Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Echocardiogram normal, Haemodialysis, Hypotension, Hypovolaemia, Ischaemia
Clinical narrative: Admission Date: 4/25/2022 Discharge Date: Aug 25, 2022  PRESENTING PROBLEM: Osteomyelitis (HCC) [M86.9] Chest pressure [R07.89] Chronic ulcer of left foot with necrosis of muscle (HCC) [L97.523] Subacute osteomyelitis of left foot (HCC) [M86.272] Dyspnea, unspecified type [R06.00]   HOSPITAL COURSE: 4 y.o. male with a pertinent past medical history of ESRD on PD, CAD s/p CABG/stent 2005, HFpEF, T1DM, PVD s/p R BKA, pAfib, PUD, hx PE/DVT, and LLE diabetic ulcer, and severe Aortic stenosis/mitral stenosis who presented essentially for left lower extremity osteomyelitis status was initially on empiric antibiotic therapy that was stopped after achieving surgical BKA on 05/03. Prior to his BKA needed cardiac optimization the setting of his severe AS, MS. Cardiology was consulted who took the patient for BAV and RHC on 04/26. From admission till 05/02 he required to have intermittent oxygen requirements and was volume up (visible on daily chest x-ray) as result nephrology continued aggressive peritoneal dialysis until 05/02. Nephrology ultimately recommended transition to hemodialysis on 6/4/22. During this hospitalization, patient developed hypotension secondary to hypovolemia leading to ischemia (in the setting of low-flow state, however echocardiogram limited performed with gradient within normal range) he received 1.5 L of fluid resuscitation, and his midodrine of 20 mg 3 times a day was continued. He was then optimized for BKA and underwent on 05/03 by vascular surgery. Additionally during this admission he was noted to have witnessed aspiration as result SLP was consulted recommended swallow study and now on dysphagia diet. GI with no emergent indication for EGD. Lastly he is a type 1 diabetic on insulin pump being managed by the GMS. His diabetes was managed in the hospital. Dietitian was consulted to optimize nutrition intake. Difficulty placing patient in SAR given peritoneal dialysis and HBO treatment, discharges could be getting delayed. Further complicated by wound necrosis and dehiscence. Vascular was reconsulted who performed wound washout on 6/13, 6/15, 6/17 with wound vac placement. Intraoperative wound cultures positive for Klebsiella. ID was consulted who recommend 10 days of Ceftriaxone. Given the nonhealing surgical site, HBO was started on 7/6. Patient tolerated it well. Patient presented with otitis media which was well controled cipro drops 7 days and atrovent. Hospitalization complicated by moderate suicidal ideation as discovered by social work team. Psychiatry was consulted and patient was evaluated on 7/14 with recommendation that patient benefit from rehab instead of inpatient psych.  Patient continued to receive dialysis as well as HBO treatment. On 8/11, patient was diagnosed with COVID infection and was placed on isolation for 10 days.  Patient was started on Decadron 6 mg for a period of 10 days.  Respiratory status continues to improve requiring minimal oxygen support.  We will continue to follow up with social work and care management SAR placement. On 08/20, patient completed full course of Decadron and respiratory precautions were discontinued.  PaInitially, patient was supposed to complete hemodialysis on 08/22 and get discharged after.  However, patient was seen by Nephrology with recommendation to complete hemodialysis daily.  After completing 4 days of daily dialysis, patient was medically stable for discharge.  Further follow-up appointments and instructions were discussed with patient at bedside.  Patient understands and agrees with the plan of care.  Patient was hemodynamically stable at discharge.