Age: 54.0
Sex: M
Vaccine: COVID19
Symptoms: Lymphocyte percentage decreased, Magnetic resonance imaging head abnormal, Monocyte count normal, Monocyte percentage increased, Neutrophil percentage
Clinical narrative: Date of Admission: 12/12/2023   Date of Discharge: 12/13/2023   Issues to be Addressed at Follow-up:   Hypocalcemia: Suspect due to tertiary hyperparathyroidism.  Serum calcium 8.7 at time of discharge (serum albumin not available at this time, but last value was close to normal.)  Appreciate Dr.'s assistance with management.  Will discharge on the following: Times 2000 mg nightly Calcitriol 2 mcg daily PhosLo 3 times daily with meals Ergocalciferol 50,000 units daily for 7 days, then weekly.     Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/12/2023  8:14 PM CALCIUM, IONIZED In process --   12/12/2023  3:15 PM VITAMIN D, 1,25-DIHYDROXY In process --   12/12/2023  3:15 PM CALCIUM, IONIZED In process --   12/12/2023  8:47 AM CALCIUM, IONIZED In process --   12/12/2023  1:43 AM VITAMIN D, 1,25-DIHYDROXY In process --   12/12/2023  1:43 AM PARATHYROID RELATED PROTEIN, RIA In process --   12/12/2023  1:43 AM ALUMINUM In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) HYPOCALCEMIA   ? TERTIARY HYPERPARATHYROIDISM   ? COVID-19 PNEUMONIA   ? ESRD ON DIALYSIS       1/9/2022 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  Followed by Dr. (nephrology) On dialyses since 12/2021   ? HTN (HYPERTENSION)       6/8/2022 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  Amlodipine 10mg daily  Hydralazine 75mg three times daily.  Coreg 6.25 - 1.5 tablets twice daily    Blood pressure has been in the systolic 150s-160s at home (consistent with hospital blood pressure readings). No chest pain or shortness of breath. No headaches.  Verified blood pressure medications.    A/P: advised increase hydralazine to 100mg three times daily (max dose).  Sending message to his nephrologist.     BP Readings from Last 3 Encounters: 05/11/22 152/80 04/29/22 140/78 04/25/22 154/77       ? HX OF STROKE       1/31/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  On crestor 5mg.  aspirin 81mg   From hospital note: Hx of Stroke; new  Stroke vs TIA vs Hypoglycemia  - highly suspect either TIA vs recrudescent symptoms of old stroke from hypoglycemia vs hypertension  - hypoglycemia likely due to use of glipizide in renal failure, hold glipizide - s/p 1 amp d50 and 4 boxes juice - q 2 hour blood sugar checks x 3, then q 4 hours - D10 at 20 cc/hr - s/p MRI - s/p CT scan - check ECHO - Neurology consulted (Dr.) in ED by Dr., reviewed case and advised start ASA and Atorvastatin, no DAPT - event monitor on discharge   1/4/2022 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  Lovastatin - consider atorvastatin Aspirin   7/11/18 MRI brain  Impression Acute infarct in the left dorsal brainstem.           Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 56-year-old male with end-stage renal disease on hemodialysis and hyperparathyroidism who was asked to come to the hospital due to severely low serum calcium 5.8).  Remarkably, asymptomatic.  Received intravenous calcium supplementation and hemodialysis.  Calcium at time of discharge was 8.7.  As patient remained asymptomatic, and has a plan for medical management of his hyperparathyroidism put in place with the assistance of his nephrologist Dr., I felt it safe for patient to return home today.  See above for management of hypocalcemia.   Incidentally found to have COVID-19 disease.  On further questioning, patient reports he developed a cough 2 days ago on December 11.  However he  was not observed to be coughing in the hospital.  As the patient was not hypoxic and had no respiratory symptoms, he did not receive directed treatments for COVID-19 while hospitalized.  Isolation instructions given at time of discharge.   Hemodialysis has been arranged for the patient and the facility that accepts COVID patients.  Patient will receive hemodialysis tomorrow, and again on Saturday.   Primary Procedures:  None   Secondary Procedures: Hemodialysis   Reason for Hospital Admission (Admitting Diagnosis):  Hypoglycemia   Complications: none   Consults:  NEPHROLOGY - INITIAL INPATIENT CONSULTATION. NEPHROLOGY - ONGOING INPATIENT CONSULTATION. HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code   Day of Discharge Exam:    Objective: Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery 12/13/23 1530 99.8 °F (37.7 °C) Oral 80 169/85 11 99 % RA 12/13/23 1440 100.2 °F (37.9 °C) ? 72 211/77 16 98 % RA 12/13/23 1415 100.2 °F (37.9 °C) Oral 66 211/77 12 ? ? 12/13/23 1400 ? ? 68 209/84 18 ? ? 12/13/23 1345 ? ? 65 202/96 16 ? ? 12/13/23 1330 ? ? 74 202/92 13 ? ? 12/13/23 1315 ? ? 71 212/95 16 ? ? 12/13/23 1300 ? ? 64 221/95 17 ? ? 12/13/23 1245 ? ? 63 202/89 18 ? ? 12/13/23 1230 ? ? 63 192/97 12 ? ? 12/13/23 1215 ? ? 73 204/81 14 ? ? 12/13/23 1200 ? ? 62 181/88 11 ? ? 12/13/23 1145 ? ? 67 181/87 19 ? ? 12/13/23 1130 ? ? 63 159/102 14 ? ? 12/13/23 1115 ? ? 59 167/86 16 ? ? 12/13/23 1100 ? ? 60 175/88 17 ? ? 12/13/23 1045 ? ? 62 184/86 20 ? ? 12/13/23 1015 98.5 °F (36.9 °C) ? 62 133/78 16 98 % RA 12/13/23 0949 100.5 °F (38.1 °C) Oral 68 133/78 12 98 % RA 12/13/23 0552 99.8 °F (37.7 °C) Oral 75 137/80 16 98 % RA 12/13/23 0052 99.1 °F (37.3 °C) Oral 78 185/91 20 99 % RA 12/12/23 2300 ? ? 78 138/85 21 95 % RA 12/12/23 1900 ? ? 69 142/87 12 98 % RA 12/12/23 1800 ? ? 75 159/86 20 96 % RA 12/12/23 1704 ? ? 74 158/87 15 97 % RA   Weight: 80.1 kg (176 lb 9.4 oz)   Intake/Output Summary (Last 24 hours) at 12/13/2023 1702 Last data filed at 12/13/2023 1415  Gross over last 24 hours Intake 0 ml Output 2000 ml Net -2000 ml       Physical Exam:   General appearance: Well appearing  Level of consciousness: Awake and alert Cardiac Exam: RRR. No ectopy. No murmur.  Respiratory Exam: Breathing even and non-labored. Speaking in full sentences. Lungs clear to ausculation bilaterally.  Abdominal Exam: non distended, soft, non tender Extremity Exam: Left BKA. Hemodialysis access in the left upper arm.    Selected Results: Last CBC    Recent Labs   12/13/23 0210 WBC 4.0 HGB 12.1* HCT 38.5* PLT 127*   Last Auto Dif    Recent Labs   12/13/23 0210 NEUT 67 LYMPH 17 | 0.7* MONO 0.6 | 15 EOS 0 | 0.0   Last Chem 7    Recent Labs   12/13/23 0210 NA 135 K 4.6 CL 96* CO2 23* BUN 58* CR 9.75* RBS 125   Last Ca, Mg, Phos    Recent Labs   12/13/23 1446 12/12/23 1430 12/12/23 0847 CA 8.7*   < > 7.0* MG  --   --  1.9 PHOS  --   --  4.6*  < > = values in this interval not displayed.   MD  12/13/2023 5:07 PM         Note Details  Author (M.D.) File Time 12/13/2023  5:07 PM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 12/12/2023  ED to Hosp-Admission (Discharged) on 12/12/2023  ED to Hosp-Admission (Discharged) on 12/12/2023   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   Hospital Problem List   HTN (HYPERTENSION)  ESRD ON DIALYSIS  TERTIARY HYPERPARATHYROIDISM  HYPOCALCEMIA  HX OF STROKE  COVID-19 PNEUMONIA Care Timeline  12/13   Admitted from ED (Observation) 0024    Discharged 2000  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/13/2023) 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  amlodipine besylate 10 mg Oral DAILY  aspirin 81 mg Oral DAILY  blood-glucose control, normal Use as directed with blood glucose meter  blood-glucose meter Use as directed to test blood sugar  calcitriol 2 mcg Oral DAILY  calcium acetate 1,334 mg Oral 3 TIMES A DAY WITH MEALS  calcium carbonate 2,000 mg Oral EVERY BEDTIME  carvedilol 12.5 mg Oral 2 TIMES A DAY WITH MEALS  ergocalciferol (vitamin D2) 1,250 mcg (50,000 unit) Take 1 capsule by mouth daily for 7 days, then take one capsule by mouth once per week.  ezetimibe 10 mg Oral DAILY  folic acid/vit B complex and C 0.8 mg 1 tablet Oral DAILY  hydralazine HCl 100 mg Oral 3 TIMES A DAY, with food  lancets 30 gauge 1 Each Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  pantoprazole sodium 40 mg Oral 2 TIMES A DAY BEFORE MEALS  rosuvastatin calcium 5 mg Oral DAILY