Pale, elderly Caucasian man who appears in moderate distress and
generally weak and lethargic
VS
BP 89/43 mm Hg (77/32 mm Hg on standing), P 123 bpm, RR 25, T
36.1°C; Wt 171.6 lb (78 kg), Ht 5′9″ (175 cm)
Skin
Pale and cool with poor turgor
HEENT
PERRLA; EOMI; fundi normal; conjunctivae pale and dry; TMs
intact; tongue and mouth dry
Neck/Lymph Nodes
No JVD or HJR; no lymphadenopathy or thyromegaly
Lungs
No crackles or rhonchi
CV
Tachycardic with regular rhythm; normal S1,
S2; no S3; faint S4; no MRG
Abd
Rigid with guarding, epigastric tenderness, ND; no HSM;
hyperactive BS
Genit/Rect
Stool heme (+); slightly enlarged prostate
MS/Ext
Weak pulses; no peripheral edema; mild swelling of MCP joints of
both hands
Neuro
A&O × 3; CNs intact; DTRs 2+; Babinski (–)
Labs
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Na 132 mEq/L
Ca 8.6 mg/dL
K 5.6 mEq/L
Mg 2.1 mg/dL
Cl 97 mEq/L
Phos 4.3 mg/dL
CO2 22 mEq/L
WBC 8.6 × 103/mm3
BUN 53 mg/dL
Hgb 7.6 g/dL
SCr 1.8 mg/dL
Hct 22.5%
Glu 123 mg/dL
Plt 96 × 103/mm3
Assessment
Admit to hospital for evaluation and management of dehydration,
evaluation for acute GI bleed, and potential acute renal
failure.
Clinical Course
On admission, the patient was resuscitated aggressively with IV
normal saline and multiple transfusions (4 units of PRBCs). His
home medications were held, he was started on a continuous IV
pantoprazole infusion of 8 mg/hr, and he underwent an emergent EGD.
During endoscopy, a large ulcer in the gastric antrum was found
with an exposed spurting artery. Endoscopic therapy was
unsuccessful, and the patient was taken to the OR for surgical
intervention. He was hypotensive in the OR (BP 70 mm Hg systolic on
average) and was started on a norepinephrine infusion to maintain a
stable BP. Postoperatively, he remained on mechanical ventilation,
and his urine output averaged 35 mL/hr over the first 12
postoperative hours despite continued aggressive IV hydration and
repeated transfusions in the OR. He also remained on norepinephrine
for a continued low BP. On the morning of postoperative day 1, his
labs were as follows:
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Na 134 mEq/L
Ca 8.2 mg/dL
K 5.4 mEq/L
Mg 2.2 mg/dL
Cl 111 mEq/L
Phos 4.7 mg/dL
CO2 19 mEq/L
WBC 14.6 × 103/mm3
BUN 49 mg/dL
Hgb 10.3 g/dL
SCr 2.5 mg/dL
Hct 29.8%
Glu 145 mg/dL
Plt 112 × 103/mm3
Urinalysis also showed muddy brown casts, urine sodium of 72
mEq/L, and specific gravity of 1.004. The patient remained on
mechanical ventilation and norepinephrine, his urine output had not
improved, and his chest radiograph showed diffuse bilateral
pulmonary edema with a decrease in O2 saturation to
86%. An echocardiogram revealed hypokinesis of the anterior portion
of the left ventricle and an EF of 25%. The patient was started on
dobutamine, and an internal jugular vein catheter was inserted and
CVVH-DF was begun.
On postoperative day 5, his pulmonary edema had resolved,
norepinephrine and dobutamine had been weaned off, the dialysis
catheter was removed, and he was extubated. His subsequent hospital
course was uneventful, and his kidney function gradually
improved.