Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: AST/ALT ratio, Acute kidney injury, Alanine aminotransferase normal, Anaemia of chronic disease, Anion gap
Clinical narrative: Date of Service Jan-04-2023 0731  Date of Admission Admit Date: Dec-29-2022  Date of Discharge Date of discharge Jan-04-2023  Allergies No Known Allergies  Chief Complaint Altered mental status  Final Diagnoses Bacteremia  Urinary tract infectious disease  Procedure(s) Performed None  Lab Results Jan-04-2023 0420 Hematology WBC  9.5RBC  3.39HGB  9.9HCT  31.0MCV  91.4MCH  29.2MCHC  31.9RDW  14.7RDWSD  49.3PLT  417MPV  10.2AUTONEU%  84.5AUTOLYM%  7.0AUTOMON%  7.0AUTOEOS%  0.6AUTOBAS%  0.3AUTONEU#  8.0AUTOLYM#  0.7AUTOMON#  0.7AUTOBAS#  0.0AUTOEOS#  0.1NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.06IG%  0.6 Jan-04-2023 0420 Chemistry GLUCOSE  115BUN  28CREAT  1.0MDRD GFR  71NA  146K  4.6CL  114CALCIUM  7.9ALK PHOS  744CO2  26.5AST  29ALT  20AST/ALT  1.5TL PROT  4.5ALBUMIN  1.1TBILI  0.2OSMO  296.9ANION GP  10.1BUN/CRE  28.0CRP  10.90MAGNESIU  1.9 Jan-03-2023 0830 Urinalysis Department SPECGRAV  1.020U-PH  5.0LEUCOCYT  NegativeNITRITES  NegativePROTEIN  NegativeGLUCOSE  NegativeKETONES  NegativeUROBILIN  0.2BILRUBIN  NegativeBLOOD  SmallCOLOR  Lt. YellowCLARITY  ClearMICROSCP  YCULTURE  NWBC  NoneRBC  0-2SQUAM EP  NoneRENAL EP  NoneBACTERIA  NoneMUCUS  None Jan-03-2023 0440 Chemistry PREALB  13.1 Jan-03-2023 0440 Serology PROCALC  0.24 Dec-31-2022 1415 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Dec-31-2022 1405 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Dec-30-2022 1915 Microbiology MRSA  No methicillin resistant staphylococcus aureus isolated after one night incubation. Dec-30-2022 0625 Chemistry LACTATE  0.70 Dec-30-2022 0245 Urinalysis Department SPECGRAV  1.020U-PH  5.0LEUCOCYT  TraceNITRITES  NegativePROTEIN  NegativeGLUCOSE  NegativeKETONES  NegativeUROBILIN  0.2BILRUBIN  NegativeBLOOD  ModerateCOLOR  YellowCLARITY  ClearMICROSCP  YCULTURE  YWBC  10-15RBC  5-10SQUAM EP  0-2RENAL EP  NoneBACTERIA  4+MUCUS  TraceHYALINE  1-5RBC CAST  1-5CRYSTALS  1+TYPE  Amorph Dec-30-2022 0245 Microbiology C UR  Staphylococcus epidermidis Dec-30-2022 0050 Microbiology C BLD  Staphylococcus epidermidis Dec-30-2022 0040 Microbiology C BLD  Staphylococcus epidermidis Dec-29-2022 1829 Serology COVID  PosINFLUA  NegINFLUB  NegCVD1TEST  NCVDEMPHC  NCVDSYMP  YCVDSYMDT  12202022CVDHOSP  NCVDICU  NCVDRESID  NCVDPREG  N Dec-29-2022 1321 Reference Lab  Dec-29-2022 1320 Hematology WBC  10.5RBC  4.08HGB  12.1HCT  36.4MCV  89.2MCH  29.7MCHC  33.2RDW  14.4RDWSD  47.1PLT  432MPV  10.5AUTONEU%  83.6AUTOLYM%  5.3AUTOMON%  7.1AUTOEOS%  0.2AUTOBAS%  0.2AUTONEU#  8.8AUTOLYM#  0.6AUTOMON#  0.7AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.2NRBC  0.0HGB/HCT  3.0IG#  0.38IG%  3.6 Dec-29-2022 1320 Chemistry GLUCOSE  106BUN  136CREAT  4.4MDRD GFR  13NA  137K  4.3CL  102CALCIUM  7.9ALK PHOS  658CO2  21.2AST  44ALT  24AST/ALT  1.8TL PROT  6.0ALBUMIN  1.7TBILI  0.7OSMO  318.3ANION GP  18.1BUN/CRE  30.9CRP  >25.0 Dec-29-2022 1320 Serology PROCALC  2.14 Imaging Results xray pelvis and right hip 12/29/22: Right hip arthroplasty. No interval change or hardware complications. No joint dislocation. No acute fractures. Mild left hip joint degenerative disease. Multiple vascular calcifications. Read by: MD  Chest xray 1/3/23 post-PICC line: 1) Left subclavian approach PICC line with tip near innominate confluence. 2) Diffuse interstitial and patchy airspace opacities and left basilar consolidation concerning for infection. 3) Small pleural effusions with possible loculation on the right. Read by: DO  Functional Status* Impaired mobility  Mental Status* Impaired Cognition  Social History tobacco use Unknown If Ever Smoked, Smoking Cessation Not Applicable  alcohol use No Known Use  drug use No Known Use  marital status Unknown  Health Concerns Bacteremia  Urinary tract infectious disease  Essential hypertension  Hyperlipidemia  Osteoarthritis  Father Deceased Osteoarthritis; Heart disease  Mother Deceased  Brother Deceased Seizure disorder  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Jan-04-2023 0644 T 98.3 HR 93 RR     23 BP   132 / 65 O2Sat 93 Dec-29-2022 2200 T 98.4 HR 90 RR 18 BP   107 / 68 O2Sat 94 MAPBP 79 PHYSICAL EXAM CONSTITUTIONAL: Patient lying in bed on back, awake, pleasant and cooperative. In no acute distress. EYES: Vision is grossly intact, pupils are equal, and conjunctivae are without injection and pallor. EARS, NOSE, & THROAT: Oral mucosa is moist and the tongue is without fissures. CARDIOVASCULAR: Regular rate and rhythm without murmurs, gallops, or rubs. Pulses are 2+ in the bilateral upper and lower extremities. No edema noted. RESPIRATORY: Lungs are clear to auscultation bilaterally without rales and wheezes. Respiratory effort is not labored. No retractions or accessory muscle use noted. On room air. GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. Bowel sounds are normoactive. GENITOURINARY: Urine clear and yellow in foley catheter bag. About 50cc. Bladder non-tender. INTEGUMENTARY: Sacral stage I decubitus ulcer, same as on admission. Left heel 4cm black decubitus ulcer, stage I with skin intact, same as on admission. PSYCHIATRIC: The patient?s mood is euthymic and affect is appropriate. RASS of 0.  Consultations Dr. for left heel ulcer  Hospital Course Patient is an 83-year-old male who was admitted on 1/29/22 from Nursing Home for severe sepsis secondary to UTI and resolving COVID-19. He was significantly dehydrated with an AKIN stage 3 AKI. Fluid resuscitation was initiated with NS but was changed to 1/2NS and then LR due to hypernatremia. Patient was started on meropenem and vancomycin for empiric antibiotics. Urine and blood cultures grew Staph epidermidis sensisitive to vancomycin, thus meropenem was discontinued. Repeat blood cultures were negative as of 3 midnights upon discharge. A PICC line was placed for need for 2 weeks of IV antibiotics due to bacteremia. Antibiotics were de-escalated to cefazolin per pharmacy.  A foley catheter was placed on admission. Patient failed a urination trial and had >630cc retention. Foley was placed again and will be left indwelling upon discharge.  It was found that patient's Alk Phos was elevated and has been elevated for the last 4 years in our system. A GGT was ordered and resulted as elevated, indicating likely liver origin of Alk Phos.  Condition at Discharge Stable  Discharge Medications Acetaminophen Oral Tablet 500 MG 1000 MG ORALLY EVERY 8 HOURS AS NEEDED for MILD-MODERATE (PAIN 1-5 ) Ammonium Lactate External Lotion 12 % 1 APP TOPICAL DAILY AT BEDTIME ceFAZolin Sodium Injection Solution Reconstituted 2 GM 2 GM INTRAVENOUSLY EVERY 8 HOURS Colace Oral Capsule 100 MG Continue taking same as home DICLOFENAC GEL 1 % 1 APP TOPICAL TWICE A DAY AS NEEDED for OTHER-SEE COMMENTS Famotidine Oral Tablet 20 MG 20 MG ORALLY TWICE DAILY HYDROcodone-Acetaminophen Oral Tablet 7.5-325 MG 7.5 MG ORALLY EVERY 8 HOURS AS NEEDED for MILD-MODERATE (PAIN 1-6) Lidocaine External Patch 4 % 1 PAT TRANSDERMAL EVERY 12 HOURS AS NEEDED for MILD-MODERATE (PAIN 1-5 ) Lisinopril Oral Tablet 20 MG 20 MG ORALLY ONCE A DAY Magnesium Hydroxide Powder 30 ML ORALLY DAILY AS NEEDED for CONSTIPATION Polyethylene Glycol 3350 Powder Continue taking same as home TAMSULOSIN HCL 0.4 MG ORALLY DAILY AT BEDTIME traMADol HCl Oral Tablet 50 MG 50 MG ORALLY 3 TIMES A DAY AS NEEDED for MILD-MODERATE (PAIN 1-5 ) Tums Oral Tablet Chewable 500 MG 1000 MG ORALLY 3 TIMES A DAY Tussin Cough Oral Syrup 15 MG/5ML 200 MG ORALLY EVERY 4 HOURS AS NEEDED for COUGH Discharge Disposition Transfer to skilled nursing facility (SNF)  Back to facility  Plan ASSESSMENTS: -Sepsis, secondary to UTI, Temperature 98.6 HR 86 RR 20 WBC 10.7 on 12/30/2022, resolved -Acute complicated cystitis, cultures grew Staph epidermidis, resolved -Bacteremia secondary to Staph epidermidis, on cefazolin -Acute kidney injury on chronic kidney disease 3a, AKIN stage 3, Cr 4.4 GFR 13 on admission, secondary to urinary retention and UTI, resolved -Acute urinary retention secondary to chronic benign prostatic hyperplasia requiring catheter placement -Acute COVID-19 infection, COVID positive 12/20/2022, malaise and body aches without respiratory failure, precautions removed -Severe generalized weakness secondary to acute illness, is currently full assist, baseline is independent, occasionally uses walker -Stage I decubitus ulcer sacral region, identified on 12/30/2022 likely due to severe general weakness and acute illness, stable -Stage I decubitus ulcer left heel, present on admission, stable -Hypomagnesemia, Mg 1.5, supplemented -Chronic hypernatremia, acute onset Na 149 on 12/31/2022, secondary to fluid replacement necessary for treatment of sepsis, improved -Elevated alkaline phosphatase, alk-phos 658 on admission, chronic since 2019 -Benign prostatic hyperplasia with outflow obstruction, chronic on tamsulosin, requiring foley catheter placement -Chronic normocytic anemia, present on admission HGB 12.1, HCT 36.4, MCV 89.2, likely anemia of chronic disease secondary to CKD, stable -Osteoarthritis, multiple joints, chronic -Essential hypertension, chronic -Hyperlipidemia, chronic -Peripheral venous insufficiency, chronic -Dementia, chronic, baseline oriented to self -History of chronic UTI secondary to urinary retention and BPH  PLANS: The patient's condition is stable at this time and will be discharged today back to facility. We will discharge the patient on their home medications as reconciled above. We will send the patient home with cefazolin 2 g q.8 hours IV on discharge. We recommend the patient follow up with Dr., general surgery, in 2 weeks for left wound follow-up. A left lower leg doppler should be considered outpatient. We also recommend he see Urology, likely Dr., as soon as possible for urinary retention requiring Foley catheter upon discharge.  His GGT was elevated at 92 and his Alk Phos was 744 on discharge, after PICC line placement. I recommend scheduling an outpatient RUQ ultrasound to evaluate his liver.  New blood cultures will need to be drawn at the end of antibiotics to ensure clearance of bacteremia.  MED CHANGES: -Continue cefazolin 2g Q8H via PICC line until 01/14/2023. -Add Ensure t.i.d. with meals  We thank Dr. and his team for the assistance in caring for this patient.  The patient was evaluated by Dr. and the plan of care was discussed with this resident.  PGY-2  Discharge Instructions Diet Regular with Ensure supplementation TID with meals  Activity As tolerated  Follow up Appointments -2 weeks with Dr. for wound follow-up -As soon as possible with Dr., urology, for urinary retention requiring foley catheter  Primary Care Provider DO  Electronically signed by PGY-1 on Jan-04-2023 0852