Progress Note
Subjective
No issues overnight. Patient noted to be coughing on breakfast this morning. Pleasant and appropriate. Working with PT.
Hospital Course
78-year-old male with a past medical history of Alzheimer’s Disease, DM2, HTN, ESRD on T/Th/Sa HD who presents from home shortness of breath. The patient was noticed by family to be short of breath the day of hospitalization. They stated that his chronic cough had slightly worsened over the course of the day. He typically brings up minimal clear/yellow sputum that has not changed in quality of quantity. He was recently around his grand children who had URIs. He denied fevers, chills, chest pain, palpitations, abdominal pain, n/v/d/c, urinary symptoms or lower extremity swelling.
No missed dialysis sessions. No longer makes urine.
At his baseline, he is Alert and oriented to person and place. He is able to ambulate with a cane. He requires assistance with cooking and cleaning. He no longer drives.
In ED, vitals initially febrile to 38.2, HR 100s, BP:100s/60s, RR18, sat 96% 5L NC. WBC elevated to 13, Electrolytes wnl. CXR showed hazy opacity in RLL. He was started on Vanc and Zosyn and was admitted to GMF for further management. Antibiotics were deescalated to ceftriaxone which he finished 2 days ago. Dialyzed with aid of nephrology.
HOME MEDICATIONS
- Aspirin 81 mg Tab, 1 by mouth daily
- Atorvastatin 20mg daily
- Amlodipine 10mg daily
- Coreg 12.5 mg tablet, 1 by mouth two times daily
- Donepezil 5mg daily.
- Hydralazine 25mg tablet, 1 tab by mouth every 8 hours
- Folic acid 1 mg tablet, 1 by mouth daily
- Famotidine 20mg daily
- Metformin ER 1000mg BI
- Vitamin D2 50,000 unit tablet, 1 tablet q7D
- Sevelamer 800mg TID w/ meals.
HISTORIES
- Past Medical History: As above
- Family History: Mother: Alzheimer’s Dementia, Father: “Bad Heart”
- Procedure History: Procedure History: Knee replacement (3 years ago)
- Social History: Alcohol: Denies Tobacco: Former smoker, 30 pack years, quit 20 years ago Illicits: Denies
- Travel: Not applicable
- Exposure: Not applicable
REVIEW OF SYSTEMS:
- Gen: Feeling well
- Resp: Slight difficulty breathing.
- Cardiac: Denies chest pain or palpitations
- GI: Denies Abd pain, nausea vomiting, constipation or diarrhea
- GU: Denies dysuria symptoms
PHYSICAL EXAMINATION
- Vitals Signs BP 150/85, HR 68, RR18, O2 94% on room air
- General: Alert, responsive, oriented to self only
- Eye: Pupils are equal, round and reactive to light, Normal conjunctiva.
- HENT: Normocephalic, Oral mucosa is moist.
- Respiratory: Symmetrical chest wall expansion, Clear To Auscultation Bilaterally
- Cardiovascular: Normal rate, Regular rhythm, No murmur, Normal peripheral perfusion, No edema noted.
- Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.
- Integumentary: Warm, Dry, Pink.
- Neurologic: CNII-XII intact. No focal deficits.
IMPRESSION AND PLAN
Impression:
78-year-old male with a past medical history of Alzheimer’s Disease, DM2, HTN, ESRD on T/Th/Sa HD who presents from home shortness of breath, treated for PNA. Now working with PT.
Plan:
- CAP
- Initial CXR with RLL consolidation. Febrile, with leukocytosis on admission.
- O2 weaned now on room air satting well.
- Urinary Strep and Legionella Ags neg
- RVP neg
- COVID neg
- Blood Cultures neg
- Sputum Cultures with normal flora.
- s/p 5 days of ceftriaxone
- S&S recommending dysphagia diet with honey thickened liquids.
- HTN
- Initially borderline hypotensive, however now hypertensive
- c/w Norvasc 10mg daily
- c/w Coreg 12.5mg BID
- c/w Hydralazine 25mg q8h
- ASA 81mg for primary prevention
- ESRD
- On T/Th/Sa HD, last dialysis today with 2.5L Ultrafiltrate
- Appreciate Nephrology Recs
- c/w BP meds as above
- c/w Sevelamer 800mg TID w/ meals
- F/U Iron studies
- Will consider Epo depending on Iron studies
- Electrolytes wnl.
- Renally dose meds
- Avoid nephrotoxins.
- DM
- A1C 6.8
- holding home metformin
- LDSS
- Diabetic diet
- Alzheimer’s Disease
- c/w Aricept 5mg daily
Dispo: Home PT vs SAR
DVT PPX: Heparin SubQ
FULL CODE