Date of Admission: 10/12/2023   Date of Discharge: anticipate 10/24/2023   Issues to be Addressed at Follow-up: 1. Monitor wound healing. 2. Adjust insulin regimen as appropriate. 3. Adjust anti hypertensive regimen as appropriate. 4. Long term management of deconditioning.   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 9/24/2023 to 10/25/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) OSTEOMYELITIS OF LEFT FINGER   ? DM 2 W CKD, ESRD ON DIALYSIS   ? COVID-19 DISEASE   ? DEEP TISSUE PRESSURE INJURY OF LEFT HEEL   ? VENOUS STASIS EDEMA W ULCER OF BILAT LEGS, UNSPECIFIED SITE AND DEPTH   ? CAD       10/10/2013 normal Myocardial perfusion study; hx of MI Plan 5/29/2022  Continue ASA and Statin while admitted.    ? LEGAL BLINDNESS        Since 2003 due to diabetes   ? OBSTRUCTIVE SLEEP APNEA       Plan 5/29/2022  Offer CPAP nightly    ? CHRONIC PAIN       Dx: chronic Low Back Pain, lumbar DEGENERATIVE DISC DISEASE/DJD, Morbid Obesity Outpatient: Norco 5-325mg q12 hours; Gabapentin  Plan 5/29/2022  - continue home dose of Norco and Gabapentin    I consulted the database on 12/29/2022 MD     ? HTN   ? SEVERE OBESITY (BMI >= 40)   ? CHRONIC RESPIRATORY FAILURE       On home oxygen as needed at night.   ? PRESENCE OF LEFT ARM ARTERIOVENOUS FISTULA ON HEMODIALYSIS       Please avoid blood draws left arm.   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN PARTIAL REMISSION   ? SECONDARY HYPERPARATHYROIDISM, RENAL ORIGIN   ? ANEMIA        Lab Results Component Value Date   Hgb 9.6 (L) 06/01/2022 Due to chronic renal failure  Epogen  2000units IV at dialysis     ? HYPERLIPIDEMIA        Lab Results Component Value Date   Low density lipoprotein calculated 80 02/03/2014   Low density lipoprotein direct 58 04/17/2014   Cholesterol 150 02/03/2014   Triglyceride 100 02/03/2014   HDL 50 02/03/2014   Plan Continue statin   ? DM 2       Home insulin regimen: NPH 30 U before each meal; Lispro 30 U before each meal Plan 5/29/2022   Inc NPH 25 BID; Lispro SSI High  Lab Results Component Value Date   Hgb A1c % 7.3 (H) 03/25/2022         Resolved Hospital Problems No resolved problems to display.     Discharge Disposition: SNF   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Reason for Hospital Admission (Admitting Diagnosis):        Hospital Course and Significant Findings: Per Dr. on 10/16: 66 yo M w hx of ESRD on HD, OSA on CPAP and nocturnal O2, admitted for surgical management of L 4th finger osteomyelitis. Also COVID (+)   10/13: Stable no complaints. No respiratory issues. Still w some fatigue, possibly attributed to COVID Wound RN req pod c/s for L heel pressure ulcer   10/14: Prelim cultures from finger w pseudomonas Bld cx 1 of 2 gram Pos Rods -- > bacillus not anthracis, which was considered contaminant. L heel xray concerning for possible chronic osteomyelitis -- podiatry to see patient to discuss options   10/15: Stable Podiatry performed bedside debridement of L heel  C.diff sent per protocol for loose BM x3   Regarding COVID, pt was incidental (+) at SNF in August, then (-) 9/21, tested (+) again on admission this time and now with some potential symptoms (fatigue/low energy) No clear respiratory symptoms Start of symptoms was determined as 10/11. Pt completed 3d remdesivir. Isolation was continued for 10 days - through 10/21.   -------------------------------------------------------------------------------------------- I took over care on 10/17: Wound cx from 10/13 ultimately grew MSSA and pseudomonas. Pt was continued on zosyn.   Diarrhea persisted. C diff came back negative. Probiotic was started. Zosyn was switched to ancef and PO cipro on 10/18 to help with diarrhea. Diarrhea slowly improved.   Aerobic wound cx of L ankle wound from 10/16 grew rare skin flora. Anaerobic cx remained negative after 4 days. Per podiatry, LLE was strictly non weight bearing.   Wound vac was placed on on 10/17 in anticipation of discharge. PT eval recommended SNF.   PO hydralazine was up titrated to 100 mg TID for BP control. Home IMDUR was continued without change. Routine HD was continued.   Home insulin regimen was reduced during course. NPH 5 units BID, lispro 5 units TIDWM were prescribed on discharge. Rx was sent for ancef 2 g with HD through 10/26 and PO cipro daily through 10/26.   Pt was deemed medically stable for discharge on 10/18. SNF placement was secured but outpatient HD chair took longer than expected to secure due to COVID isolation and wound vac status. After arrangements were made, pt/family appealed discharge. After appeal was denied, a second appeal was filed.   Vital signs: BP 114/50  | Pulse 84  | Temp 99.3 °F (37.4 °C)  | Resp 18  | Ht 6'  | Wt 142 kg (313 lb 0.9 oz)  | SpO2 93%  | BMI 42.46 kg/m²    Physical Exam: General appearance - chronically ill appearing; NAD; obese HEENT - normocephalic, atraumatic Neuro - alert, conversational/answers questions appropriately Heart - normal rate, regular rhythm, normal S1-S2. No murmurs/gallops/rubs Lungs - normal work of breathing on RA. CTAB. No crackles/wheezes/rhonchi Abdomen - normoactive BS, soft, non distended, nontender Extremities - L hand wrapped in gauze, clean, dry; L foot with wound vac in place, no leakage Skin - warm, dry; chronic venous stasis changes in LLE   Primary Procedures:  Procedure(s): FINGER AMPUTATION, RING   Secondary Procedures: REQUEST FOR REGIONAL ANESTHESIA BLOCK REQUEST FOR REGIONAL ANESTHESIA BLOCK   Complications: none   Consults:  HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. NEPHROLOGY - ONGOING INPATIENT CONSULTATION. PODIATRY - INITIAL INPATIENT CONSULTATION. PODIATRY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR     Linked Episodes  FINGER AMPUTATION, RING From 10/12/2023 to 10/13/2023  Hospital Problem List   DM 2  HYPERLIPIDEMIA  ANEMIA  SECONDARY HYPERPARATHYROIDISM, RENAL ORIGIN  MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN PARTIAL REMISSION  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  PRESENCE OF LEFT ARM ARTERIOVENOUS FISTULA ON HEMODIALYSIS  CHRONIC RESPIRATORY FAILURE  SEVERE OBESITY (BMI >= 40)  OSTEOMYELITIS OF LEFT FINGER  DM 2 W CKD, ESRD ON DIALYSIS  COVID-19 DISEASE  CAD  VENOUS STASIS EDEMA W ULCER OF BILAT LEGS, UNSPECIFIED SITE AND DEPTH  LEGAL BLINDNESS   DEEP TISSUE PRESSURE INJURY OF LEFT HEEL  OBSTRUCTIVE SLEEP APNEA  HTN  CHRONIC PAIN