Age: 50.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Hypothyroidism, Intensive care, Malnutrition, Necrotising fasciitis, Pleural effusion
Clinical narrative: #Right pulmonary effusion  - s/p 2L fluid removal on right side thoracentesis on 8/30  - Bronch also preformed which showed lots of localized edema likely from anasarca, pulm recommending more aggressive fluid removal.    f/u CXR no new findings, Ive encouraged coughing and use of IS   #Anasarca # protein malnutrition- nutrition following. - TPN .        # RLE DVT -  heparin gtt.  - H&H stable    # Bacteremia W/Serratia and pseudomonas - Repeat blood dx from 8/21 (negative)  - ID had recommend to continue with abx until flap surgery.    Per ID Dr. on 09/06 Switch Cefepime/Flagyl to Vantin 400 mg PO BID x 2 more weeks, if patient doesn't pass his swallow eval today then ceftriaxone 1 g IV q 24 h       # Anemia - has received multiple blood transfusions since his initial hospitalization back in 6/30 and c/b DIC  H/H is stable     # Acute acalculous cholecystitis s/p cholecystostomy tube placement (8/24) - discussed with IR on 9/1 regarding no output through drain-- > surgery was to manage drain, more brisk output after RN milked tubing a few days ago - IR states " drain needs to be in for at least 6 weeks to allow maturity"   # Asymptomatic covid 19 - positive 8/21, isolation ended 8/30     # DM, monitor   # Renal Failure after hospitalization , now on HD - HD started on 7/2, had TDCA placed 7/13 - Appreciate nephrology following - On discharge, will need outpatient HD arranged    # NSTEMI - Seen by cardiology 8/1 -" Patient with minimal troponin elevation in the setting of severe anemia and sepsis.   Plan: Overall - not concerned by the highest troponin I found (0.87 - old scale) - Likely supply/demand mismatch as opposed to plaque rupture. Would medically treat for CAD with bb, statin, aspirin - he is already on all three. I see no role for nuclear stress test because he is in no shape for even considering cardiac cath, has normal EF, and does not have any anginal symptoms. Should be develop angina or possible angina in the future - a perfusion evaluation could be considered" and re " cardiac arrest"-The patient was marginally stable when taken to the OR and after initial induction - likely BP too low and required resuscitation and pressors, which he received. This is different than if he had VT or VF requiring defibrillation. Wife concurred with my readin.    Plan: The use of the term Cardiac arrest implicitly suggests VT/VF and that is not true in this case. In this case seems he had HD collapse from combination of septic and cardiac shock and required resuscitation from that with fluids, pressors. Yes he received brief CPR, but had acceptable HR and BP when he was in ICU. No role for ICD in this patient. His EF was 20% - normalized by 7/20/23 and now is 55%. Normal EKG. So - no concerns that this patient needs any device."   # HYPERTENSION  continue clonidine patch, hydralazine PRN,  BP remains elevated despite hydralazine IV, ok to give Labetalol IV PRN Oral meds are on hold    # Hypothyroid- was on oral levothyroxine   Appreciate Dr. who accepted patient in transfer      Complications: none   Isolation Status/Ongoing Infection Issues:  No isolation orders Allergies:   Allergies Allergen Reactions ? Pepcid [Famotidine] Rash     Rash in testicles. ? Morphine Other. and Swelling     Periorbital swelling/edema after first IV dose     Transfer/Discharge Medications:      Current Facility-Administered Medications Medication Dose Route Frequency Last Admin ? cefTRIAXone Adapter Vial 1 g (ROCEPHIN)  1 g intraVENOUS Q24H (INPT RN check 1st dose) 1 g at 09/06/23 1842 ? [Manual Hold] hydrALAZINE Tab 50 mg (APRESOLINE)  50 mg Oral Q8H (INPT RN check 1st dose)   ? Insulin Regular Human Sliding Scale Inj (HumuLIN R/NovoLIN R)   Subcutaneous Q6H 6 Units at 09/07/23 1244 ? cloNIDine 0.1 mg/24 hr 2 Patch (CATAPRES-TTS 1)  2 Patch Transdermal QTHU 2 Patch at 09/07/23 0813 ? 1.2 Micron Filter 1 Each  1 Each MISCELLANEOUS Daily 1 Each at 09/06/23 2126 ? Collagenase Clostridium hist. 250 unit/gram Ointment (SANTYL)   Topical Daily Given at 09/06/23 0929 ? Albuterol 2.5 mg /3 mL (0.083 %) Neb Soln 2.5 mg (PROVENTIL/VENTOLIN)  2.5 mg NEBULIZATION -UNSPEC QID 2.5 mg at 09/07/23 0742 ? Sodium Chloride 3 % Neb Soln 4 mL  4 mL NEBULIZATION -UNSPEC QID 4 mL at 09/07/23 0744 ? Nystatin 100,000 unit/gram Topical Powder (MYCOSTATIN)   Topical TID Given at 09/07/23 0812 ? Sodium Chloride 0.9 % IV Bolus  250 mL intraVENOUS Transfusion   ? HYDROmorphone Inj Syg 0.8 mg (DILAUDID)  0.8 mg intraVENOUS X1   ? TPN/PPN Per Protocol  1 Each intraVENOUS see instruction   ? [Manual Hold] Gabapentin Cap 300 mg (NEURONTIN)  300 mg Nasogastric BID   ? [Manual Hold] NEPHRO-VITE / FULL SPECTRUM 0.8 mg 1 tablet (Vitamin B Complex-Vit C-FA)  1 tablet Oral Daily   ? Chlorhexidine Gluconate Oral Soln 15 mL (PERIDEX)  15 mL Oral Q12H 15 mL at 09/07/23 0811 ? Sodium Chloride 0.9% Inj Syg 3 mL (NORMAL SALINE FLUSH)  3 mL intraVENOUS Q8H while awake 3 mL at 09/06/23 0658 ? Pantoprazole Inj 40 mg (PROTONIX)  40 mg intraVENOUS Daily (INPT RN check 1st dose) 40 mg at 09/07/23 0811 ? [Manual Hold] Levothyroxine Tablet 25 mcg (LEVOTHROID/SYNTHROID)  25 mcg Nasogastric Daily AC   ? [Manual Hold] Amiodarone Tab 200 mg (PACERONE)  200 mg Nasogastric Daily (INPT RN check 1st dose)   ? [Manual Hold] Carvedilol Tab 25 mg (COREG)  25 mg Nasogastric BID with meals   ? Pharmacy Renal Monitoring  1 Each Miscell. (Med.Supl.;Non-Drugs) see instruction        Current Facility-Administered Medications Medication Dose Route Frequency Last Rate Last Admin ? Parenteral Nutrition Adult Ion-Based 3-in-1   intraVENOUS CONTINUOUS Parenteral Nutrition     ? Parenteral Nutrition Adult Ion-Based 3-in-1   intraVENOUS CONTINUOUS Parenteral Nutrition 62.5 mL/hr at 09/06/23 2126 New Bag at 09/06/23 2126 ? [Manual Hold] D10-NaCl 0.45 % IV Premix   intraVENOUS Continuous     ? Heparin (Porcine) in D5W 25,000 unit/250 mL(100 unit/mL) IV Premix  2,000 Units/hr intraVENOUS Per protocol - continuous 20 mL/hr at 09/03/23 1950 2,000 Units/hr at 09/03/23 1950      Current Facility-Administered Medications Medication Dose Route Frequency Last Admin ? Labetalol IV Syg 10 mg  10 mg intraVENOUS Q10MIN PRN 10 mg at 09/07/23 1219 ? hydrALAZINE Inj 10 mg (APRESOLINE)  10 mg intraVENOUS Q6H PRN 10 mg at 09/07/23 1019 ? HYDROmorphone Inj Syg 0.8 mg (DILAUDID)  0.8 mg intraVENOUS Daily PRN 0.8 mg at 09/04/23 0947 ? HYDROmorphone Inj Syg 0.5 mg (DILAUDID)  0.5 mg intraVENOUS Q2H PRN 0.5 mg at 09/07/23 1235 ? Saliva Substitution Combo Mouthwash 15 mL (BIOTENE DRY MOUTH ORAL RINSE)  15 mL Oral Q6H PRN 15 mL at 08/27/23 2038 ? D10W IV Premix   intraVENOUS PRN   ? Lidocaine (PF) 10 mg/mL (1 %) Inj 1 mg (XYLOCAINE)  0.1 mL Intradermal PRN   ? Sodium Chloride 0.9% Inj Syg 3 mL (NORMAL SALINE FLUSH)  3 mL intraVENOUS PRN 3 mL at 09/07/23 1019 ? Metoclopramide Inj 5 mg (REGLAN)  5 mg intraVENOUS Q6H PRN 5 mg at 08/31/23 1246 ? Acetaminophen Tablet 650 mg (TYLENOL)  650 mg Oral Q4H PRN     Or ? Acetaminophen Supp 650 mg (TYLENOL)  650 mg Rectal Q4H PRN   ? oxyCODONE IR Tab 5 mg (ROXICODONE)  5 mg Oral Q6H PRN     Or ? HYDROmorphone Inj Syg 0.2 mg (DILAUDID)  0.2 mg intraVENOUS Q2H PRN   ? Lactulose Oral Soln 20 g  30 mL Oral BID PRN   ? WEB LINK HYPOGLYCEMIA  1 Each Miscell. (Med.Supl.;Non-Drugs) Per protocol - multiple doses   ? D50W Inj Syg 12.5 g  25 mL intraVENOUS Per protocol - multiple doses   ? D50W Inj Syg 25 g  50 mL intraVENOUS Per protocol - multiple doses   ? Glucagon Inj 1 mg (GLUCAGEN HYPOKIT)  1 mg intraMUSCULAR Per protocol - multiple doses   ? D5W IV Premix  100 mL/hr intraVENOUS Per protocol - multiple doses   ? Heparin Per Protocol  1 Each intraVENOUS Per protocol - multiple doses   ? WEB LINK HEPARIN (NON-CARDIAC)  1 Each Miscell. (Med.Supl.;Non-Drugs) Per protocol - multiple doses   ? Albuterol 90 mcg/actuation HFA MDI 4 Puff (PROAIR/PROVENTIL/VENTOLIN)  4 Puff Inhalation Q4H PRN 4 Puff at 08/26/23 1315         Diagnoses:   Active Hospital Problems   Diagnosis   ? (Principal) NECROTIZING FASCIITIS   ? ACUTE DVT OF RIGHT FEMORAL VEIN   ? ACUTE NON ST ELEVATION MI       In setting of septic and cardiogenic shock due to necrotizing fasciitis. Highest troponin was 0.87 (old scale).   ? ATRIAL FIBRILLATION, UNSPECIFIED   ? HX OF CARDIAC ARREST       This was a misnomer, as no VT/VF event that I could find and no defibrillations recorded. No code note. Best summary was loss of blood pressure upon induction for surgery and was in septic shock treated with 3 pressors in ICU on 6/30/23.   ? ACUTE RENAL FAILURE, UNSPECIFIED   ? DM 2 W CKD STAGE 4 (GFR 15-29)     Resolved Hospital Problems No resolved problems to display.     Primary Procedures:  Procedure(s): CHOLECYSTOSTOMY   Secondary Procedures:  None   Consults: NEPHROLOGY - ONGOING INPATIENT CONSULTATION. GASTROENTEROLOGY - INITIAL INPATIENT CONSULTATION. GASTROENTEROLOGY - ONGOING INPATIENT CONSULTATION. HEAD AND NECK SURGERY - INITIAL INPATIENT CONSULTATION. HEAD AND NECK SURGERY - ONGOING INPATIENT CONSULTATION. GENERAL SURGERY - INITIAL INPATIENT CONSULTATION. GENERAL SURGERY - ONGOING INPATIENT CONSULTATION.   Condition on Discharge:  stable   Code Status at Time of Discharge: Full Code   Discharge Disposition:          Note Details  Author (M.D.) File Time 9/7/2023  1:43 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine  Admission (Discharged) on 8/23/2023  Admission (Discharged) on 8/23/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  CHOLECYSTOSTOMY From 8/24/2023 to 8/25/2023  Hospital Problem List   DM 2 W CKD STAGE 4 (GFR 15-29)  ATRIAL FIBRILLATION, UNSPECIFIED  HX OF CARDIAC ARREST  NECROTIZING FASCIITIS  ACUTE RENAL FAILURE, UNSPECIFIED  ACUTE NON ST ELEVATION MI  ACUTE DVT OF RIGHT FEMORAL VEIN Care Timeline  08/23   Admitted 0121 09/07   Discharged 0115  Discharge   Acute Care Facility (another hospital)