DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
BRIEF HISTORY AND HOSPITAL COURSE: This is a (XX)-year-old male who was transferred from the nursing home with sepsis, UTI, and acute renal failure. The patient has a history of bladder cancer, status post radical cystectomy and conduit. The patient has severe depression, dementia, BPH, CAD, and history of MI. On admission to the hospital, the patient had a BUN/creatinine ratio of 174:5.8, potassium was high at 5.7, calcium was 10.6, white count was in the range of 26,000, and hemoglobin and hematocrit were stable. UA had shown more than 4000 wbc’s, large blood, and leukocyte esterase large.
The patient was admitted to the regular medical floor, IV fluids started, and renal evaluation was obtained. The patient was pancultured, and IV antibiotics were started with Levaquin and DVT prophylaxis. Blood culture showed gram-negative rods and gram-positive cocci in clusters. Urine cultures had shown more than 100,000 lactose fermenter. In view of septicemia, with blood cultures and urine cultures positive, the patient was continued on IV antibiotics. Renal ultrasound was obtained, which showed bilateral mild hydronephrosis. The patient has history of bladder cancer, status post surgery. IV fluids were continued, and the patient slowly started improving.
A GU evaluation was obtained; they advised renal scan. Urine culture had shown E. coli, and blood culture had shown Staphylococcus aureus species. BUN and creatinine responded very well to IV fluids, and white count responded well to antibiotics. CT abdomen and pelvis, noncontrast, showed bilateral hydronephrosis, bilateral hydroureter, questionable soft tissue mass in the pelvis, 10.5 x 5.5 cm, questionable bowel, questionable abscess, questionable diverticulitis, questionable tumor, questionable renal calculus.
It was found out that the patient did not have any evidence of abscess contributing to sepsis. Wound care was obtained. Renal scan did not show any obstruction. The patient was continued on the present treatment. Renal failure in the meantime was getting better with fluids. The patient was approached for further evaluation regarding poor oral appetite. However, the family was very opposed to PEG due to advanced Alzheimer disease, aphasia, and lack of overall quality of life.
It was arranged for the patient to go back to the nursing home once IV fluids and IV antibiotics were completed. The patient was much better and was transferred to nursing home for further management. At the time of discharge, sodium was managed at 148, BUN 64, and creatinine 2.4. Antibiotics were completed.
DISCHARGE DIAGNOSES:
1. Septicemia, blood culture and urine cultures positive.
2. Acute renal failure, resolved.
3. Bladder cancer, status post radical cystectomy and conduit.
4. Dementia.
5. Depression.
6. Benign prostatic hyperplasia.
7. Coronary artery disease.
DISCHARGE INSTRUCTIONS: Follow up at the nursing home.
