Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Dialysis, End stage renal disease, Gastrointestinal haemorrhage, Hyperkalaemia, Hypertension
Clinical narrative: Date of Admission: 11/14/2023   Date of Discharge: 11/25/2023   Issues to be Addressed at Follow-up: Please assess wound to ensure wound is healing appropriately  Please ensure patient has appointment in Vascular clinic for staple removal   Please repeat thyroid labs in 4 weeks from discharge.    Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 10/25/2023 to 11/25/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ATHEROSCLEROTIC ISCHEMIC ULCER OF LEFT FOOT   ? HYPERTENSION       Per nephro -     Please try amlodipine or felodipine or nifedipine.   Plan to d/c amlodipine, start w nifedipine 60 and titrate prn   06/12/23 BP 113/74 this am prior to coffee   ? COVID-19 DISEASE   ? HX OF CABG       5/11/23 - CABG X 2 (LIMA-LAD, SV-PDA) - by Dr.    06/10/2023 1. Whether or not to resume plavix - due to recurrence of GI bleeding after DAPT was resumed, and in discussion with Cardiology, final plan was to resume aspirin alone and not plavix given patient had CABG and not PCI - and post CABG really only ASA is indicated not DAPT as would be case in PCI. However, PCP to consider resuming Plavix in 5 to 7 days post discharge if no recurrence of bleeding with aspirin alone given this was his outpatient regimen. Furthermore - patient told me that he was on DAPT because he previously had peripheral arterial stents placed due to PAD, discussed with vascular surgery Dr. and peripheral arterial stents are NOT like cardiac artery stents which require DAPT, ASA alone should be fine especially in the setting of bleeding. On discharge sending out on aspirin alone      ? ANEMIA DUE TO CKD   ? ELEVATED TROPONIN I   ? ESRD ON DIALYSIS       Nephrologist Dr   06/12/23 Tuesday, Thursday, Saturday   ? STRUCTURAL HEART DISEASE WO SYMPTOMS OF HF (HF, STAGE B), UNSPECIFIED       1/10/2022 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  LVH with diastolic dysfunction    ? MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION       1/10/2022 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.        ? HYPOTHYROIDISM       11/2/2022  Pt was advised on dc from hospital to decrease to 88 mcg levothyroxine Will need f/u TSH approx 12/7/22 H/o toxic nodule, not symptomatically improved w methimazole Now w hypothyroidism, levothyroxine started 1/10/2022    Lab Results Component Value Date   TSH <0.1 (L) 10/16/2022    Lab Results Component Value Date   Free T4 1.1 10/16/2022         ? CAD (CORONARY ARTERY DISEASE) WO ANGINA       Coronary calcification noted on chest CT CCL 3/24/2023Rt dom, LM: 0%, LAD: 30% prox, then 75-80% prox to mid significant RFR, D2: small 75% diffuse, CIRC: 60% mid not sign by hemodynamic assessment, RCA: 100% CTO L-R collats diabetic patient with history of ESRD on HD, on dual anti-platelet therapy for PAD, who is exploring renal transplant. He doesn't have active cardiac symptoms -CABG OP consult referral send to Doctor per pt request   6/10/2023 1. Whether or not to resume plavix - due to recurrence of GI bleeding after DAPT was resumed, and in discussion with Cardiology, final plan was to resume aspirin alone and not plavix given patient had CABG and not PCI - and post CABG really only ASA is indicated not DAPT as would be case in PCI. However, PCP to consider resuming Plavix in 5 to 7 days post discharge if no recurrence of bleeding with aspirin alone given this was his outpatient regimen. Furthermore - patient told me that he was on DAPT because he previously had peripheral arterial stents placed due to PAD, discussed with vascular surgery Dr. and peripheral arterial stents are NOT like cardiac artery stents which require DAPT, ASA alone should be fine especially in the setting of bleeding. On discharge sending out on aspirin alone        ? ATHEROSCLEROSIS OF AORTA       1/10/2022 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  Aortic Atherosclerosis identified on a prior imaging study. Will follow longitudinally as an independent risk factor for CVD and CVA, with management per standard risk factor controls over time.     ? DM 2 W PERIPHERAL VASCULAR DISEASE       11/2/2022 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.   Aspirin Clopidogrel started 4/6/2022 pantoprazole started hospitalization 4/18-20/2022 for gi protection while on asa and clopidogrel   With bilat leg ischemia   ? DM 2 W DYSLIPIDEMIA       10/13/23 OV  Needs refill of Humulin 70/30 25 units twice a day.  Humulin N 10 units twice per day       Resolved Hospital Problems   Diagnosis Date Resolved ? ANEMIA 11/14/2023     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 60 year old male with PMHx of HTN, DM, GERD, Hypothyroidism, Depression, Diastolic Heart Failure, ESRD (on HD), Chronic Anemia, CAD (s/p CABG 5/2023),  Hx of Toxic Uninodular Thyroid Goiter, Hx of Ischemic Colitis and GI bleed (6/2023), Peripheral Vascular Disease s/p L TMA,  admitted 11/14/23 for ischemic ulcer of left foot and non healing amputation stump and also noted to be COVID-19 positive and hyperkaelmic, s/p I/D 11/15/23 with podiatry now BKA on 11/19. Drain removed on 11/21. Antibiotic discontinued on 11/23 per vascular recs.  One month follow up with vascular for staple removal.  Patient will be discharged home to resume dialysis on routine days (TTS).  Patient will need repeat thyroid lab in 4 weeks.     Vitals:   11/25/23 0306 11/25/23 0325 11/25/23 0353 11/25/23 0822 BP: 111/57     143/45 Pulse:       62 Resp: 18   20 20 Temp: 98.3 °F (36.8 °C)     97.8 °F (36.6 °C) SpO2: 95%     95% Weight:   92.7 kg (204 lb 5.9 oz)     Height:             General appearance - NAD HEENT: Sclera anicteric.  Neck:  No JVD Chest - clear to auscultation, no wheezing Heart - regular rate and rhythm, no murmurs Abdomen - soft, nontender, nondistended, + bowel sounds Extremities -left BKA with surgical bandage Neuro - A&O x3   Primary Procedures:  Procedure(s): LEG AMPUTATION BELOW KNEE   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Left foot ulcer   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. NEPHROLOGY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Data unavailable     Linked Episodes  FOOT WOUND INCISION AND From 11/14/2023 to 11/16/2023 ANGIOGRAM From 11/16/2023 to 11/22/2023 LEG AMPUTATION BELOW KNE From 11/17/2023 to 11/21/2023  Hospital Problem List   ATHEROSCLEROTIC ISCHEMIC ULCER OF LEFT FOOT  DM 2 W DYSLIPIDEMIA  DM 2 W PERIPHERAL VASCULAR DISEASE  ATHEROSCLEROSIS OF AORTA  CAD (CORONARY ARTERY DISEASE) WO ANGINA  HYPOTHYROIDISM  MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION  STRUCTURAL HEART DISEASE WO SYMPTOMS OF HF (HF, STAGE B), UNSPECIFIED  ESRD ON DIALYSIS  ANEMIA DUE TO CKD  ELEVATED TROPONIN I  HX OF CABG  ANEMIA Resolved  COVID-19 DISEASE  HYPERTENSION Care Timeline  11/14   Admitted from ED (Observation) 1658 11/15   Admitted 1014    FOOT WOUND INCISION AND DRAINAGE 11/17   ARTERIOGRAPHY DIAGNOSTIC 11/19   LEG AMPUTATION BELOW KNEE 11/25   Discharged 2228  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/25/2023)