Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Intentional medical device removal by patient, Leukocytosis, Lymphocyte count decreased, Lymphocyte percentage decreased, Malnutrition
Clinical narrative: Date of Admission:  10/11/2023    Date of Discharge:  10/23/2023    Primary Care Physician:  MD   Pending Study Results at Discharge: None   Issues to be Addressed in Follow-up: - TPN labs to monitor? - Has oral intake improved? - discomfort/pain management?   Reason for Hospital Admission (Admitting Diagnosis):  abdominal infection, hypoglycemia    HPI on admission per Dr:  Patient is a 85 Y female with past medical history of advanced dementia, status post extensive subtotal pancreatectomy, subtotal colectomy on 9/8/2023 for pancreatic cancer, recent admission 9/26 through 10/2 for hemoperitoneum status post IR PEG tail drainage on 9/27/2023, cachexia, hypertension, GERD, who presented to IR for outpatient PICC line and then initiation of TPN for poor p.o. intake.  Patient has not done well after surgery she is essentially been nonambulatory since that time.  Also she has been unable to eat or drink much with coughing gagging and choking after eating.  Recently she has been able to consume approximately 200 mL only of a nutritional supplement and a couple teaspoons of cottage cheese in a day.  No recent fevers or chills.  No nausea vomiting.  Her colostomy is working well and has brown stool output, she has an intraperitoneal drain placed 9/27/23 for possible abscess but only drained blood.  Her daughter has been flushing the drain every 8 hours and has been working well.  No pus no foul odor.  Minimal output.  The daughter does note coughing gagging choking with drinking.  The patient over the last day has been obtunded not speaking.  For me now the patient barely opens her eyes and is nonverbal and not answering any questions.  At baseline the patient almost always remembers her first name and with some coaxing can remember her last name.  She recognizes her daughter and grandson at baseline.  Since the surgery she is essentially been bedbound she is walked 7 steps with a walker with a two-person assist per the daughter just after the surgery but has been completely bedbound at home recently. The daughter confirms the patient's DNR/DNI, she says that she is hoping that like a flower her mother will "perk up" with nutrition.   ED course: After the patient's outpatient IR procedure in which she received no IV sedation she was sent to the emergency department given her obtunded state and for further initiation of TPN.  Sodium 158,  WBC 14.5. fluids, abx ordered.  covid positive- not clear if patient has symptoms (possibly fatigue)   Hospital Course: Patient is a 85 Y  female with history of advanced dementia, pancreatic cancer status post subtotal pancreatectomy and subtotal colectomy 9/8/23 complicated by hemoperitoneum status post IR pigtail drainage on 9/27/2023, presented with cachexia and failure to thrive.  Patient admitted from our department for outpatient PICC line with plan to start TPN due to poor oral intake.  After procedure patient was obtunded and found to have COVID along with hyponatremia and leukocytosis and admitted on 10/11.  During admission patient became hypotensive despite fluids and was transferred to ICU, patient was transferred to the floor on 10/14.  Patient had Dobbhoff placed but now removed.  Passed swallow study but poor p.o. intake and still needing TPN.  Family seen by palliative care on 10/18 but not ready for hospice.  TPN restarted on 10/19.  Awaiting TPN supplies to be delivered 10/23 evening prior to discharge Pt was started on 5 mg BID NPH for hyperglycemia which was decreased to 3 units for an episode of hypoglycemia. Pt's family would like to minimize finger pokes and at this point it's better for pt's sugars to run on the higher end than too low. Pt will be discharged on 3 units NPH BID.  JP drain was leaking/not draining properly. Gen surgery was consulted and repeat CT abd/pelvis ***   Significant Findings:    Please see above   Hospital Course By Problem: Patient Active Hospital Problem List: FAILURE TO THRIVE DM 2 (1/6/2006) Likely combination of surgical complications + advancing dementia Tried dobhoff without success (pt kept on trying to push tube out with her tongue) minimal po intake Poor candidate for PEG tube - Pt interested in TPN and not ready for hospice, TPN started 10/19 - awaiting TPN supplies to be dropped off at home 10/23 at 19:00 - BS elevated likely d/t TPN, started NPH 5 units BID on 10/21, decreased to 3 units BID 10/22 due to hypoglycemia - SSI, can d/c at discahrge - monitor BS while on NPH and med ISS - Pt's family would like to minimize finger pokes and at this point it's better for pt's sugars to run on the higher end than too low - Will d/c BP measurement per family request as it has been agitating pt, SBP's for the last 48 hrs 110-140s  PANCREATIC MASS (8/22/2023) PRESENCE OF COLOSTOMY (7/25/2023) NONTRAUMATIC HEMOPERITONEUM (9/27/2023) - s/p subtotal pancreatectomy, segmental colectomy on 9/8/23, complicated by pancreatic leak and hemoperitoneium - cont JP drain care, hepatobiliary surgery to determine when drain can be dc'd - Daughter reports JP drain has been leaking air/not draining for the last week. Surgery notified and evaluated, CT abd/pelvis pending to see if pt can d/c the drain  ALZHEIMERS DISEASE, LATE ONSET (10/11/2023) - supportive care.management         DYSPHAGIA - passed for mech soft but pt has no appetite    ASPIRATION PNEUMONIA - resp status stable - completed 7 days of Zosyn - aspiration precautions   PLEURAL EFFUSION - left sided, possibly related to IV received from recent / current hospitalization, 3rd spacing from malnutrition - on RA, stable respiratory status   COVID  - incidental finding 10/11, finished RDV, respiratory status stable, on RA - finished 10 days of COVID isolation   GERD (GASTROESOPHAGEAL REFLUX DISEASE) (3/25/1999) - cont PPI     Physical Exam: BP 143/54  | Pulse 62  | Temp 96.8 °F (36 °C)  | Resp 18  | Wt 61.5 kg (135 lb 9.3 oz)  | SpO2 94%  | Breastfeeding No  | BMI 24.02 kg/m²    Physical Exam    Recent Labs Recent Results (from the past 24 hour(s)) GLUCOSE, RANDOM, BLOOD, GLUCOMETER, FDA APPROVED   Collection Time: 10/22/23  3:50 PM Result Value Ref Range   GLUCOSE, BLOOD, GLUCOMETER 125 60 - 159 mg/dL   POCT CLIA SEE COMMENT   GLUCOSE, RANDOM, BLOOD, GLUCOMETER, FDA APPROVED   Collection Time: 10/22/23  6:20 PM Result Value Ref Range   GLUCOSE, BLOOD, GLUCOMETER 135 60 - 159 mg/dL   POCT CLIA SEE COMMENT   GLUCOSE, RANDOM, BLOOD, GLUCOMETER, FDA APPROVED   Collection Time: 10/22/23 10:01 PM Result Value Ref Range   GLUCOSE, BLOOD, GLUCOMETER 312 (H) 60 - 159 mg/dL   POCT CLIA SEE COMMENT   MAGNESIUM   Collection Time: 10/23/23  7:06 AM Result Value Ref Range   MAGNESIUM 2.0 1.7 - 2.3 mg/dL CHEM 7 (NA, K, CL, CO2, BUN, GLUC, CR)   Collection Time: 10/23/23  7:06 AM Result Value Ref Range   Sodium 134 (L) 135 - 145 mEq/L   Potassium 4.7 3.5 - 5.3 mEq/L   Chloride 102 100 - 111 mEq/L   CO2 27 24 - 33 mEq/L   Anion gap, ser/plas 5 5 - 16 mEq/L   BUN 22 7 - 27 mg/dL   GLUCOSE, RANDOM 382 (H) 60 - 159 mg/dL   Creatinine 0.48 <=1.11 mg/dL PHOSPHATE   Collection Time: 10/23/23  7:06 AM Result Value Ref Range   Phosphorus 2.7 2.7 - 4.5 mg/dL   Narrative   While on TPN CALCIUM, SERUM   Collection Time: 10/23/23  7:06 AM Result Value Ref Range   Calcium 7.9 (L) 8.8 - 10.5 mg/dL   Narrative   While on TPN CBC W AUTOMATED DIFFERENTIAL   Collection Time: 10/23/23  7:06 AM Result Value Ref Range   WBC COUNT 6.4 3.7 - 11.1 K/uL   Red blood cells count 3.07 (L) 3.60 - 5.70 M/uL   Hgb 9.7 (L) 11.5 - 15.0 g/dL   Hematocrit 30.6 (L) 34.0 - 46.0 %   MCV 100 80 - 100 fL   RDW, RBC 19.9 (H) 12.0 - 16.5 %   Platelets count 348 140 - 400 K/uL   RBC's, nucleated 0 <=0 /100WC   Differential panel AUTO DIF   WBC AUTO DIFF   Collection Time: 10/23/23  7:06 AM Result Value Ref Range   Neutrophils, Automated Count 4.9 1.8 - 7.9 K/uL   Lymphocytes, Automated Count 0.7 (L) 0.9 - 3.2 K/uL   Monocytes, Automated Count 0.5 0.3 - 0.9 K/uL   Eosinophils, Automated Count 0.3 0.0 - 0.4 K/uL   Basophils, Automated Count 0.0 0.0 - 0.1 K/uL   Immature Granulocytes, Automated Count 0.0 0.0 - 0.1 K/uL   Neutrophils %, Automated count 77 %   Lymphocytes %, Automated count 10 %   Monocytes %, Automated Count 8 %   Eosinophils %, Automated Count 4 %   Basophils %, Automated Count 1 %   Immature Granulocytes %, Automated Count 0 % GLUCOSE, RANDOM, BLOOD, GLUCOMETER, FDA APPROVED   Collection Time: 10/23/23 12:19 PM Result Value Ref Range   GLUCOSE, BLOOD, GLUCOMETER 237 (H) 60 - 159 mg/dL   POCT CLIA SEE COMMENT          Complications:  None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) HYPERNATREMIA   ? ALZHEIMERS DISEASE, LATE ONSET   ? COVID-19 DISEASE       No hypoxemia, no fever.    ? HYPOTENSION   ? NONTRAUMATIC HEMOPERITONEUM   ? PANCREATIC MASS       Added automatically from request for surgery 2191412   ? PRESENCE OF COLOSTOMY   ? DM 2       DM 2 WO RETINOPATHY [E11.9] » DM 2 [E11.9]   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)     Resolved Hospital Problems No resolved problems to display.     Primary Procedures:        Secondary Procedures: None   Consults:  Palliative Care General surgery    Condition on Discharge:  Stable    Code Status at Time of Discharge: DNR   Smoker: No.     Discharge Disposition:  Home with Home Health   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).      Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Oct 23, 2023  1:00 PM  CT Scan CT SCAN APPOINTMENT 128-VAC CT SCAN          DO   10/22/2023 5:58 PM               Note Details  Author (D.O.) File Time 10/23/2023 12:24 PM Author Type PHYSICIAN (D.O.) Status Incomplete Last Editor (D.O.) Specialty Hospital Medicine Hospital Acct #  Admit Date 10/11/2023  ED to Hosp-Admission (Current) on 10/11/2023  ED to Hosp-Admission (Current) on 10/11/2023   Detailed Report  Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   GERD (GASTROESOPHAGEAL REFLUX DISEASE)  DM 2  PRESENCE OF COLOSTOMY  PANCREATIC MASS  ALZHEIMERS DISEASE, LATE ONSET  HYPERNATREMIA  NONTRAUMATIC HEMOPERITONEUM  COVID-19 DISEASE  HYPOTENSION Care Timeline  10/11   Transferred to ICU 1646   Admitted from ED (Observation) 1646 10/12   Admitted 1507 10/13   Transferred out of ICU 1755 10/16   Rapid Response    Transferred to ICU 1925 10/18   Transferred out of ICU 0940  Expected Medication List at Discharge   acetaminophen 500 mg Take 1 to 2 tablets by mouth every 6 hours as needed for pain or fever. Do not exceed 6 tablets in 24 hours  blood sugar diagnostic   1 Strip Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  1 Strip Miscell. (Med.Supl.;Non-Drugs) 4 TIMES A DAY, to measure blood sugar. Measure blood sugar before meals and at bedtime  blood-glucose control, normal   Use as directed with blood glucose meter  Use as directed with blood glucose meter  Use as directed with blood glucose meter  blood-glucose meter   Use as directed to test blood sugar  Use as directed to test blood sugar  dextrose 70 % in water TPN 3:1 soln 1790 mL (Dextrose 15 %/Amino acid 5 %/Lipid 2.95 %): Infuse 1690 mL intravenously over 16 hours daily via CADD SOLIS pump, as directed for nutrition. Compounded by pharmacy. CADD SOLIS SETTINGS: inf vol = 1690 mL, duration = 16 hrs, taper up 1 hr, taper down 1 hr hr, kvo = 5 mL/hr, mode = taper, res vol = 1790 mL  dronabinol 5 mg Oral 2 TIMES A DAY  empagliflozin 25 mg Oral EVERY MORNING  insulin NPH human isophane 3 Units Subcutaneous 2 TIMES A DAY BEFORE MEALS  lancets   30 gauge Misc, 1 Each Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  30 gauge Misc, 1 Each Miscell. (Med.Supl.;Non-Drugs) 4 TIMES A DAY, to measure blood sugar. Measure blood sugar before meals and at bedtime  multivit,calc,mins/iron/folic 9 mg iron-400 mcg 1 tablet Oral DAILY  oxycodone HCl 5 mg Oral EVERY 6 HOURS AS NEEDED, . Begin weaning off over the 5 days following discharge. Ok to take with tylenol.  pantoprazole sodium 40 mg Oral DAILY BEFORE BREAKFAST  sennosides 8.6 mg Take 2 tablets by mouth 2 times a day . NOTE: Change in strength and directions due to medication availability.  simvastatin 40 mg Take 1 Tablet By Mouth Daily (Note: This Medication Will Help Prevent Heart Attacks and Strokes)  sodium chloride 0.9 % (flush)   Use 10 mL by Injection route every 12 hours Flush IR drain with 10 mL every 12 hours to keep the drain patent.  0.9% Syringe, Sodium chloride 0.9 % 10 mL BD POSIFLUSH SYRINGE: Flush catheter with 10 mL before and 20 mL after TPN infusion. Flush unused lumens daily and flush after blood draws with 10 mL, or as directed by RN  syringe w-needle,disposab,3 mL 3 mL 23 x 1" Use to draw octerotide solution into syringe  syringe with needle, 1 mL 1 mL 27 x 1/2" Use as directed  syringe, disposable, 1 mL 1 mL 1 Each Miscell. (Med.Supl.;Non-Drugs) 3 TIMES A DAY PT is in house Bed