r. Orville is a 68-year-old community living male
with past medical history of COPD, CHF, BPH, hypertension, stroke, short gut
syndrome, status post 18 inches of small intestine removed, PEG tube in the past
and then removal, chronic urine retention. At home, wife does one time straight
cath after the patient urinates. The patient is being followed by the
urologist. Lives with the wife. The patient appears to be very weak,
cachectic, thin appearance at baseline with underlying dementia, presented to
Medical City Arlington from outside facility with a diagnosis of pneumonia and
urinary tract infection. As per the patient’s wife, the patient has not been
feeling well, has had a raspy voice and shortness of breath and low oxygen
levels at home, went to one of the facility where the patient was noted to have
bilateral pneumonia on the CAT scan. Urinalysis also was positive. The patient
was transferred due to the capacity limitation at outside facility to Medical
City Arlington, was evaluated by the ER physician. The decision was made to
admit the patient to the hospitalist service. As I come to see the patient, the
patient appears very weak, thin and cachectic. Oral mucosa is dry. The patient
has mouth open. The patient appears to be chronically ill. I spoke to the
patient’s wife, Ms. Alina at the bedside and she informed to me that this is
most of the time his baseline. He has dementia and he is very weak, poor
appetite, has had history of short gut syndrome with 18 inches of small
intestine removed as well as H. Pylori in the past and had PEG tube placed and
subsequently it was pulled out and then, the patient has not been eating and
drinking much. In the Emergency Room, the patient had a Foley catheter, which
was placed by the outside facility. I confirmed with the patient’s wife and
wife stated that the patient is able to urinate at home and after he urinates,
wife does one time in and out catheterization to empty the bladder. The patient
follows with urologist on outpatient basis.
GENERAL ASSESSMENT:
Acute hypoxic respiratory failure secondary to evidence of acute left
basilar pneumonia with small left sided pleural effusion as well as chronic
obstructive pulmonary disease exacerbation and acute chronic obstructive
pulmonary disease and bronchitis, present on admission. Continue with
nebulization treatments,
supplemental oxygen to keep the saturation more than 92% and IV antibiotic,
suppression medication and look for further improvement in the patient’s
symptomatology. Patient is requiring 5 L of oxygen. Patient is saturating
around 88-92 percentage.
Symptomatic GNB complicated urinary tract infection, complicated due to in and
out
catheterization at home by the wife. The patient at this point of time had a
Foley placed from outside facility. The patient does not use Foley at home.
Patient’s Foley was removed on 9/7/2023. Patient was seen by the urologist
Discussed with Dr. Hay. Continue Flomax and finasteride.
Discontinue oxybutynin.
Check postvoid residual every shift and straight catheterize if residual
greater than 300 mL.
Check CT abdomen and pelvis without contrast secondary to recurrent urinary
tract infections.
The patient may follow up with the VA Urology for me at their discretion.
We will follow with the final urine culture results
Urine retention. Patient does have history of urine retention even in the past.
Continue Flomax and finasteride. I was informed by the nursing staff that he
had to do in and out catheterization for him due to urine retention 412 cc
urine. After in and out catheterization, 400 mL of the urine was taken out on
9/8/2023.
Severe protein-calorie malnutrition with thin, cachectic appearance at
baseline with underlying advanced dementia. Supportive care. PT, OT, ST and
dietitian consultation initiated.
Metabolic alkalosis with bicarbonate more than 45 with underlying COPD,
unclear etiology, rule out CO2 retention. We will get ABG stat at this point of
time. Will get ABG today. Still not done.
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