Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Hypophagia, Hypoxia, Imaging procedure abnormal, Klebsiella test positive, Leukocytosis
Clinical narrative: Date of Admission: 11/27/2023   Date of Discharge: 1/4/2024   Issues to be Addressed at Follow-up: + follow up respiratory status, wean off oxygen as tolerated ( on 1-2L) + will need follow up imagine in a couple weeks to follow up the resolution of the mediastinal LAD ( suspected reactive due to covid and pneumonia)       Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 12/5/2023 to 1/5/2024.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? MEDIASTINAL LYMPHADENOPATHY       On CT chest, suspect reactive 2/2 pneumonia . Will need follow up imagine   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? BASAL CELL CARCINOMA, CHEST WALL   ? ACUTE ON CHRONIC RENAL FAILURE       1/11/2021 TAV -   Basename Value Date/Time ? CREATININE              1.60 (H) 01/08/2021 ? CREATININE, BLOOD, POCT 1.6 (H) 08/05/2020   Likely obstructive and possibly due to UTI as well. Now treated and on proscar for BPH to help prevent. Doing catheterization also. Will track the Cr q4 weeks.    ? BPH W URINARY RETENTION   ? ESSENTIAL HTN       5/9/2022   Briefly reviewed medications/plan today: Cont current regimen   HTN-Established diagnosis BP Goal: <139/89 Control: Well controlled with current meds -------------------------------------------- Current Meds: Beta-Blocker Adherence: Always takes meds Meds tried in past and stopped: No other meds tried than current regimen Last medication adjustment: No changes today -------------------------------------------- ASCVD: ASCVD-Risk (A-Risk): 35.3%   Labs: Reviewed on   next due:  Next visit due:  ----------------------------------------------  Lab Results Component Value Date   Creatinine 1.91 (H) 03/21/2022      BP Readings from Last 3 Encounters: 02/08/22 134/71 09/14/21 107/70 07/23/21 127/70   --------------------------------------------- PharmD Medication Plan:  Start ACE/HCTZ (Replace ACE w/ ARB if intolerant)-- >Add CCB (Amlodipine 2.5..>5-- >10mg)-- >Replace HCTZ w/ Chlorthalidone 25mg-- >Spironolactone 12.5-- >25 (unless pt not on thiazide,GFR <60 or K>4.5.  If not able to do Spironolactone-- >Atenolol 25-- >50mg.  Titrate to goal BP and HR >55 Education:  Handout/discussion of DASH, weight reduction, moderation of EtOH, salt intake, regular exercise 150min/week, track/monitor home BPs and goals     ? ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE       10/30/2023 Established diagnosis  Stopped metoprolol. So far HR is ok. Will report BLOOD PRESSURE. If normal stay off med for now. Caused diarrhea.    CHA2DS2-VASc score:   2   Anticoagulation? Yes - pradaxa Rate control? metoprolol Anti-arrhythmic?  Hx of ablation? No       ? PROSTATE CANCER       5/9/2022 some urinary issues, but PSA stable.   Lab Results Component Value Date   PSA 8.6 (H) 04/11/2018   PSA 9.6 (H) 11/08/2017   PSA 8.2 (H) 09/19/2017   PSA, CANCER MONITORING 6.9 (H) 03/24/2021   PSA, CANCER MONITORING 9.9 (H) 10/28/2019   PSA, CANCER MONITORING 11.3 (H) 05/10/2019   PSA free      0.4 08/10/2007   PSA free      0.6 05/29/2007   PSA free      0.7 03/01/2007   PSA % FREE     12.9 (L) 08/10/2007   PSA % FREE     15.0 (L) 05/29/2007   PSA % FREE     21.9 (L) 03/01/2007   Followed by urology.      Resolved Hospital Problems   Diagnosis Date Resolved ? COMMUNITY ACQUIRED PNEUMONIA 11/28/2023     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Background 82 year old male with history of HTN, Atrial Fibrillation on DOAC, CKD, Hx of RCC (s/p R nephrectomy), Hx of Urinary Retention (ISC at home), BPH, Prostate Cancer,  Presented hypoxemia  , found to have COVID pneumonia and acute on chronic renal failure initial Diuresis was held and renal function back to baseline.  He completed RDV / dexamethasone course. Was doing better but then started having leukocytosis. Repeat imaging was concerning for bacterial pneumonia. Respiratory status got worse, he required HFNC. Diuretics were restarted, and subsequently Cr started to rise. Renal US 12/11/23 revealed mild left hydronephrosis and circumferential bladder wall thickening. Foley cath was placed 12/12. No improvement in renal function and the patient was started on HD on 12/15. HD held 12/25-12/29 as trial but progressive rise serum creatinine and shortness of breath with continued hypoxia. temp removed 12/28/23 and Permcath was placed on 12/29/23         Urine culture              Klebsiella oxytoca         MBINT     Ampicillin >32  RESISTANT     Ampicillin+Sulbactam 8  SUSCEPTIBLE     Cefazolin <=4  SUSCEPTIBLE     Ciprofloxacin <=0.25  SUSCEPTIBLE     Ertapenem <=0.5  SUSCEPTIBLE     Gentamicin <=1  SUSCEPTIBLE     Meropenem <=0.25  SUSCEPTIBLE     Nitrofurantoin   SUSCEPTIBLE 1     Piperacillin+Tazobactam 8  SUSCEPTIBLE     Trimethoprim+Sulfamethoxazole <=1/19  SUSCEPTIBLE               Assessment and Plan:   ACUTE RESPIRATORY FAILURE COVID 19 PNEUMONIA BACTERIAL PNEUMONIA   - finished RDV and steroid, then developed bacterial pneumonia with worsening respiratory status, required HFNC. - Currently doing better, on 1-2L oxygen . Finished 10 days of zosyn - COVID test negative, d/c isolation (d/w ID Dr.) 12/29/23  -Plans:  + monitor respiratory status + follow up with PCP to wean off home oxygen        LEUKOCYTOSIS UTI  - leukocytosis: been ok until 12/29, started trending up slowly. No fever, bp stable, requires less oxygen . Recheck UA with possible UTI . Previous urine culture with coag negative stap.  Started on empiric cefazolin. Foley was removed 1/2 -Been on empirice Cefazolin. Urine culture back with Kleb.  Leukocytosis continue  improving Plans: + switch empiric cefazolin to keflex ( renally dosed) . + continue intermittent straight cath at home as previously done       ACUTE ON CHRONIC KIDNEY FAILURE CKD HX OF RCC - s/p right nephrectomy for RCC. Cr baseline ~ 2-2.56. patient self-cath 2-4 times/ day at home - Seen by nephro, suspected AKI 2/2  multifactorial ATN - Cr improving after lasix was stopped, back to baseline . However, Cr trends back up again. Foley was placed , started back on diuretic but no improvement. Patient was started on HD on 12/15  - permacath placed 12/29/23  - HD per renal TTS schedule as outpatient Plans: + continue HD per nephro + continue nephro-vite      DELIRIUM - suspect due to prolong hospitalization and possible UTI. Patient was a&o x 4 on exam . On antibiotic          MEDIASTINAL LAD - suspect reactive in the setting of pneumonia  - plan: will need follow up imagine in a couple weeks to follow up the resolution         AFIB with RVR - not on any antinodal agent at home, on pradaxa, which was switched to Eliquis due to AKI - started on dilt, HR overall acceptable - plans: continue dilt, Eliquis. DOAC clinic after discharge        BPH HX OF URINARY RETENTION H/O PROSTATE CA - patient self-cath 2-4 times a day at home.  - foley was placed but d/c'd 1/2 due to recurrent UTI - plan:  + continue intermittent straight cath at home as previously done + continue proscar            CONSTIPATION - S/P methylnaltrexone 6 mg subQ x 1 12/5/23 ,  fleet enema 12/6/23  - continue bowel regimen at home        SACRAL SORE - continue  wound care      POOR PO INTAKE - discussed with dr. ok to liberate patient's diet     Complications: none   Consults:  NEPHROLOGY - ONGOING INPATIENT CONSULTATION.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code        Note Details  Author (D.O.) File Time 1/5/2024 12:23 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine Hospital Acct #  Admit Date 11/27/2023  Linked Episodes  TUNNELED CENTRAL VENOUS From 12/22/2023 to 1/3/2024 TUNNELED CENTRAL VENOUS From 12/23/2023 to 12/26/2023 TUNNELED CENTRAL VENOUS From 12/29/2023 to 1/3/2024 Renal Episode 1 Noted 1/4/2024  Hospital Problem List   PROSTATE CANCER  ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE  ESSENTIAL HTN  BPH W URINARY RETENTION  COVID-19 DISEASE  ACUTE ON CHRONIC RENAL FAILURE  BASAL CELL CARCINOMA, CHEST WALL  COMMUNITY ACQUIRED PNEUMONIA Resolved  ACUTE HYPOXEMIC RESPIRATORY FAILURE  MEDIASTINAL LYMPHADENOPATHY Care Timeline  11/28   Admitted from ED (Observation) 1426 11/30   Admitted 1346 12/29   TUNNELED CENTRAL VENOUS LINE PLACEMENT 01/04   Discharged 1614