Age: 35.0
Sex: M
Vaccine: COVID19
Symptoms: Nephrolithiasis, Obesity, Pickwickian syndrome, Pneumonia, Positive airway pressure therapy
Clinical narrative: HBS Discharge Summary      ID: Patient    Date of Admission:  11/18/2023    Date of Discharge:  11/22/2023    Primary Care Physician:  MD   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/22/2023  4:24 AM MRSA SCREENING CULTURE In process NARES   11/18/2023  3:15 PM BLOOD CULTURE Preliminary BLOOD   11/18/2023  2:45 PM BLOOD CULTURE 2 Preliminary BLOOD       Issues to be Addressed in Follow-up: [] continue oral hydration [] hold Irbesartan until reevaluation by PCP with labs for renal function stability [] strain urine to capture stone [] miralax and senna while on opioids   Reason for Hospital Admission (Admitting Diagnosis):  Kidney Stone    HPI on admission:  Patient is a 38 Y year old male who  has no past medical history on file.; who presents with NAUSEA (Pt c/o not feeling well since Thursday, with fever, sob and nausea), FEVER, and SHORTNESS OF BREATH   He has had nausea vomiting chills shakes and fever at home since leaving the ER 2 days ago.  Overall does not feel well.  He comes in tonight due to fever shortness of breath and nausea.  He denies chest pain.  He denies lightheadedness.  He does not have any pain when urinating or defecating.  Pain is severe in his left flank as well as has tenderness in his right upper quadrant.  He states that he had COVID a month and a half ago but did not seek medical evaluation.   ED HPI: Patient is a 38 Y male history of DM, CKD who presents to the Emergency Department for SOB, chills, nausea over the last 2 days. Denies associated chest pain, URI symptoms, abd pain, vomiting, diarrhea.  Was evaluated 2 days ago for L flank pain that has since resolved. Denies any abd surg.     Hospital Course: Patient is a 38-year-old man with DM2, CKD, OSA, and HTN was admitted on 11/18/23 due to respiratory failure and a 4mm proximal ureteral stone causing flank pain, nausea, and vomiting. His creatinine peaked at 2.9 due to poor intake and GI losses, with mild hyperkalemia managed using kayexalate and albuterol. Initially hypoxic (83%) with a suspected pneumonia, he received empiric antibiotics. Although COVID PCR was positive, it was attributed to a prior infection (6 weeks ago), and specific treatment was not given. CT ruled out pulmonary embolism, and he was weaned to 2 liters of oxygen. He had intermittent CPAP use, likely due to obesity hypoventilation syndrome, and previously declined home oxygen. Renal function improving but not yet at baseline but improving     BP 134/71  | Pulse 80  | Temp 99.4 °F (37.4 °C)  | Resp 22  | Ht 5' 11"  | Wt 217.2 kg (478 lb 14.4 oz)  | SpO2 96%  | BMI 66.79 kg/m²  Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is obese. He is not ill-appearing or toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal. No congestion.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear. No oropharyngeal exudate.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Swelling present. Normal range of motion.     Cervical back: Normal range of motion and neck supple. No rigidity.     Right lower leg: Edema present.     Left lower leg: Edema present.  Skin:    General: Skin is warm and dry.     Coloration: Skin is not jaundiced.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.     Sensory: No sensory deficit.     Motor: No weakness.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.    Hospital Course By Problem: Patient Active Hospital Problem List:   1. Acute Hypoxemic Respiratory Failure (1/23/2023) - resolved a. Likely chronic hypoxia due to obesity hypoventilation syndrome, declined home O2 b. Possible pneumonia - unlikely c. Continue ceftriaxone/doxy  (day 1: 11/18 until 11/20) has not had fever, leukocytosis and CXR not significant, patient not hypoxic with no respiratory symptoms. d. Wean O2 as tolerated 2. Hx of COVID-19 Disease (11/18/2023) a. Positive antigen test 6 weeks ago, PCR likely residual from prior infection 3. Nontraumatic Acute Kidney Injury (11/18/2023) 4. CKD Stage 2 (GFR 60-89) (5/5/2022) 5. Hydronephrosis 6. Ureteral calculus (4mm stone with mild hydronephrosis) a. Pain control, IVF, flomax, strain urine b. Renal function improving c. Albuterol, kayexalate for K 5.7, recheck d. Hold Irbesartan and Nifedipine (on admission) e. Will consult Urology - recommended E Consult, continue IV fluids. And pain control and flomax 7. DM 2 (1/7/2003)        a. Hold jardiance, continue insulin 8. Constipation a. Increase bowel regimen       Complications:  None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) URETERAL CALCULUS   ? HYDRONEPHROSIS   ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? HX OF COVID-19 DISEASE       Covid reported from home test in October 2023.   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? CKD STAGE 2 (GFR 60-89 W OTHER KIDNEY DAMAGE MARKER)   ? DM 2       Formatting of this note might be different from the original. Enrolled in - Comprehensive diabetes management program: No, Declined.    Last Assessment & Plan:  Formatting of this note might be different from the original. Advised to take U500 with dinner Should need decrease if having lows overnight or in the morning Will need continuous glucose monitor data to evaluate dosing as there is a discrepancy with verbal reports and a1c. He states he had a stressful month and lost his grandmother and was eating poorly. His sugars have been better with changes his his diet he states.    Sent for dexcom but if not will place after approval for continuous glucose monitor libre pro   ? SEVERE OBESITY (BMI >= 40)       Last Assessment & Plan:  Formatting of this note might be different from the original. The patient is interested in enrolling in comprehensive weight management program. Will refer for prior authorization/enrollment.   Will screen cushings with dex suppression test     Resolved Hospital Problems No resolved problems to display.     Primary Procedures:  none      Secondary Procedures: None   Consults:  Urology on the phone    Condition on Discharge:  Stable    Code Status at Time of Discharge: Full Code   Smoker: No.     Discharge Disposition:  Home   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).         MD   11/22/2023  HBS                Note Details  Author (M.D.) File Time 11/22/2023 11:02 AM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine  Admit Date 11/18/2023  ED to Hosp-Admission (Discharged) on 11/18/2023  ED to Hosp-Admission (Discharged) on 11/18/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   DM 2  SEVERE OBESITY (BMI >= 40)  CKD STAGE 2 (GFR 60-89 W OTHER KIDNEY DAMAGE MARKER)  URETERAL CALCULUS  ACUTE HYPOXEMIC RESPIRATORY FAILURE  HYDRONEPHROSIS  NONTRAUMATIC ACUTE KIDNEY INJURY  HX OF COVID-19 DISEASE Care Timeline  11/18   Admitted from ED (Observation) 2136 11/20   Admitted 1115 11/22   Discharged 1450  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/22/2023) Medication List at Discharge   acetaminophen   500 mg Oral EVERY 6 HOURS AS NEEDED  500 mg Tab, Take 1 to 2 tablets by mouth every 6 hours as needed for pain or fever. Do not exceed 6 tablets in 24 hours  albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED, . 100 days supply for asthma is 1 canister  atorvastatin calcium 40 mg Oral DAILY, to prevent heart attacks and strokes  blood sugar diagnostic 1 Strip Miscell. (Med.Supl.;Non-Drugs) EVERY MORNING, to measure blood sugar  blood-glucose control, normal Use as directed with blood glucose meter  blood-glucose meter Use as directed to test blood sugar  blood-glucose sensor Use as directed 3 times a day  empagliflozin 25 mg Take One-Half Tablet By Mouth Daily (Note: New Dose and Direction)  fluocinonide 0.05 % Apply to affected area(s) 2 times a day as needed for itchy scalp . Stop when itch is gone. Do not use on face, neck or skin folds  furosemide 20 mg Oral DAILY AS NEEDED, for leg swelling  gabapentin 400 mg Take 1 capsule by mouth daily at bedtime for 90 days  insulin regular, human 500 unit/mL (3 mL) Inject 75 Units subcutaneously every morning 30 minutes before a meal AND 175 Units every evening 30 minutes before a meal.  lancets 30 gauge 1 Each Miscell. (Med.Supl.;Non-Drugs) EVERY MORNING, to measure blood sugar  liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) Inject 1.8 mg subcutaneously daily  metformin HCl 1,000 mg Oral DAILY  metoprolol tartrate 50 mg Oral 2 TIMES A DAY  nifedipine 30 mg Oral DAILY  ondansetron 8 mg Dissolve 1 tablet in mouth every 8 to 12 hours as needed for nausea or vomiting  oxycodone HCl 5 mg Oral EVERY 6 HOURS AS NEEDED  pen needle, diabetic   31 gauge x 3/16" Needle, Use as directed to inject insulin daily  32 gauge x 5/32" Needle, Use for injection as directed  polyethylene glycol 3350 17 gram/dose Mix 17 Grams in 4 to 8 ounces of water or juice and drink by mouth daily as directed for constipation  sennosides 8.6 mg Take 2 tablets by mouth daily as needed for constipation. May increase up to 4 tablets by mouth 2 times a day as needed for severe constipation. Do not exceed 8 tablets in 24 hours  tamsulosin HCl   0.4 mg Oral DAILY, until kidney stone passes  0.4 mg Oral DAILY  trazodone HCl 100 mg Oral EVERY BEDTIME