Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Atrial fibrillation, Bacteraemia, Blood bicarbonate decreased, Blood chloride decreased, Blood creatinine increased
Clinical narrative: Hospitalized (12.31.21 - still admitted currently); COVID-19 positive (12.31.21); Fully vaccinated - moderna x2 H&P: History and Physical   Date of Admission: 12/31/2021   Chief complaint End stage renal disease on dialysis    Assessment and Plan Principal Problem:   End stage renal disease on dialysis  Active Problems:   Coronary artery disease of native artery of native heart with stable angina pectoris   Essential hypertension   Chronic diastolic heart failure    Recurrent right pleural effusion   Type 2 diabetes mellitus with hypoglycemia without coma    Atrial fibrillation, unspecified type    COVID-19     PLAN ESRD on HD Hyponatremia Hyperkalemia: - Missed multiple dialysis sessions since last week due to feeling unwell and vomiting - monitor on telemetry - consult nephrology for dialysis   COVID-19 with possible pneumonia - vaccinated but has not received booster - Developed symptoms on 1 week ago, date of positive test 12/31 - Chest x-ray shows bilateral central lung opacities, correlate for edema or pneumonia - currently not a candidate for decadron or remdesivir.  Can consider monoclonal antibodies - Symptomatic treatment with tylenol, antitussives, PRN albuterol, etc   DMII: - continue lantus and correction scale   Chronic diastolic CHF Unspecified atrial fibrillation Essential hypertension CAD: - BPs stable - continue amlodipine, carbedilol, nifedipine, losartan - continue ASA     DVT prophylaxis: heparin sq Code Status:  Full code, per discussion with patient     History of Present Illness History obtained from patient, ED physician/records, and personally reviewedpast medical records.   Patient is a 70 y.o. male who presents today with weakness, fatigue, nausea/vomiting, diarrhea.  Patient has a history of end-stage renal disease on hemodialysis, chronic diastolic CHF, unspecified atrial fibrillation, essential hypertension, coronary disease, type 2 diabetes, PRES syndrome.  He was recently hospitalized from 12/20-12/24 with hypertensive emergency.  He had a full run of dialysis on 12/24 and he was discharged home.  He states that he felt okay at the time of discharge, however, since then, he has been feeling very weak.  He was unable to go to his dialysis 1 week ago.  Since then he has missed his dialysis due to either weakness or vomiting.  He states that he feels very fatigued and has also been having diarrhea.  He denies any fever or chills.  He thinks he has some cough but denies any shortness of breath.  He denies any abdominal pain.  Overall he is feeling run down and unwell. Emergency department, patient is hemodynamically stable.  Labs do reveal hyponatremia, hyperkalemia, elevated BUN and creatinine from patient's baseline.  COVID testing is positive.  Chest x-ray reveals edema versus infiltrate. Review of Systems Review of Systems  Constitutional: Positive for activity change and fatigue. Negative for fever.  HENT: Negative for congestion.   Eyes: Negative for visual disturbance.  Respiratory: Positive for cough. Negative for shortness of breath.   Cardiovascular: Negative for chest pain and palpitations.  Gastrointestinal: Positive for diarrhea, nausea and vomiting. Negative for abdominal pain.  Endocrine: Negative for polyuria.  Musculoskeletal: Positive for myalgias.  Skin: Negative for color change.  Neurological: Negative for dizziness and light-headedness.  Hematological: Negative for adenopathy.  Psychiatric/Behavioral: Negative for confusion.  All other systems reviewed and are negative.          Physical Exam BP 119/61  | Pulse 57  | Temp 36.4 °C (Oral)  | Resp 18  | Ht 1.829 m  | Wt 85.1 kg  | SpO2 96%  | BMI 25.44 kg/m²  No intake or output data in the 24 hours ending 12/31/21 2041 Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is ill-appearing. He is not toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rales present.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No swelling, tenderness or deformity.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.   1/10/22 General Medicine progress note: Attestation signed by MD, MPH at 1/10/2022  5:23 PM Management was discussed with PA-C on 1/10/2022. I agree with the documented findings and plan of care in his note.   Brief history and medical decision making:  Patient awaiting PermCath placement.  Patient will need subacute rehab at discharge along with outpatient hemodialysis.  Can be difficult placement.      Expand All Collapse All     Hide copied text  Hover for details  Progress Note    CHIEF COMPLAINT: Bacteremia     Assessment/Plan     ASSESSMENT / PLAN:   Polymycrobial Bacteremia  -febrile 1/2, Blood Cx 1/2 positive for MRSA, Clostridium perfingens, Step mitis/oralis, staph epidermis  -repeat blood Cx 1/3 and 1/5 NGTD  -s/p permacath removal 1/4; per ID no need for foreign body culture  -echo: LVEF 51%, no evidence of endocarditis  -ID consult appreciate recs; abx history:               - vancomycin 1/3-1/5              - penicillin G 1/3-1/5               - cefazolin 1 gm q 24 hrs 1/5-present               - will need 2 weeks antibiotics following negative cultures  -Vascath placed 1/6; premacath planned for later today   Acute Encephalopathy, suspected Toxic metabolic encephalopathy; improving Hallucinations  -likely multifactorial in setting of COVID, Bacteremia, missed HD, fever -CT head w/o contrast 1/4: ventriculomegaly similar to prior; no acute process  -MRI Brain w/o contrast 1/6: global brain atrophy slightly greater than expected for age; no acute process  -EEG: GRDA, periodic discharges, no evidence of seizure activity  -ammonia, vbg unremarkable  -neurology following; appreciate recs              -b1, b12, folate wnl; tsh low t4 wnl, hiv and syphilis negative  -Minimize narcotics/sedatives as able.  -Encourage normal sleep/wake cycle.  -Encourage use of melatonin qhs.  -frequent re-orientation    ESRD on HD HD Inadherence - MWF dialysis  - Missed multiple dialysis sessions PTA   - nephrology consulted; appreciate recommendations -Na/fluid restriction, daily weights -renally dose medications -continue phos binder   COVID-19 with possible pneumonia ->vaccinated with booster  - Developed symptoms on 1 week prior to admission, date of positive test 12/31 - out of respiratory precautions  - CXR on admission with bilateral central lung opacities - COVID 19 spike antibody positive  - not candidate for monoclonal, decadron or remdesivir  - supportive care; on room air   Dysphagia -SLP recommended pureed solids and thin liquids, pills in puree   Constipation - last BM 12/31  - senna and miralax - prn suppository    DMII, insulin dependent - Hgba1c 5.0 - home regimen: lantus 5 units and sliding scale corrective  - has not required any insulin while inpt; will d/c  - diabetic liberal diet   Acute on Chronic Anemia -s/p 1 unit PRBCs 1/9 - folate, b12 wnl , ferritin significantly elevated, iron level and IBC low - no active signs of bleeding contine to monitor  - blood consent obtained via phone with RN witness from wife - Epo with HD per outpatient regimen   Epilepsy Hx Status Epilepticus -continue depakote; 1x IV dose ordered today given patient Npo for permacath and needs purees for meds -valproate levels wnl  -seizure precautions   Chronic diastolic CHF Atrial fibrillation, unspecified Essential hypertension CAD - BPs stable - continue amlodipine, carvedilol, nifedipine, losartan - continue ASA   COPD -not on home inhalers   DVT prophylaxis: Heparin SubQ Code status: Full code per admission   Dispo: Plan for permacath today. Following placement patient is medically ready for discharge pending SAR placement.   The above stated assessment and plan was discussed with Dr. and reflects his input.         Subjective     SUBJECTIVE: Patient seen and examined in bed. He was just working with PT/OT. Denies any chest pain, SOB. A&Ox3.  Review of Systems Unable to perform ROS: mental status change  Respiratory:  Negative for shortness of breath.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for nausea and abdominal pain.          Objective     OBJECTIVE: BP 150/88  | Pulse 69  | Temp 36.6 °C (Oral)  | Resp 14  | Ht 1.829 m  | Wt 83 kg  | SpO2 100%  | BMI 24.81 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is ill-appearing. He is not diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard.     Comments: vascath right chest wall with dressing clean, dry and intact Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing, rhonchi or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Comments: Small scab over left hip  Neurological:     Mental Status: He is alert.     Comments: Patient states his name, DOB and that he is in the hospital. Able to state month as Jan and year as 2022. When asked reason for hospitalization he states "high blood pressure". Slow to respond to questions. Moving all extremities in bed.   Psychiatric:     Comments: Increased participation in conversation today