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HPI:
78-year-old male admitted to Step down ICU from previous hospital where he had multiple presentations to the ER and admissions from 3/8/2020 until 5/8/2020 for acute pancytopenia, urinary retention with TURP, shortness of breath, cough and dark stools. Past medical history of COPD, current smoker with 40 pack year history, type 2 diabetes, diastolic heart failure. On 3/8/2020 he presented to the ER with weakness and was found to have hemoglobin of 4 requiring extensive blood transfusions and hematology workup. He initially refused GI workup and on 03/10 subsequent CT of the abdomen and pelvis resulted bladder mass lesion. He also underwent bone marrow biopsy on 03/11/2020 which revealed myelodysplastic syndrome. Patient was discharged home on 03/12/2020. He returned back to the hospital on 03/19/2020 for hematuria and acute urinary retention. He had a TURP done and tolerated procedure well and Foley catheter was left in place. He was sent home on 03/21/2020 with home health care to follow up with GU outpatient. Patient returned back to the hospital on 03/27/2020 for acute respiratory distress secondary to COPD exacerbation and was found with bilateral pneumonia and melena. He was found again to have a low hemoglobin on presentation of 3.2 and platelet count of 17000 and received again blood and platelet transfusions. He was stabilized in the ICU with intubation and was extubated on 04/18. This hospitalization was complicated by encephalopathy both anoxic and metabolic, with multiple blood transfusions and platelet transfusions secondary to myelodysplastic syndrome, stage III sacral wound, paroxysmal atrial fibrillation, oral dysphagia acute kidney injury. He had an upper endoscopy done by GI and no bleeding was found. GI recommended acid suppression and outpatient colonoscopy unless patient continues with melena. He was seen by the Hematology team with no plans for inpatient systemic treatment for his underlying myelodysplastic syndrome in goals to maintain platelet above 10,000 and hemoglobin above 7, cryoprecipitate if fibrinogen is < 100 and keep fibrinogen >100. Orders also given to avoid daily blood draws and avoid all unnecessary anti-platelet and thrombocytopenia inducing medications. GU also found patient not a candidate for cystectomy regarding his muscle invasive bladder cancer and will recommend repeat cystoscopy 2 months from initial tumor resection for tumor reassessment. Palliative care was consulted at the hospital with family who agreed with DNR but did not want hospice. Dobhoff was placed for severe oropharyngeal dysphagia and encephalopathy. Patient developed a stage III sacral ulcer during his prolonged hospital stay and received wound care. He was seen by Nephrology team at the hospital secondary to acute kidney injury and electrolyte imbalance but maintained good urinary output. Patient did not require dialysis and renal function stabilized with fluids.
Upon eval today, patient was found this morning with acute melena by nursing and is pale although his mental status is baseline and he is able to communicate that he has no current complaint.
Vital Signs
• Temperature: 99.5F
• Blood Pressure: 118/67mm Hg
• Respiratory Rate: 20/min
• Heart Rate: 80
• Pain Severity Score (0-10): 0
• Acute onset mental status change: 0
PHYSICAL EXAM
GENERAL: The patient is awake but nonverbal but able to answer yes and no questions by nodding his head he is awake and alert to himself.
HEENT: Head atraumatic and normocephalic
Eyes: Extraocular muscles intact. Anicteric. Pupils equal, round, and reactive to light and accommodation. Nares patient.
Mouth: Moist mucosa.
Ears: No lesions.
Nose: Dobhoff in place
Throat: No thrush, exudate, or erythema.
NECK: Supple. No JVD.
LUNGS: Breath sounds clear bilaterally without rales, rhonchi, or wheezing.
HEART: Normal S1, S2. sinus rhythm. No appreciable gallops, rubs, murmurs or extra heart sounds.
ABDOMEN: Obese. Soft, nontender, nondistended. Positive bowel sounds. No palpable masses or hepatosplenomegaly.
EXTREMITIES: Weakness to bilateral upper lower
SKIN: Stage III sacral wound. Pale
Lab Results
· FSBS 125 mg/dL
· Ammonia <9 umol/L
Blood Count;Complete w/ Auto Diff 05/17/2020
o Absolute basophils 0.2 ths/cumm
o Absolute eosinophils 0.0 ths/cumm
o Absolute lymphocytes 0.9 ths/cumm
o Absolute monocytes 0.1 ths/cumm
o Absolute neutrophils 17.0 ths/cumm
o Basophils 1 %
o Eosinophils 0 %
o Hematocrit 27.4 %
o Hemoglobin 9.4 g/dl
o Lymphocytes 4.9 %
o MCH 32.8 pg
o MCHC 34.4 %
o MCV 95.2 cu micron
o MPV 8.0 pg
o Monocytes 0.4 %
o PLT, AUTO 54 ths/cumm
o RBC, AUTO 2.9 mil/cumm
o RDW 19.0 %
o Segmented neutrophils 93.3 %
o WBC, AUTO 18.2 ths/cumm
Blood Count;Complete w/ Auto Diff 05/18/2020
Absolute basophils 0.0 ths/cumm
Absolute eosinophils 0.0 ths/cumm
Absolute lymphocytes 1.0 ths/cumm
Absolute monocytes 0.1 ths/cumm
Absolute neutrophils 6.9 ths/cumm
Basophils 0 %
Eosinophils 0 %
Hematocrit 12.8 %
Hemoglobin 4.4 g/dl
Lymphocytes 12.2 %
MCH 32.5 pg
MCHC 34.2 %
MCV 95.1 cu micron
MPV 7.9 pg
Monocytes 0.9 %
PLT, AUTO 37 ths/cumm
RBC, AUTO 1.3 mil/cumm
RDW 18.1 %
Segmented neutrophils 86.5 %
WBC, AUTO 8.0 ths/cumm
Comprehensive Metabolic Panel
o ALT 15 U/L
o AST 29 U/L
o Albumin 3.2 g/dl
o Alkaline Phosphatase 126 U/L
o Bilirubin Total 0.5 mg/dl
o Blood Urea Nitrogen 24 mg/dl
o Calcium 8.5 mg/dl
o Chloride 91 mmol/L
o Creatinine 0.50 mg/dl
o Enzymatic CO2 30 mmol/L
o GFR, African American >60.0 mL/min/1.73 sqm
o Glucose 135 mg/dl
o Potassium 3.5 mmol/L
o Protein, Total 6.5 g/dl
o Sodium 131 mmol/L
· PSA (Prostatic Spec. Ag) 2.3 ng/mL
· PreAlbumin 18.3 mg/dL
· Prothrombin time w/ INR
o INR 1.1
o Prothrombin time 12.7 seconds
Microscopic UA
o Amorphous Urine LARGE
o Bacteria 3+
o Epithelial FEW
o Mucous MODERATE
o RBC 100-200 /HPF
o WBC >200 /HPF
Urinalysis
o Appearance CLOUDY
o Bilirubin Negative
o Color YELLOW
o Glucose Negative mg/dl
o Ketone Negative mg/dL
o Leukocyte Esterase Large
o Nitrite Negative
o Occult Blood (urine) Moderate
o Protein 100 mg/dL
o Specific gravity 1.020
o Urobilinogen 1 mg/dL
o pH 7.5
Bumetanide 1 MG daily1 Oral
Acetaminophen 650 MG PRNq6h Gastrostomy Tube
Glucose Gel 15 gm PRNq4h Gastrostomy Tube
hydrALAZINE hydrochloride 10 mg PRNq6h Intravenous
Ondansetron Hydrochloride 4 MG PRNq8h Intravenous
Insulin Lispro, Recombinant 1 EA q6h Subcutaneous Sliding Scale
Folic Acid 1 MG daily1 Gastrostomy Tube
Budesonide 0.5 MG q12h Inhalation
Lactulose 20 GM PRNdaily1 Gastrostomy Tube
Pantoprazole Sodium 40 mg
Miconazole Nitrate 2% 1 EA q shift Topical application
Metoprolol Tartrate 2.5 MG PRNq4h Intravenous
Ipratropium Bromide 0.5 MG q6h Inhalation
sulfamethoxazole/TMP 800-160MG 0.5 EA q12h Gastrostomy Tube
Sodium Chloride 0.9% at 75 cc/hour
Myelodysplastic syndrome
Melana/GI bleed
Acute hypoxia respiratory failure SP intubation/extubated on 04/18
Acute renal failure
Paroxysmal atrial fibrillation
Multi factual encephalopathy
Moderate motor oral pharyngeal dysphagia currently with tube feedings
COPD tobacco use 40 pack-year history
Type 2 diabetes
Stage III sacral wound
Invasive bladder cancer
Status post multifocal pneumonia
Acute obstructive uropathy with emergency TURP
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