CC: weakness, not eating.
HPI: 84 y/o F with HTN, HLD, hypothyroidism, osteoporosis, depression brought by son for progressive weakness and poor oral intake. Husband died in June; since then son notes she "barely eats," drinks little, has lost weight, and stays in bed most of the day. No vomiting, diarrhea, fever, or urinary symptoms. Continued her HCTZ/lisinopril.
Vitals: T 36.5, HR 102, BP 104/60, RR 16, SpO2 97% RA. Wt 45.8 kg.
Exam: Thin, frail, dry MM, temporal hollowing. Abd scaphoid, soft. A&Ox3, flat affect.
Labs: Na 144, K 3.6, HCO3 26, BUN 62, Cr 2.4 (baseline 0.8, 02/2026), glucose 92. Albumin 3.0. WBC 7.2, Hgb 11.6. UA concentrated, otherwise bland. TSH 3.4.
ED course: 1 L NS.
Impression: AKI, dehydration. Admit.
HISTORY AND PHYSICAL
HPI: 84F with HTN, HLD, hypothyroidism, osteoporosis, depression (worse since husband's death 3 months ago) presenting with weakness, poor PO intake, Cr 2.4 from baseline 0.8, BUN 62.
Meds: lisinopril 10 mg, HCTZ 12.5 mg, atorvastatin 10 mg, levothyroxine 50 mcg, sertraline 50 mg, alendronate 70 mg weekly, vitamin D.
Exam: T 36.6, HR 96, BP 108/62. Thin, dry MM. RRR. Lungs clear. No edema. A&Ox3.
ASSESSMENT/PLAN:
1. AKI, prerenal - due to dehydration from poor PO intake plus ACEi/thiazide. Hold lisinopril, HCTZ. NS 100 mL/h, BMP in AM, I/O. Avoid nephrotoxins.
2. Dehydration - IVF as above, encourage PO.
3. Poor PO intake / weight loss - dietitian consult. Calorie counts.
4. Depression - continue sertraline; SW consult for bereavement support.
5. HTN - holding antihypertensives.
6. HLD - continue statin. 7. Hypothyroidism - continue levothyroxine, TSH nl.
8. Osteoporosis - hold alendronate inpatient.
DVT ppx heparin SQ. Full code.
NUTRITION ASSESSMENT
Reason: MD consult, poor PO intake/weight loss.
Anthropometrics: Ht 157 cm, Wt 45.8 kg, BMI 18.6. Usual body weight 52 kg (06/2026 PCP visit) -> 12% loss in 3 months.
Intake: Per son and pt, eating < 50% of estimated needs for > 3 weeks (since early August); mostly tea and toast.
NFPE: Severe temporal wasting, moderate-severe clavicular and acromial muscle loss, moderate orbital fat loss. Hand grip weak. No edema.
Estimated needs: 1400-1550 kcal, 55-65 g protein.
Nutrition diagnosis: Severe protein-calorie malnutrition in the context of social/environmental circumstances (bereavement, depression), as evidenced by 12% weight loss in 3 months, energy intake < 50% of estimated needs for > 7 days, and severe muscle and fat loss on NFPE. Meets ASPEN/AND criteria.
Interventions: Ensure Plus BID, liberalized diet, MVI with minerals daily, monitor refeeding labs (Phos, Mg, K) x 3 days, weekly weights.
Recommend MD document nutrition diagnosis if in agreement.
S: Feels a bit stronger. Ate 40% of breakfast, drank 1 Ensure.
O: T 36.7, HR 82, BP 126/70. Cr 2.4 -> 1.7 -> 1.2. BUN 31. Phos 2.9, Mg 1.9, K 3.9.
A/P:
1. AKI, prerenal - improving with IVF, Cr 1.2. Decrease IVF to 50 mL/h, stop tomorrow if PO OK.
2. Dehydration - improving.
3. Poor PO intake / weight loss - appreciate dietitian recs; Ensure Plus BID, MVI. Refeeding labs stable.
4. Depression/bereavement - SW saw pt, outpatient grief counseling info given; continue sertraline, discuss dose increase with PCP.
5. HTN - BP 120s off meds, continue holding.
6. HLD, hypothyroidism, osteoporosis - stable.
DISCHARGE SUMMARY
Admit 09/06/2026 - Discharge 09/10/2026. Home with son; home health PT/RN.
Principal diagnosis: Acute kidney injury, prerenal, due to dehydration.
Secondary diagnoses: Dehydration. Depression. Hypertension. Hyperlipidemia. Hypothyroidism. Osteoporosis.
Hospital course: 84F with weakness and poor oral intake in the setting of bereavement, Cr 2.4 from baseline 0.8. Treated with IV fluids and holding of lisinopril/HCTZ; Cr 0.9 at discharge. Seen by dietitian for poor intake and weight loss (BMI 18.6); started on oral supplements, intake improved to ~50-60% of meals. Social work provided bereavement resources.
Discharge meds: Ensure Plus BID, multivitamin daily, sertraline 50 mg, levothyroxine 50 mcg, atorvastatin 10 mg, alendronate weekly, vitamin D. HOLD lisinopril and HCTZ until PCP visit.
Follow-up: PCP 1 week with BMP and weight check.