Age: 60.0
Sex: M
Vaccine: COVID19
Symptoms: Renal impairment, Renal injury, Vitamin D decreased
Clinical narrative: Date of Admission  12/30/2021   Date of Discharge  01/08/2022 - INTERNAL MEDICINE   Reason for Hospitalization   Shortness of breath  Hospital Course   Patient was admitted for acute hypoxic respiratory failure secondary to COVID-pneumonia requiring supplemental oxygenation.  He was initially on 4 L of supplemental oxygenation.  Started on steroids.  Held tocilizumab or baricitinib or remdesivir given CKD status with history of renal transplant.  ID consulted and agreed to hold off on COVID-related therapies other than steroids.  He was also treated with 5-day course of Levaquin for secondary bacterial pneumonia as well.  Nephrology consulted for AKI on CKD in the setting of renal transplant.  His antirejection medications were adjusted (CellCept was held, tacrolimus was reduced in dose, and prednisone was switched to dexamethasone) as per nephrology recommendations.  Allopurinol was renally dosed.  His AKI slowly improved but he also had hyperkalemia in the setting of renal injury.  Hyperkalemia was treated with Lokelma administration with eventual resolution by discharge day.  Metabolic acidosis was treated with sodium bicarb supplementation per nephrology.  Vitamin D levels were low despite of being on vitamin D supplementation.  It was increased to vitamin D3 2000 units daily.  Renal function returned to baseline.  As a result of systemic steroids, he had hyperglycemia and hypertension.  Hypertension was managed with restarting his amlodipine and continuation of carvedilol.  Lisinopril was held due to hyperkalemia.  Basal bolus insulin therapy was utilized for hyperglycemia.  A1c was 7.5 however in the setting of acute infection and steroid use unsure whether this is an accurate measurement.  His previous A1c's remained within prediabetic range.  As we stopped his steroids by discharge today, we anticipated that his hyperglycemia will also get better.  He was given supplies to measure his glucose at home and will see endocrinology outpatient.  Nephrology recommended decreased dose of tacrolimus and decreased dose of CellCept at discharge.  He was also switched back to his home prednisone as part of antirejection therapy.  He will all follow-up with renal transplant clinic in 1 week for repeat labs and assessment of renal function.  Home O2 eval showed that he would require 3 L of oxygen during ambulation.  Discharged home with home O2 to follow-up with outpatient renal transplant clinic and endocrinology.  Of note his PCP is listed as renal transplant physician.  Discharge Diagnoses      Acute hypoxic respiratory failure 2/2 combination of COVID viral pneumonia and possible multifocal bacterial pneumonia Vaccinated but immunosuppressed s/p renal transplant  Possible multifocal pneumonia s/p levofloxacin History of ESRD s/p renal transplant, now CKD (baseline creatinine 1.7-2.0)  AKI on CKD, resolved s/p renal transplant 2/2 APDKD on immunosuppression Hypophosphatemia  Hyperkalemia, resolving  Normal anion gap metabolic acidosis Hyperglycemia 2/2 systemic steroids HTN Gout Epistaxis  Other Diagnoses   Ongoing  BMI 33.0-33.9,adult  Obesity  Historical  No qualifying data  ESRD on HD   Prediabetes    Consultants  Medicine Nephrology     Discharge Disposition  Home    Medications  New, Changed, or Refilled Medications  Glucose Meter 1 Each, Blood Test, qAM, 1 Each, 0 Refill(s)    Glucose Test Strips 1 Each, Blood Test, qAM, 25 Each, 13 Refill(s)    Lancets 1 Each, Blood Test, qAM, 100 lancet, 3 Refill(s)    albuterol (albuterol  HFA 90 180 mcg, 2 Puff, Inhalation, q6h, for 30 day(s), 1 Each, 0 Refill(s)    allopurinol (allopurinol 100 50 mg, 0.5 Tablet(s), Oral, q"other"Day, for 30 day(s), 7.5 Tablet(s), 0 Refill(s)    benzonatate (benzonatate 100 100 mg, 1 capsule(s), Oral, q12h, for 5 day(s), PRN: Cough, 10 capsule(s), 0 Refill(s)    cholecalciferol (Vitamin D3 5 50 mcg, 1 Tablet(s), Oral, Daily, for 30 day(s), 30 Tablet(s), 0 Refill(s)    guaiFENesin (guaiFENesin 600 600 mg, 1 Tablet(s), Oral, bid, for 7 day(s), 14 Tablet(s), 0 Refill(s)    mycophenolate mofetil (mycoph 500 mg, 1 Tablet(s), Oral, Daily, for 30 day(s), 30 Tablet(s), 0 Refill(s)    tacrolimus (Prograf 1 mg) 4 mg, 4 capsule(s), Oral, qAM, 120 capsule(s), 0 Refill(s)    tacrolimus (tacrolimus 1 mg) 3 mg, 3 capsule(s), Oral, At Bedtime, 90 capsule(s), 0 Refill(s)      Medications to be Continued  amLODIPine (amLODIPine 5 mg) 5 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)    carvedilol (carvedilol 25 mg) 25 mg, 1 Tablet(s), Oral, bid, 120 Tablet(s), 0 Refill(s)    cinacalcet (cinacalcet 90 mg) 90 mg, 1 Tablet(s), Oral, Daily, care of privacy, 60 Tablet(s), 0 Refill(s)  Instructions:care of privacy  predniSONE (predniSONE 5 mg) 5 mg, 1 Tablet(s), Oral, Daily, for 90 day(s), 90 Tablet(s), 3 Refill(s)      Discontinued Medications  diazepam (Valium 5 mg) See Instructions, 1 Tablet(s) Oral 30 min prior to MRI. will need driver home, 1 Tablet(s), 0 Refill(s)    lisinopril (lisinopril 20 mg) 20 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)       Physical Exam at Discharge       General: Alert, conversational, in no acute distress  HEENT: Normocephalic, atraumatic head  Cardiovascular: RRR  Respiratory: CTAB. No wheezing  GI: Soft, non tender  MSK: Absent lower extremity pitting edema (wearing compression stockings)  Derm: Warm and dry skin  Neuro: No focal neurological deficits  Time Spent  Spent >35 minutes discussing discharge plan Addendum by HCP on January 10, 2022 07:36:13 CST (Verified)    Attestation by HCP on January 10, 2022 07:36 I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with the author of this document.  I agree with everything documented above with the following exceptions/additions:    Spent a lot of time regarding possibliity of diabetes and the importance of long term control and repeat measurements of his A1c to eval given his history of prediabetes. Management of renal rejection meds adjusted as per neph recs. D/C with home oxygen and home glucose monitoring. Close f/u with nephro.