Problem:
Mr. Zimmerman is an 84-year-old man presenting to your clinic with his daughter to evaluate confusion and increased incidence of falls. His past medical history includes CVA, HTN, insomnia, hypercholesterolemia, congestive heart failure, mild dementia, osteoarthritis, chronic back pain, depression, and BPH. This morning The patient appears to be groggy and is having a difficult time paying attention. The patient sees six different specialists in addition to today's visit Medications are as follows: Aspirin 81 mg by mouth daily Acetaminophen 650 mg PO Q6H PRN Valsartan 160 mg PO daily metoprolol 50 mg PO BID Atorvastatin 40 mg by mouth at bedtime Celecoxib 200 mg by mouth daily Melatonin 10 mg under the tongue at hour of sleep Lisinopril 30 mg by mouth daily Diphenhydramine 50 mg by mouth every six hours as needed for itching Gabapentin 600 mg QID Tamsulosin 0.8 mg by mouth daily Citalopram 40 mg by mouth daily Amitriptyline 25 mg by mouth at hour of sleep Duloxetine 30 mg by mouth daily KlorCon 40 meq by mouth twice daily Zolpidem tartrate 10 mg by mouth at hour of sleep Oxycodone ER 20 mg every 12 hours as needed Terazosin 10 mg by mouth at hours