death Narrative:  2/17/21 Hematology/oncology note: 79-year-old with JAK 2 essential thrombocythemia. Recently hospitalized from 1/8/21 to 1/21/21 with acute kidney failure. Possibly related to sepsis and chronic obstructive uropathy. Patient currently is on dialysis Tuesday, Thursday, Saturday. Previously he had been on Hydrea 500 mg daily and has been continued on this post discharge. Patient obviously is frustrated on the development of acute kidney failure requiring dialysis. Previous workup for autoimmune associated acute renal failure was negative. Patient had a low albumin and proteinuria in the nephrotic range and there was consideration for renal biopsy but this was not done. Patient continues to have obstructive uropathy with indwelling Foley. He is scheduled to have cystoscopy and TURP Exam: Alert very pleasant male. Lungs: Clear. Cardiac: Rate regular, no rub. Abdomen: No tenderness, no organomegaly. Extremities: No DE, no calf tenderness. Review of lab: Hgb 9, WBC 5100, platelet 240,000. Electrolytes normal, blood sugar 118, BUN/creatinine 20/2.6, LFTs - normal, albumin 3.1. Plan: Hydrea is discontinued. Can find no evidence that Hydrea has been associated with acute renal failure. RTC 4 weeks with follow-up lab. 2/17/21 Cardiology note: LOCAL TITLE: CARDIOLOGY CONSULT FOR SURGICAL RISK STRATIFICATION DATE OF NOTE: FEB 17, 2021@10:31 reason for phone visit: f/up for CAD PMH: 1) CAD, candidate for chronic DAPT--NSTEMI *LHC: diffuse non-critical dz LAD, occluded small D1, occluded mid LCX & small occluded RCA, rec: med mgmt, Hosp, 11/21/2017 *Relative hypotension, low LVEDP managed with IVF 2) preserved LVF, EF 60-65% by echo in 11/2019 3) Aortic Stensos -echo: mild AS, pk/mn grads 11.99/6.82, AVA 1.4cm2, EF 50-55%, mild-mod Pulm, HTN, 1/2018 -echo: moderate AS, EF 60-65%, 11/2019 4) HTN 5) HLD 6) ESRD, now on HD, started 2 wks ago Cardiac Meds: - ASPIRIN 81MG EC TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY FOR THE HEART - TAKE WITH FOOD - ATORVASTATIN CALCIUM 40MG TAB TAKE ONE-HALF TABLET BY ACTIVE MOUTH EVERY DAY FOR CHOLESTEROL - CHLORTHALIDONE 25MG TAB TAKE ONE-HALF TABLET BY MOUTH HOLD EVERY DAY FOR BLOOD PRESSURE - CLOPIDOGREL BISULFATE 75MG TAB TAKE ONE TABLET BY HOLD MOUTH EVERY DAY FOR THE HEART OR TO HELP WITH STROKE PREVENTION - METOPROLOL TARTRATE 25MG TAB TAKE ONE-HALF TABLET BY ACTIVE MOUTH EVERY 12 HOURS FOR THE BLOOD PRESSURE AND HEART RATE HPI: 79y/o M followed by MV CAD by non-agency center performed in 11/2017 following NSTEMI. Noted small vessel occlusions with diffuse noncritical LAD disease, medically managed. LVF preserved with EF 60-65% by echo in 11/2019. Also with Aortic stenosis, estimated as moderate by last echo. Has upcoming surveillance echo in 3 months. Patient reports stable cardiovascular status. Denies chest pain. Has always had fatigue with exertion requiring him to stop and rest periodically when working in the yard. This is chronic without recent acceleration. Most recent change in health is rapid decline in kidney function and has started dialysis 2 weeks ago. He reports still adjusting to the idea of needing dialysis. Reports HD is well-tolerated without significant malaise or lightheadedness during same. ROS: neg x per HPI EXAM: T.98.2 F [36.8 C] (02/17/2021 12:40) P.65 (02/17/2021 12:40) BP.134/72 (02/17/2021 12:40) GEN: very slender, in w.c, nad HEAD: ncat NECK: no jvd CHEST: ctab HEART: 3/6 SEM, rrr EXT: no edema NEURO: alert, appropriate, grossly intact today's ekg: NSR 71bpm, IL TWIs similar to previous (in 2017 and earlier) ASSESSMENT: CAD s/p NSTEMI in 2017 LHC then: small vessel CTOs and diffuse noncritical LAD dz, medically managed preserved LVF, EF 60-65% with moderate aortic stenosis by echo 11/2019 Overall Impression: stable cv status. No evidence of active cardiac condition such as unstable angina, decompensated heart failure, uncontrolled arrhythmia, or severe symptomatic valvular heart disease. Patient is at least intermediate risk patient going for intermediate risk procedure. By Lee/RCRI, he is Class III risk (~10.1% risk for perioperative cardiac event), given his history of CAD and CKD. This risk is nonmodifiable - no preoperative cardiac testing/intervention will change this. Recommendation: -advise no perioperative interruption of statin or BB (unless BB must be held d/t low BP) -ok to hold either/both ASA, plavix as needed perioperatively *previous note indicates ok to change to monotherapy antiplatelet med -return in 3 months for recheck and echo as scheduled *offered to perform echo today but patient declines 2/24/21 Urology Surgeon: REASON FOR VISIT: Preop and consent for TURP NOTES: 78 y/o with obstructing median lobe of the prostate in retention on hemodialysis. He is scheduled for TURP on Monday. He will hold his ASA and plavix begining today. His catheter will be changed today and culture sent he will be covered with antibiotic till surgery monday. He is to take one cipro today in clinic, Thursday after dialysis and Saturday after dialysis. No information on cause of patient death. Medical record: Pt did not show for surgery. My nurse spoke with his wife who told us he passed away yesterday. This is reported in respect of vaccination timing (10 days) from death.