Chronic Renal Failure case

Chronic Renal Failure
HD, a 67-year-old African-American male at clinic. His complaints from
chronic fatigue and weakness, unchanged from his last visit 1 month ago,
occasional nausea/vomiting, decreased appetite, and "funny" heart beat.
In present illness: nausea/vomiting started 2 weeks ago, antacid
(magnesium hydroxide/ aluminum hydroxide) used without relief , denies
shortness of breath, edema, or weight gain, reports compliance with
medicine and diet regimen. In his past medical history: chronic renal
insufficiency X 2 years secondary to analgesic abuse for chronic pain,
baseline Cr (3.3-3.5), congestive heart failure (CHF) X5 years, New York
Heart Association Class II, hypertension X 20 years. His father has HTN
and he is smoke 1 cigar per week. He is taking Digoxin 0.25 mg PO QD,
Lisinopril 30 mg PO QD, Triametrene/HCTZ 37.5/25 mg PO QD,
Acetaminophen 650 mg PO Q4hr PRN pain.
Physical Examination:
GEN: well-developed, well-nourished male in no acute distress.
VS: BP 135/80.HR 54, RR 20, T 37.1 oC, Wt 73 kg, Ht 173 cm.
HEENT: pale mucous membrane and skin.
COR: normal S1 and S2 early S3.
CHEST: few rales and dullness over bases of lungs.
GU: no flank plan
EXT: pale nail beds
Lab Results:
Na 133 (133)
Hct 0.28 (.028)
Alk. Phos 2.0 (1.22)
K 5.5 (5.5)
Hgb 93 (9.3)
Alb 31 (3.1)
Cl 105 (105)
Plts 3.75 x10
T Bili 13.7 (0.8)
HCO3 17(17)
Lkcs 504 x 10
Ca 2.2(8.9)
BUN 20 (56)
MCV 85 fL
PO4 1.97 (6.1)
Cr 309.4 (3.5)
ALT 47 (28)
Mg 1.15 (2.8)
Glu 5.27 (95)
Peripheral smear: normochromic, normocytic,
Chest radiography: enlarged heart
ECG: prolonged P-R interval with occasional PVCs
Digoxin level: 2.8 ng/ml