Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Atrial fibrillation, Blood bicarbonate decreased, Blood creatinine increased, Blood gases
Clinical narrative: Date of Admission  01/24/2022   Date of Discharge  01/26/2022   Reason for Hospitalization   tested + for COVID, genearl fatigue  Hospital Course   Patient is a 86-year-old male that was admitted to family medicine team on 1/24 for acute on chronic renal failure, metabolic acidosis, hyperkalemia in the setting of COVID-19. PMHx significant for renal cancer status post nephrectomy with resultant CKD, CAD status post CABG, diabetes, hypothyroidism.   Patient found to be Covid positive on 1/19 while at PCPs office.  Patient was urged at that time after laboratory testing to present to the ED however patient refused.  Brought in by daughter on 1/24. Upon presentation to the ED patient was afebrile, slightly hypertensive, breathing well on room air.   Labs remarkable for marked leukocytosis, hyperkalemia of 6.9, bicarb of 7, BUN 176, creatinine of 7.5 (baseline 3.0).  VBG showed pH 7.17. EKG showed atrial fibrillation with a rate of 84 bpm.  No EKG evidence of hyperkalemia or ischemia.  CXR with right opacities concerning for developing pneumonia. He was started on azithromycin and ceftriaxone. COVID treatments deferred as patient was not requiring oxygen.  Nephrology was consulted in the ED and patient was started on  D5W + sodium bicarb and Lokelma. Discussed possibility of dialysis and patient is not amenable at this time nor in the future.  Kidney function improved to his baseline, and patient was ambulatory and tolerating oral hydration prior to discharge. We discussed with patient that he would likely qualify for hospice at this time however patient is not interested in setting up an evaluation.  Will discharge home with daughter.    Of note, urine culture from admission grew > 100,000 CFU of gram negative rods, sensitivities pending.  Received 3 days of ceftriaxone in hospital and will transition to cefpodoxime upon discharge for 7 day course.  Will provide script for Zofran for occasional emesis.  Follow up with PCP.  Discharge Diagnoses      1. COVID-19 virus infection  Stable, on RA   2. Hyperkalemia  s/p Lokelma while inpatient   3. Acute-on-chronic kidney injury  Resolved, patient at baseline  - does not desire dialysis or further intervention   4. Atrial fibrillation  resolved   5. Metabolic acidosis   Resolved - secondary to acute renal failure   7. UTI (urinary tract infection)  s/p ceftriaxone x3 days  - cefpodoxime 200mg daily x 4 days  - follow urine culture sensitivities   Orders:   cefpodoxime, 200 mg = 1 Tablet(s), form: Tablet, Oral, q24h, first dose 01/27/22 9:00:00  cefpodoxime, 200 mg = 1 Tablet(s), Oral, q24h, Take one (1) tablet by mouth once daily x 4 days., # 4 Tablet(s), Refill(s) 0, 166.7, cm, 01/25/22 13:12:00, Height (cm), kg, 01/24/22 15:20:00, Weight (kg), 69.5  insulin glargine, 10 units = 0.1 mL, form: Injection, Subcutaneous, At Bedtime, first dose 01/25/22 21:00:00  ondansetron, 4 mg, Oral, q8h, Scheduled / PRN PRN Nausea, X 7 day(s), # 21 Tablet(s), Refill(s) 0, 02/02/22,  166.7, cm, 01/25/22 13:12:00, Height (cm), kg, 01/24/22 15:20:00, Weight (kg), 69.5  Discharge Patient  Follow Up Appt Family Medicine  Provider to Nursing Communication  Other Diagnoses   Ongoing  Basal cell carcinoma of left side of neck  Chronic kidney disease, stage 3  Diabetes  History of kidney cancer  Hypothyroid  Historical  Bowel obstruction  Constipated  Hypertension  Metabolic acidosis  Recurrent dehydration  Operations and Procedures   None  Consultants  Medicine Nephrology   Pending Labs  Urine Culture sensitivities  Discharge Disposition  Home    Medications  New, Changed, or Refilled Medications  cefpodoxime (cefpodoxime 200 mg) 200 mg, 1 Tablet(s), Oral, q24h, Take one (1) tablet by mouth once daily x 4 days., 4 Tablet(s), 0 Refill(s)  Instructions:Take one (1) tablet by mouth once daily x 4 days.  ondansetron (Zofran 4 mg) 4 mg, Oral, q8h, for 7 day(s), PRN: Nausea, 21 Tablet(s), 0 Refill(s)      Medications to be Continued  aspirin (aspirin 81 mg oral delayed release tablet) 81 mg, 1 Tablet(s), Oral, Daily    cholecalciferol (Vitamin D3 1000 intl units) 25 mcg, Oral, Daily, 0 Refill(s)    docusate-senna (Senna Plus 50 mg-8.6 mg) 2 Tablet(s), Oral, At Bedtime, 60 Tablet(s), 0 Refill(s)    donepezil (donepezil 5 mg) 5 mg, 1 Tablet(s), Oral, At Bedtime, 90 Tablet(s), 3 Refill(s)    insulin glargine (insulin glargine (LANTUS) 100 uni 30 units, Subcutaneous, At Bedtime, for 30 day(s), 15 mL, 11 Refill(s)    levothyroxine (levothyroxine 75 mcg (0.075 mg)) 75 mcg, 1 Tablet(s), Oral, Daily, 90 Tablet(s), 3 Refill(s)    mupirocin topical (mupirocin 2% topical ointment) See Instructions, Topical daily, 22 g, 0 Refill(s)  Instructions:Topical daily  polyethylene glycol 3350 (polyethylene glycol 3350 17 g, Oral, bid    pravastatin (pravastatin 40 mg) 40 mg, 1 Tablet(s), Oral, At Bedtime, 90 Tablet(s), 3 Refill(s)    sertraline (sertraline 25 mg) 25 mg, 1 Tablet(s), Oral, Daily, 90 Tablet(s), 3 Refill(s)      Discontinued Medications  None  Physical Exam at Discharge  Vitals & Measurements  T: 36.8 °C  TMIN: 36.5 °C  TMAX: 36.8 °C  HR: 63  RR: 18  BP: 137/78  SpO2: 96%      General: Alert and oriented. No acute distress  HEENT: EOMI, Normocephalic, atraumatic. Moist oral mucosa. Cardiovascular: RRR, no murmurs, rubs or gallops. Respiratory: CTABL, no wheezes, rhonchi, or rales. Effort normal on RA. Gastrointestinal: Soft, nontender, non-distended, no guarding or rebound. BS + Musculoskeletal: No edema. Integumentary:  Warm, Dry.  No rashes Neurologic:  No focal defects. Psychiatric: Cooperative. Appropriate mood and affect.     Follow Up Appointments     Follow Up Appt Family Medicine, Clinic, Within 14 Days, No tests    Appointment Type  When  With  Where  Contact Information  Status    With  When  Contact Information              Nursing/Other Orders   Renal Diet. Ordered on 01/24/22 14:56:00, Meal Start Time Breakfast 0700 to 0900   Intake and Output (I&O, Strict). 01/24/22 23:11:00, Continuous Order   Fall Precautions. 01/24/22 11:07:10. Order comment: order placed from nursing documentation   Code Status. Code Status Description: DNAR (Do Not Attempt Resuscitation)     Addendum by medical doctor on January 27, 2022 08:08:23 (Verified)    Attestation by medical doctor on January 27, 2022 08:08 I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with the author of this document.  I agree with everything documented above with the following exceptions/additions:    none