Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Pain, Pain in extremity, Peripheral arterial occlusive disease, Peripheral artery occlusion, Pneumonia
Clinical narrative: Admit date: 2/19/2024  Discharge date:  3/4/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD Reason for Admission: Patient is a 76 year old married male long term resident at facility due to worsening debility with PMH significant for close to blindness with enucleation of left eye and minimal vision in right eye due to glaucoma, debilitating chronic low back, bilateral leg pain and right flank pain which never got better after back surgery, PAF/atrial flutter not on anticoagulation, SSS s/p PPM, prostate cancer with neurogenic bladder with chronic indwelling foley catheter with recent hospitalization for UTI and recently failed voiding trial presented to the ER with septic shock with AKI in the setting of persistently positive COVID 19 test, left lower lobe pneumonia and concern for recurrent UTI.  Admitted to the ICU due to the need for pressure support with intensivist consulting. Was weaned off Levophed on 2/20; found to have PAD and severe anemia requiring transfusion of 1 PRBC.   Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  Patient complains of debilitating chronic right flank pain with low back pain with radiculopathy - has significant constipation issues -escalate bowel regimen to include suppository and enemas, patient more comfortable after treatment of constipation -continue home oxycodone for now -physical therapy is now recommending rehab for patient..  Left Lower Lobe Pneumonia, indwelling catheter associated Proteus UTI Septic Shock, resolved - CT with dependent consolidation of LLL.  - Received 30mL/kg bolus IVF in ER and then required vasopressor support, weaned off vasopressors prior to transfer to hospital - completed 10 days of therapy for of cefepime for CAP coverage and Proteus UTI -; received 7 days of Doxycycline. - consult SLP ruled out risk for aspiration  Acute Kidney Injury, resolved - Likely prerenal 2/2 hypoperfusion in setting of septic shock, resolved with treatment of sepsis as above - Cr 1.4 on admission decreased to 0.9 (close to baseline) by time of discharge -held Lisinopril while treating sepsis and AKI  Covid-19 positive test (positive on 1/14/24 and still positive on admission on 2/19) Initially started on Remdesivir but discontinued with no treatment indicated with initial positive test one month prior to admission and patient with no evidence of hypoxia  PAD with left SFA occlusion -Cardiothoracic surgery attempted angioplasty on 3/1 on totally occluded mid to distal segment left SFA which was not successful -recommendation for dual antiplatelet therapy and high-intensity statin We will add clopidogrel to low-dose aspirin per CT surgery recommendations -Follow-up with CT surgery outpatient  Normocytic Anemia, acute on chronic with iron deficiency and history of low B12 and Folic Acid, ferritin elevated because of sepsis -nadir of 6.9, received transfusion of 1 unit of PRBCs, Hgb trended up from 6.0 -> 8.8 by time of discharge -received IV iron after resolution of sepsis -continued Folic Acid and B12 supplementation -hematology felt anemia related in part to malnutrition  Right rib fracture, new Per nuclear bone scan, conservative management  Malnutrition, anorexia, weight loss with evidence of severe protein calorie malnutrition Per daughter lost about 45 lbs since April of last year along with low appetite - consulted dietary which made recommendations and added protein shakes among others -calorie counts with improved oral intake during later part of hospitalization, ate 1673 kcal and 2248 kcal on last two days of admission with additional assistance with meals and after starting Megace as appetite stimulant  -cosyntropin stim test unremarkable -severe Vitamin D deficiency, will start cholecalciferol 50,000 units weekly  Acute on chronic constipation in setting of chronic opiate use -aggressive bowel regimen for constipation which may be contributing to anorexia -continuing aggressive bowel regimen on discharge  Chronic right flank/low back pain for many years never got better after multiple prior back surgeries -right hip x-ray unremarkable -lumbar spine x-ray shows evidence of prior fusion with no evidence of acute pathology -patient declines MRI of lumbar spine at this time -Gabapentin started at low dose of 100 TID and increased to 200 TID by prior provider, will escalate to 300 mg BID and then possibly 300 mg TID -continue home oxycodone dose, recommend consideration for referral to pain specialist for transition to buprenorphine -encouraging patient to use lidocaine patch which was started  Chronic indwelling catheter in the setting of prostate Ca, air in the bladder likely related to instrumentation Pending outpatient cystoscopy in May Failed outpatient voiding trial, per chart review patient open for definitive surgical options Urology follow up outpatient Prostate Ca was under active surveillance for many years without treatment or intervention (other than foley catheter); bone scan recommended by heme/onc showed no evidence of metastatic disease  Follow up with Dr. outpatient who verbally accepted to take on his care  Hypertension Held BP medications with septic shock, restarted by end of hospitalization, beta blocker at lower dose of 50 mg BID  Bilateral foot pain likely 2/2 PAD and possibly additionally 2/2 B12 deficiency - continue B12 supplementation - switched zoloft to cymbalta targeting neuropathic pain - continue gabapentin, titrated to 300 mg TID  Aflutter - CHADS2vasc is 3. He is on metoprolol and amiodarone, both were on hold due to hypotension. Restarted amiodarone at usual dose and metoprolol at lower dose. Currently not on anticoagulation. He follows with cardiology and issue of AC was discussed with patient and wife in their office but with his chronic back pain, unsteadiness and fall risk, they decided against AC.    Possible vascular dementia Per CT chronic small vessel ischemic changes, per daughter fluctuating mentation On low-dose aspirin and statin therapy  There is no evidence of Colon wall thickening on most recent CT -patient does have mild iron-deficiency anemia with prior imaging raising some suspicion for mucosal wall enhancement but patient has declined colonoscopy  Glaucoma- continue dorzolamide-timolol ophthalmic solution on right eye. Left eye enucleated due to severe glaucoma according to him.   Depression - will continue quetiapine and switched Zoloft to Cymbalta to also treat neuropathic pain.  SSS s/p PPM   Issues Requiring Follow Up: (Who, what, when, and how communicated?)  Follow-up peripheral vascular disease with cardiothoracic surgery, follow-up urinary retention, indwelling Foley catheter and prostate cancer with Urology; follow-up unintentional weight loss with outpatient dieticians (see interventions in the hospital with patient's caloric intake improved, needs maximum assistance with meals, improved appetite with Megace; follow-up chronic pain with pain specialist for consideration of possible transition from Oxycodone to Suboxone to improve pain control; follow-up anemia and history of prostate cancer with hematologist, Dr. Discharged to Intermediate Care Facility