Identifying Data:

Full Name: R.B.

Age: 80

Sex: Male

Marital Status: Widowed

Race/Nationality: Spanish

Address: Queens, NY

Date of Birth: XX/XX/1940

Date and Time: 7/12/2021 9:30 PM 

Location: New York Presbyterian Hospital Queens   

Religion: Catholic

Source of Information: Self/Daughter

Source of Referral: Self

Reliability: Fair

Mode of Transport: EMS

Chief Complaint: chest pain x 1 week

History of Present Illness: 

80-year-old Spanish male, living with daughter and son-in-law, ambulating with assistance of cane, requiring assistance for some ADLs, able to perform IADLs independently, with a PMHx of T2DM, HTN, BPH, CHF, sick sinus syndrome requiring permanent pacemaker, prostate cancer s/p chemotherapy and radiation, anemia due to chronic kidney disease, left nephrostomy tube for BPH/CKD who presented to the ED complaining of chest pain x 1 week. Patient reports the chest pain is non-radiating, with a stabbing sensation and is associated with shortness of breath. He reports the pain lasts two minutes and is gradual in onset. He states the chest pain and shortness of breath are exacerbated when lying down and with exertion and alleviated when sitting upright. He denies taking anything for the pain. Patient reports dry cough and lower extremity edema for the past week as well. He also reports hematuria, dysuria for the last few days but denies any warmth, swelling or discharge from his nephrostomy tube. He reports throat pain but denies fever, chills, hemoptysis, diaphoresis, palpitations, syncope, nausea, vomiting or abdominal pain. He denies recent sick contacts or travel. In the ED the patient was found to have a urinary tract infection and started on ceftriaxone. BNP was elevated at 4,839, troponin elevated at 0.117 likely secondary to CKD with creatinine at 6.2. CXR showed cardiomegaly, left-sided pacemaker, and no consolidations. EKG was regular paced rhythm at 78 bpm with no ST elevations or T wave inversions. Patient was admitted to medicine for CHF exacerbation and UTI.

During his admission course, the patient had a TTE with EF of 60-65%, with aortic valve sclerosis without significant stenosis. Renal US showed prostamegaly and no evidence of hydronephrosis. Patient is still receiving ceftriaxone for UTI. Left PCNT was found to not be draining and IR exchanged the PCNT and placed a new left ureteral stent. AV fistula was created in left forearm to start dialysis. He also received packed RBCs for a hemoglobin 8.9 and IV iron. As of today, attempted to place left PCNU, which was unsuccessful secondary to closed tract.

Currently, patient hemodynamically stable and is observed to be sitting in bed comfortably. He reports left arm discomfort and swelling since the left AV graft placement. He denies any other symptoms including fever, chills, current chest pain, shortness of breath, cough, nausea, vomiting, abdominal pain, dysuria, or hematuria at this time.

Geriatric Assessment:

• ADLs: Requires assistance with ambulating, uses a cane. Does not require assistance with transferring, bathing, dressing, or grooming.  
• IADLs: independent
• Home health aid: Does not have a home health aid
• Social support: Daughter and family. Speaks with family daily.
• Visual impairment: None
• Hearing impairment: Patient has hearing aids.  
• Dental: Does not recall last dental exam. Does not use dentures.  
• Falls: Last mechanical fall was in 2019 after slipping on a rug. No recent falls.
• Assistive device used: Cane
• Nutritional concerns: No nutritional concerns.  
• Gait impairment: None
• Urinary incontinence: Denies
• Fecal incontinence: Denies
• Depression: Admits to occasional depression
• Health care proxy: Daughter
• Advance directives: Full code

Past Medical History:

• Present illnesses:
  • CKD Stage V
  • T2DM
  • HTN
  • BPH
  • Pacemaker due to sick sinus syndrome
  • CHF

Past Surgical History:

• Permanent pacemaker 2014
• TURP 2019
• Left ureteral stent September 2020
• Cystoscopy/L ureteral stent placed/attempted right ureteral stent/urethral dilatation 3/7/2021
• Nephrostomy tube (L PCNT) placed 5/19/2021

Family History:

• Unknown family history

Medications:

• Amlodipine 10 mg tablet – 1 tablet daily
• Clopidogrel 75 mg tablet – 1 tablet daily
• Ergocalciferol 50,000 units capsule once daily
• Finasteride 5 mg tablet by mouth daily
• Insulin glargine 100 unit/mL solution pen-injector – under skin nightly
• Lisinopril 20 mg tablet – 1 tablet daily
• Rosuvastatin 5 mg tablet – 1 tablet daily

Allergies:

• Denies any food, medication, or environmental allergies.

Social history:

• Widowed, lives with daughter and son-in-law in private home.
• Currently retired. Supported by pension and family. 
• Habits: Former smoker. Smoked 5 cigarettes/day for a few months in his teens. Denies present tobacco use, alcohol use or illicit drug use.
• Recent travel: Denies
• Diet: Healthy diet
• Exercise: Denies
• Sleep: Reports to sleeping six hours a night. 
• Sexual history: Denies being currently sexually active, formerly with one female partner.

Review of Systems: 

General: Denies fever, chills, night sweats, fatigue, weakness, decreased appetite, weight gain/weight loss.

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pruritis or changes in hair distribution.

Head: Denies headache, dizziness, or head trauma. 

Eyes: Denies blurry vision, double vision, loss of vision, photophobia, pruritus, or lacrimation.

Ears: Denies hearing loss, discharge, tinnitus, ear pain or use of hearing aids.

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Admits to sore throat. Denies bleeding gums, mouth ulcers, voice changes or use of dentures. Last dental exam unknown.

Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.

Respiratory: Admits to shortness of breath and cough. Denies wheezing, sputum production. 

Cardiovascular: Admits to chest pain. Denies palpitations, leg edema, hypertension, irregular heartbeat, syncope or known heart murmur. 

Gastrointestinal: Denies abdominal pain, abdominal distention, nausea vomiting, hematemesis, diarrhea, constipation, hemorrhoids, rectal bleeding. Last colonoscopy unknown.  

Genitourinary: Admits to dysuria and hematuria. Denies hesitancy, flank pain, nocturia, oliguria, polyuria, frequency, urgency, incontinence.

Musculoskeletal: Denies muscle or joint pain, back pain, redness, stiffness, unsteady gait, or deformities.

Peripheral vascular exam: Admits to peripheral edema. Denies intermittent claudication, coldness or trophic changes, varicose veins, or color changes.

Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions or a history of DVT/PE.

Neurologic: Denies weakness, dizziness, lightheadedness, headaches, sensory disturbances, changes in cognition/memory, LOC, loss of strength, ataxia, or numbness.

Psychiatric/Behavioral: Denies sleep disturbance, depression, suicidal ideations or seeing a mental health professional.

Physical Exam: 

VS: T 98.8 F, BP 144/56, HR 78 bpm, RR 14, O2 sat 95%, Ht 5’6”, Wt 129 lb, BMI 20.83  

Gen: Awake, alert, and oriented, in no acute distress. Frail appearing. 

Skin: Warm and moist, no rash, bruises, or pallor. Normal skin turgor. Non-icteric skin.

Head: Normocephalic, atraumatic.

Eyes: Symmetric OU. No eyelid swelling, ptosis or lesions. Sclera non-icteric. PERRLA. EOMI. 

ENT: Mucous membranes moist. No erythema or exudates in oropharynx. Uvula midline. Trachea midline, thyroid non-enlarged. No lymphadenopathy. Poor dentition.

Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. Radial pulses, DP/PT pulses 2+ bilaterally. Capillary refill less than 2 seconds bilaterally. +1 pitting edema to bilateral lower extremities up to the ankle. No JVD.

Respiratory: No respiratory distress. Crackles at bilateral bases.

Abdomen: Bowel sounds present in all quadrants. Soft, nontender, nondistended with no rebound or guarding. Left nephrostomy tube area clean, dry and intact with mild left CVA tenderness. No right sided CVA tenderness.

Extremities: Edema in LUE from arm at AVG to hand with mild erythema. Clean/dry/intact sutures at left forearm graft site with some tenderness to palpation. Palpable thrill of AVF. Full range of motion of all extremities. Strength grossly intact. No ecchymosis, atrophy, or deformities.

Neuro: Alert and oriented to person, place, and time. No focal neurological deficit.

Differentials:

• Myocardial infarction
• Angina
• CHF exacerbation
• Urinary tract infection
• Chronic kidney disease
• Pneumonia

Labs as of 7/12:

• CBC: WBC 12.99,, Hgb 8.7, HCT 26.9, MCV 89.4, MCH 28.9, MCHC 32.3, MPV 11.2, RDW 15.1, PLT 292, neutrophil 78%, lymphocyte 11.70%, monocyte 8.7%, eosinophil 0.80%, immature granulocytes 0.50%
• BMP: Na 138, K 4.3, Cl 98, CO2 18, BUN 90.6, Creatinine 6.05, Glucose 164, Ca 8.4, anion gap 22
• GFR 8
• Glucose 181
• Additional labs in ED 6/30:
  • Troponin T: 0.117
  • Pro-BNP: 4,839
  • SARS-CoV-2 RNA: Not Detected
  • Drug Screen: Negative for amphetamines, barbiturate, benzodiazepine, cocaine, opiates, cannabinoids
  • Hemoglobin A1c: 8.7
  • D-dimer: 487
  • PT: 11.3, INR: 0.98
  • PTT: 29.8
  • Ferritin: 61
  • Iron: 48, transferrin: 245, TIBC: 318, iron saturation: 15
  • B12: 687
  • UA: pH 7.5, color yellow, appearance turbid, glucose 100, bilirubin negative, ketones negative, specific gravity 1.012, blood moderate, protein 300, nitrite negative, leukocyte esterase large, WBC >100, RBC 30, bacteria positive, squamous epithelial cells 2, hyaline cast 2

EKG:

• Paced rhythm at 78 bpm with no ST elevations or T wave inversions

Imaging:

• CXR 6/30: Cardiomegaly left-sided pacemaker, no consolidation noted.
• CT abdomen/pelvis 6/30: left-sided nephroureteral stent with distal tip in the distal ureter, stable in position. Left sided nephrostomy tube in appropriate position. Unchanged thickening of urinary bladder wall which can be seen in cystitis. Unchanged prominent retroperitoneal lymphadenopathy. Unchanged nodular thickening of left adrenal gland.
• Renal US 7/6: Prostamegaly. No evidence of hydronephrosis.
• 7/6 IR Nephroureteral catheter: nephrostomy tube exchange of 8 French left 22 French nephroureteral catheter.
• 7/7 IR tunneled catheter placement: placement of 24 cm tunneled dialysis catheter in jugular vein ready for use.
• 7/12 IR fistulogram: closed left nephrostomy tract precluding replacement of the nephroureteral catheter. A new puncture left nephroureteral catheter placement will be performed after several days of being off Plavix.

Assessment/Plan: 

80 y/o male with a PMHx of T2DM, HTN, BPH, CHF, sick sinus syndrome requiring permanent pacemaker, prostate cancer s/p chemotherapy and radiation, anemia due to chronic kidney disease, left nephrostomy tube for BPH/CKD who presented complaining of chest pain x 1 week. He was admitted to medicine. Chest pain has since resolved and labs/imaging consistent with CHF exacerbation. Dysuria and hematuria correlated with urinalysis findings of urinary tract infection which has been treated. Currently hemodynamically stable with left arm pain s/p AV graft placed for dialysis.

• Chest pain
  • Elevated troponin at admission in the setting of CKD
  • Electrophysiology study performed with normal functioning of pacemaker
  • TTE showed EF 60-65%, diastolic dysfunction
  • Holding Plavix due to hematuria and for scheduled procedure on 7/15 for PCNU
• Sick sinus syndrome
  • Patient has permanent pacemaker
  • EKG with paced rhythm at 78 bpm.
• Heart failure with preserved ejection fraction
  • TTE with EF 60-65%
  • Continue holding ACEI
  • Carvedilol twice a day
  • Heart healthy diet
• Chronic Kidney Disease Stage V
  • Left sided obstructive uropathy with left nephrostomy
  • CT showed no hydronephrosis
  • Hemodialysis started on 7/10, next hemodialysis will be tomorrow
  • s/p left AV graft on 7/9
  • Left PCNU attempted today but unsuccessful, plan to place new PCNU on 7/15
  • Elevation and supportive care of LUE s/p AVF. Light compression bandage placed.
  • Keep on renal diet
  • Arrange for outpatient dialysis for when patient is discharged
• Anemia due to CKD
  • Received ferric gluconate
  • S/p PRBC for hemoglobin of 8.9
  • Continue with EPO 10K SC once a week  
• Urinary Tract Infection
  • Continue with ceftriaxone until 7/14
  • Leukocytosis present but no signs or symptoms of worsening infection
• T2DM
  • Continue with insulin regimen
• Benign essential HTN
  • Continue current medications – Amlodipine and Carvedilol
  • Holding ACEI for CKD