The patient is a 92-year-old white female with past medical history significant for hypertension, hypothyroidism, and insulin-requiring type 2 diabetes mellitus, who was brought to the emerg

1. Doppler ultrasound of the left lower extremity which showed no evidence of DVT
2. Transthoracic echocardiogram which showed normal left ventricular function
Hospital Course: The patient is a 92-year-old white female with past medical history significant for hypertension, hypothyroidism, and insulin-requiring type 2 diabetes mellitus, who was brought to the emergency department for evaluation of fever and dyspnea. The patient at that time was a poor historian; however, family corroborated abrupt onset of symptoms with no clear source. Generally, the patient has been healthy although she is minimally active and most of her activities of daily living consist of ambulating around her bedroom with the assistance of family.
In the emergency department the patient was febrile to 40?C. Urinalysis was significant for pyuria with evident bacteria. No focal infiltrate was seen on chest x-ray. The patient had marked leukocytosis with a white count of 25,000, 80 polys and 15 band forms. She was admitted for intravenous antibiotics. She was treated with Ceftriaxone and by the following morning was noticeably brighter and more alert. She remained afebrile for the duration of her hospital course. Also on the morning of first hospital day, blood cultures were negative. Urinalysis grew out streptococcus. The patient had some mild erythema on her left lower extremity and had marked discomfort to touch over both of her ankles, which she attributed to her “diabetes.” She remained on Rocephin and was actually tolerating near normal diet.
On the evening of the second hospital day, the patient complained of increased pain and was noted to be increasingly incoherent. She had been placed on nasal cannula overnight for have markedly increased erythema in her left lower extremity concerning for desaturation. On evaluation by cross covering physician, she was noted to have markedly increased erythema in her left lower extremity concerning for possible DVT. Doppler ultrasound showed no evidence of clot. She was started on Vancomycin for improved gram positive coverage. Respiratory status remained stable. However, the patient was minimally arousable later that morning. She had been administered a 1-mg dose of morphine for leg pain. Chest x-ray showed increased interstitial edema possibly consistent with heart failure. The patient received Narcan with some improvement in her mental status. Arterial blood gas showed evidence of significant CO2 retention with pH of 7.19, pCO2 70, pO2 50, serum bicarbonate of 26. She was diuresed and administered nebulizer treatments. She was moved to the Medical Intensive Care Unit for possible ventilation with BiPAP. Echocardiogram showed no wall motion abnormalities and no left ventricular dysfunction. Chemstix remained greater than 100 mg/dL. The patient had prompt improvement in her respiratory status with diuresis and prevision of Narcan. No further invasive ventilation was necessary.
Of note during these events the patient’s family was in close attendance including her three daughters and grandson. There was extensive consultation with them regarding any advanced directives that the patient might have specified previously. It was the consensus of the family that reasonable attempts at aggressive intervention were indicated as long as there was a possibility of a reversible etiology for her problems. Fortunately the patient’s condition stabilized.
For the remainder of her hospital course, intervention focused on improving her pulmonary status as well as renal function. Her creatinine had increased from prior baseline of 1.2 up to 1.7 with noticeable drop-off in her urine output. The patient had received intravenous antibiotics during her hospital course but had not had any noticeable hypotensive episodes. She was receiving diuretics, which complicated calculation of her urine sodium; however, overall picture appeared consistent with acute tubular necrosis. Renal ultrasound was obtained and showed no evidence of hydronephrosis or obstruction. She was restarted on her oral Indapamide and continued to have steady improvement in her pulmonary status. She did not require any supplemental oxygen following resolution of her pulmonary edema.
Infectious Disease was consulted with regards to her cellulitis and was concerned that it was not resolving as would be expected with a streptococcal organism. Therefore she was continued on Vancomycin for an additional five days and by the time of this dictation erythema had completely resolved and the patient was consistently alert, sitting up in bed and actually ambulating around her room. Leukocytosis resolved and, as noted above, renal function normalized. The plan was to continue her on oral Dicloxacillin for an additional 10 days of oral antibiotic therapy. Only additional intervention was provision of a combined albuterol Atrovent inhaler given the patient’s signs of chronic interstitial lung disease. This appeared to improve her ventilatory status as she had no further episodes of nocturnal desaturation. The patient at this time is stable for discharge.
I briefly discussed her hospital course with her primary physician, who will continue to follow her. Family is requesting the assistance of home health nurse for overall assessment over the next two weeks while the patient continues to recuperate at home. Other peripheral issues addressed during this hospitalization included the patient’s probable iron deficiency anemia. Recent colonoscopy and endoscopy showed evidence of diverticular disease but no other pathology. The patient has had upper GI bleeding. She was guaiaced during this admission, had stable hematocrit. B12 and folate were checked and were within normal limits. Other issue was the patient’s diet and she was evaluated by a speech therapist who noted that she did fine without any aspiration as long as she was provided with somewhat thickened feeds and had her usual foods provided. It was particularly requested that she be given pills, tablets, and capsules with a spoonful of pudding, applesauce, or yogurt instead of fluid. It was also recommended that she continue to have thickener available. The family was aware of these recommendations and is extraordinarily attentive to the patient’s needs.
Medications on Discharge: Insulin NPH 10 units qam; Synthroid .05 mg po qd; Aspirin 325 mg po qd; Lorazepam 0.5 mg po qhs; Iron 324 mg po tid; Colace 100 mg po qd; Dulcolax 10 mg prn constipation; Combivent MDI 2 puffs bid; Indapamide 2.5 mg po qd; Dicloxacillin 125 mg po qid × 10 days
Follow-up: The patient’s family has been instructed to call for appointment.
Diet: Soft mechanical 1,800 calorie ADA
Activities: The patient may ambulate to a chair with assistance.
Special Instructions: The patient should seek prompt medical attention for any recurrent fever, increased erythema in her lower extremity, or mental status changes as reported by the family.
Code Assignment Including POA Indicator
ICD-10-CM Principal Diagnosis:
ICD-10-CM Additional Diagnoses:
ICD-10-PCS Procedure Code(s): ___________________________________________
Issues to Clarify:

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