Age: 63.0
Sex: M
Vaccine: COVID19
Symptoms: Chronic kidney disease-mineral and bone disorder, Condition aggravated, Cough, Differential white blood cell count, Dyspnoea
Clinical narrative: Hospitalized (11.28.21 - d/c 11/29/21 -30 hr stay); COVID-19 positive (11.28.21); Fully vaccinated -moderna x2  Hospitalist History and Physical   ASSESSMENT/PLAN: Acute hypoxemic respiratory failure due to COVID pneumonia: Symptom onset 11/18. Positive PCR 11/28/2021: Detected  o Trend appropriate labs daily o Prone patient TID for 1 hour if they can tolerate o Dexamethasone for 10 day course o Continuous pulse oximetry. Goal SpO2 >92%.   ESRD on HD TTS via RUE fistula, missed dialysis 11/27 Hyperkalemia o Nephrology consult and managing, planning to remove 3L o Repeat BMP a couple hours after dialysis tonight   Insulin dependent type 2 diabetes mellitus: last hemoglobin A1c 11/26/2021: 6.4 %.  o Moderate dose corrective insulin o Continue home glargine 20 units qhs   Obesity Obstructive sleep apnea Hepatitis-C History of cocaine use Alcohol use disorder Dyslipidemia o Continue essential home medications unless otherwise stated above o   o Holding recently prescribed azithromycin and prednisone   VTE Prophylaxis:   This patient is high risk per the VTE risk assessment tool, pharmacologic prophylaxis is indicated. SQH has been ordered.    Diet: Renal diet Code Status: Full code   HPI    CHIEF COMPLAINT: SHORTNESS OF BREATH (pt reports shortness of breath since yesterday. denies other symptoms, chest pain. was seen a couple days ago and diagnosed with pneumonia on antibiotics.)    HISTORY OF PRESENT ILLNESS: Patient is a 64 y.o. male with a pertinent past medical history for obesity, obstructive sleep apnea, hepatitis-C, h/o cocaine use, alcohol use disorder, end-stage renal disease on hemodialysis TTS, insulin-dependent type 2 diabetes with neuropathy, dyslipidemia who presented to the ED primarily with shortness of breath. Found to have hyperkalemia to 8.0 and receives albuterol, calcium gluconate, insulin/dextrose was taken to HD from the ED. He saw his PCP 11/26 for persistent cough after being diagnosed with pneumonia and was started on azithromycin and prednisone taper. Patient starts that he started feeling more short of breath 3 days ago, but has had a cough for a couple of weeks. Patient admits to orthopnea and PND. He denies any fevers, rigors, chest pain, abdominal pain, vomiting, diarrhea. He states that he missed his Saturday 11/27 HD session.   ROS: Please see HPI for pertinent positives. All other systems were reviewed and are negative unless otherwise stated above in the HPI.   Past Medical History Past Medical History: Diagnosis Date ? Arthritis   ? Cocaine abuse, continuous  8/6/2014 ? Constipation   ? Diabetes   ? Diabetes mellitus, type II    ? ESRD on peritoneal dialysis  10/20/2015 ? Foot pain   ? High blood pressure   ? History of drug abuse, coccaine and marijuana  5/16/2017 ? Liver dysfunction     Liver problems ? Nephritis and nephropathy, not specified as acute or chronic, with other specified pathological lesion in kidney, in diseases classified elsewhere 10/29/2009 ? Nocturia   ? Obesity (BMI 30-39.9)   ? OSA (obstructive sleep apnea) 7/6/2016 ? Polyneuropathy in diabetes(357.2) 12/30/2013 ? Proliferative diabetic retinopathy(362.02) 10/29/2009 ? Prostate     Prostate problem ? Stiffness of hip joint   ? Type II or unspecified type diabetes mellitus with neurological manifestations, uncontrolled(250.62)  10/29/2009 ? Type II or unspecified type diabetes mellitus with ophthalmic manifestations, uncontrolled(250.52)  10/29/2009 ? Type II or unspecified type diabetes mellitus with renal manifestations, uncontrolled(250.42)  10/29/2009 ? Unspecified essential hypertension 12/30/2013 ? Vitamin D deficiency 5/9/2012   Lab Results Component             Value                Date                VITD25D2                26                05/07/2016                VITD25DD3                14                05/07/2016                VITD25TTL                29 (L)           05/10/2018                VITD25TTL                16 (L)           04/29/2017   ? Weakness     face/arms/legs? ? White coat syndrome with hypertension 11/16/2017  Past Surgical History Past Surgical History: Procedure Laterality Date ? ENDOSCOPY, COLON, DIAGNOSTIC     ? HX CATARACT REMOVAL Bilateral 06/22/2021   right - 5/2021, Dr.  ? HX COLONOSCOPY   07/23/2019   Dr  ? HX COLONOSCOPY N/A 7/23/2019   COLONOSCOPY POLYPECTOMY ENDO performed by MD at ENDOSCOPY ? HX HERNIA REPAIR   age 8   naval ? HX OTHER SURGICAL HISTORY   1970   head injury, benign growth removed ? HX PORT PLACEMENT   10/2020 ? HX TRANSRECTAL BIOPSY PROSTATE   10/2020 ? HX VASECTOMY   1989 Social History  Socioeconomic History ? Marital status: Married ? Number of children: 2 ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Occupation: Factory worker ? Occupation: Retired Tobacco Use ? Smoking status: Former Smoker     Packs/day: 0.25     Years: 3.00     Pack years: 0.75     Types: Cigarettes     Quit date: 11/2/2016     Years since quitting: 5.0 ? Smokeless tobacco: Never Used Vaping Use ? Vaping Use: Never used Substance and Sexual Activity ? Alcohol use: Yes     Comment: 1 beer per month ? Drug use: No     Types: Cocaine     Comment: quit 1/2015 ? Sexual activity: Not on file Other Topics Concern ? Not on file Social History Narrative ? Not on file Social Determinants of Health   Financial Resource Strain: Not on file Food Insecurity: No Food Insecurity ? Worried About Running Out of Food in the Last Year: Never true ? Ran Out of Food in the Last Year: Never true Transportation Needs: No Transportation Needs ? Lack of Transportation (Medical): No ? Lack of Transportation (Non-Medical): No Physical Activity: Not on file Stress: Not on file Social Connections: Not on file Housing Stability: Low Risk  ? Unable to Pay for Housing in the Last Year: No ? Number of Places Lived in the Last Year: 1 ? Unstable Housing in the Last Year: No Family History Family History Problem Relation Age of Onset ? Hypertension Mother   ? Stroke Sister   ? Coronary Artery Disease Sister    I personally reviewed the past medical history, problem list, family history, social history, medication reconciliation, and allergies.     No current facility-administered medications on file prior to encounter.   Current Outpatient Medications on File Prior to Encounter Medication Sig Dispense Refill ? amLODIPine (NORVASC) 10 MG tablet Take 1 tablet by mouth Daily. 90 tablet 3 ? atorvastatin (LIPITOR) 80 MG tablet Take 10 mg by mouth nightly.     ? azithromycin (ZITHROMAX Z-PAK) 250 MG tablet Take 2 the first day then 1 daily 6 tablet 0 ? B-D ULTRAFINE III SHORT PEN 31G X 8 MM MISC TEST BLOOD SUGAR THREE TIMES DAILY (Patient taking differently: Patient states checking once weekly) 300 Each 3 ? benzonatate (TESSALON) 100 MG capsule Take 1 capsule by mouth 3 times daily as needed for Cough. 30 capsule 0 ? calcium acetate, Phos Binder, (PHOSLO) 667 MG CAPS Take 3 capsules by mouth three times a day after meals.     ? ciclopirox (LOPROX) 0.77 % SUSP APPLY TO SCALP DAILY FOR MAINTENANCE     ? Ciclopirox 1 % SHAM Apply  to skin.     ? cinacalcet (SENSIPAR) 30 MG tablet 30 mg. Every Tuesday, Thursday, and sat during dialysis     ? cloNIDine (CATAPRES) 0.1 MG tablet 1 Tablet     ? donepezil (ARICEPT) 10 MG tablet Take 1 tablet by mouth daily. MAINTENANCE DOSE 30 tablet 11 ? fluocinonide (LIDEX) 0.05 % external solution APPLY TO SCALP TWICE DAILY ON WEEKENDS ONLY OR MINIMALLY AS NEEDED FOR ITCH     ? gabapentin (NEURONTIN) 100 MG capsule Take one cap per mouth three times per week on dialysis days AFTER dialysis. 36 capsule 1 ? insulin aspart (NOVOLOG) 100 UNIT/ML vial Inject 20 Units under the skin 3 times daily (before meals). Up to 60 units daily     ? insulin glargine (LANTUS) 100 UNIT/ML vial Inject 20 Units under the skin nightly. 10 mL 0 ? insulin syringe (BD) 29G X 1/2" 0.5 ML misc 1 each by Other route 3 times daily (before meals). 200 each 3 ? ketoconazole (NIZORAL) 2 % shampoo     4 ? labetalol (NORMODYNE) 200 MG tablet Take 1 tablet by mouth 2 times daily. 180 tablet 0 ? lanthanum (FOSRENOL) 1000 MG chewable tablet Chew 1,000 mg 2 times daily. 2 tablets after meals     ? ofloxacin (OCUFLOX) 0.3 % ophthalmic solution 1 drop 4 times daily.     ? ONE TOUCH LANCETS MISC 1 Each by Does not apply route 4 times daily.  400 3 ? Polyethylene Glycol 3350 (MIRALAX PO) Take 17 g by mouth.     ? prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 1 drop 4 times daily.     ? predniSONE (DELTASONE) 10 MG tablet 4/d x3d, 3/d x3d. 2/d x3d, 1/d x3d 30 tablet 0 ? VELTASSA 8.4 g PACK powder Take 1 packet by mouth daily.       Allergies Allergen Reactions ? Oxycodone Hallucinations and Confusion Objective    OBJECTIVE: Physical Exam:   1. Constitutional:  o Vitals: BP 162/91  | Pulse 70  | Temp 36.4 °C (Oral)  | Resp 21  | SpO2 100%  FIO2 (%): 50 % o Does not appear distressed  2. Eyes:  o Conjunctiva clear o Pupils equal round and reactive to light 3. Ears, Nose, Throat, and Mouth:  o No significant lesions of the ears or nose appreciated  o Moist mucosal membranes 4. Cardiovascular:  ? Regular rhythm without murmurs or other abnormal sounds appreciated o No lower extremity edema 5. Respiratory:  o Diffuse ronchi o BiPAP mask in place o Satting 100% o No use of accessory muscles appreciated 6. Gastrointestinal:  o Abdomen non-tender to palpation o Abdomen soft and nondistended 7. Skin: o Warm and dry o No rashes appreciated in visible areas 8. Neurologic:  o No facial droop appreciated o Equal facial sensation to light touch 9. Psychiatric: o Alert and oriented to person, place, and time o Normal mood   Diagnostics: All labs, radiological studies, and other diagnostics obtained on patient presentation reviewed. I personally reviewed the patient's EKG if one was done on presentation.  consult: INPATIENT CONSULTATION DATE OF SERVICE: 11/29/2021      Admission Date: 11/28/2021 Primary Care Provider: DO Hospital Consulting Physician:  MD   REASON FOR CONSULTATION: End-stage kidney disease   ASSESSMENT: o End-stage kidney disease, dialyzes on a TTS schedule under the direction of Dr.  o Anemia in chronic kidney disease o Chronic kidney disease - mineral and bone disorder o Hyperkalemia post emergent HD on 11/28 o COVID 19 pneumonia o Other co morbidities   PLAN: o Will plan HD tomorrow o Hold epogen due to COVID o Trend renal panel/CBC o Please continue all the supportive care as you are doing o Renal diet o Per the ACR and NKF, class 2 gadolinium agents may be used due to the low risk of nephrogenic sclerosing fibrosis. However, if patient is on dialysis then please inform nephrology team about plans for class 2 gadolinium exposure. o Dose all medications for above HD schedule.   Thank you for allowing Associates to participate in the care of this patient. We will continue to follow along with you.   MD