Date of Admission: 11/4/2023   Date of Discharge: 11/11/2023    Issues to be Addressed at Follow-up: Hospice Care   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/10/2023  8:05 PM BLOOD CULTURE 2 In process BLOOD   11/10/2023  8:00 PM BLOOD CULTURE In process BLOOD   11/7/2023  7:47 AM KAPPA/LAMBDA LIGHT CHAINS, FREE WITH RATIO, SERUM In process --   11/7/2023  7:47 AM IMMUNOFIXATION, SERUM In process --   11/7/2023  7:47 AM PROTEIN ELECTROPHORESIS, SERUM. In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? SEVERE PROTEIN CALORIE MALNUTRITION   ? CKD STAGE 4 (GFR 15-29) W MINERAL BONE DISEASE   ? MALAISE AND FATIGUE   ? HYPONATREMIA   ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? FAILURE TO THRIVE SYNDROME, ADULT   ? ANEMIA OF CHRONIC DISEASE   ? BPH (BENIGN PROSTATIC HYPERPLASIA)   ? HYPOTHYROIDISM   ? HTN (HYPERTENSION)     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Hospice   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   The patient is a 94 years old gentleman, with history of a compression fracture of the spine earlier this year, who presented to the ED with complaints of generalized weakness, decreased p.o. intake, and fever.   He had a positive PCR test for COVID and was admitted for treatment.   The patient has defervesced after 3 doses of remdesivir, he has never been hypoxic.   However, he remained physically weak, was noted to have significant degree of obstipation, and had what appears to have been vasovagal syncope on 11/6.   Review of the chart revealed presence of chronic anemia and chronic renal failure.  While the patient only started being seen at clinic fairly recently, a month ago was the first time, he apparently has had abnormal renal function in the past. Per his outpatient record, his creatinine was 2.15 and his GFR was 28 in July 2022. He was noted to have significantly more impaired renal indices on this admission.   As of the last month, his Cr was 3.8, and it is currently 5.97 as of today. He has been having good urine output since a foley catheter has been placed.   The labs were notable for a monoclonal spike on the SPEP, in the M-band. Immunofixation report is pending.   11/10-11/11 the patient developed worsening respiratory distress, hypoxia, associated with B/L pulmonary infiltrates.   He was treated with IV Lasix for fluid overload. Decadrone IV for treatment of COVID-19 associated hypoxia was also started.   Unfortunateyl, patient's overall condition continued to deteriorate. He's remained uremic, despite fair urine output.   The family has made a decision to transition to Hospice care.     Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  COVID-19 infection   Complications: Acute non traumatic kidney injury   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. PALLIATIVE CARE - INITIAL INPATIENT CONSULTATION. PALLIATIVE CARE - ONGOING INPATIENT CONSULTATION. NEPHROLOGY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: Guarded   Code Status at Time of Discharge: DNR       Note Details  Author (M.D.) File Time 11/11/2023  5:10 PM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 11/4/2023  ED to Hosp-Admission (Current) on 11/4/2023  ED to Hosp-Admission (Current) on 11/4/2023   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   HTN (HYPERTENSION)  HYPOTHYROIDISM  FAILURE TO THRIVE SYNDROME, ADULT  CKD STAGE 4 (GFR 15-29) W MINERAL BONE DISEASE  SEVERE PROTEIN CALORIE MALNUTRITION  COVID-19 DISEASE  BPH (BENIGN PROSTATIC HYPERPLASIA)  ANEMIA OF CHRONIC DISEASE  MALAISE AND FATIGUE  HYPONATREMIA  NONTRAUMATIC ACUTE KIDNEY INJURY  GRAM POS BACTEREMIA Care Timeline  11/05   Admitted from ED (Observation) 1606 11/08   Admitted 1503  Expected Medication List at Discharge   acetaminophen   650 mg Oral EVERY 6 HOURS AS NEEDED  650 mg Supp, Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  atropine sulfate 1 % Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT". Do not dispense with ophthalmic route instruction  benzonatate 100 mg Oral 3 TIMES A DAY AS NEEDED  bisacodyl   5 mg Oral DAILY AS NEEDED  10 mg Supp, Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  calcitonin,salmon,synthetic 200 unit/actuation 1 Spray nasal (alternating) DAILY  guaifenesin/dextromethorphan 10-100 mg/5 mL 10 mL Oral EVERY 6 HOURS AS NEEDED  haloperidol lactate 2 mg/mL Use as directed by hospice medical staff. Please supply with two 1 mL oral syringes or 1 mL syringes without needle. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  levothyroxine sodium 50 mcg Oral EVERY MORNING BEFORE A MEAL  lorazepam 0.5 mg Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  morphine sulfate 100 mg/5 mL (20 mg/mL) Use as directed by hospice medical staff. Please supply with two 1 mL oral syringes or 1 mL syringes without needle. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  phenobarbital 97.2 mg Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  polyethylene glycol 3350 17 g Oral DAILY AS NEEDED  sennosides 17.2 mg Oral 2 TIMES A DAY AS NEEDED  surgical lubricant Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT". PT NOT SHOWING VACCINATED