THE CASE: An 84-year-old man with a history of stable angina, type 2 diabetes, hyperlipidemia, and hypertension presents to the emergency department with worsening dyspnea and peripheral edema. Congestive heart failure is diagnosed, and the patient is admitted to the care of a hospitalist. A standard therapeutic regimen, including diuretics, angiotensin-converting enzyme inhibitors, and oxygen, is instituted, in addition to the patient's home regimen of isosorbide mononitrate, glipizide, and amlodipine. The hospitalsubstitutes pravastatin for the patient's atorvastatin. A Foley catheter is inserted by a urologist because of the patient's benign prostatic hypertrophy. The patient complains of insomnia and is given diphenhydramine. His hospital course is otherwise uneventful.
By the third day, the patient is stable enough for discharge. His social history reveals that he lives alone, does not drive, and has help from his daughter every Saturday. She lives 45 minutes away, works full time, and has 3 children. She picks the patient up at discharge, fills his prescriptions, drives him home, and instructs him to call her if he has any problems. A home health care nurse is instructed to check on him as soon as possible after discharge.
During the next 5 days, the patient takes all his medications, old and new. He is having increased difficulty in starting his urine stream and feels that he is not emptying his bladder. He notices that his ankles are swollen. The home health care nurse makes her first visit 5 days after the patient's discharge. She finds him confused and short of breath and notes that his home smells of urine. She calls Emergency Medical Services to transport him to the hospital.
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