ADMITTING DIAGNOSES:
1. Medical deconditioning.
2. Complicated acute hospitalization resulting from ruptured diverticula with complication of abdominal abscess requiring a right colon resection and right partial ileum resection with associated respiratory failure, bacteremia, acute renal failure and Clostridium difficile colitis.
3. Hypertension.
4. Hyperlipidemia.
5. Coronary artery disease.
6. Chronic obstructive pulmonary disease.
7. Right hemiparesis due to remote residual weakness from a prior cerebrovascular accident.
ESTIMATED LENGTH OF STAY: Three and a half weeks.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a history of multiple medical comorbidities who presented to an outside hospital with approximately a 9-day history of abdominal pain. He was diagnosed with diverticulitis with associated abscess. He underwent surgical draining with right colectomy and a partial ileum resection.
His hospital course was notable for persistent dependence on mechanical ventilator, requiring tracheostomy tube placement, abnormal elevated LFTs, DVTs in bilateral lower extremities and one upper extremity, acute renal failure, anemia, sepsis and Clostridium difficile colitis. He had a Greenfield filter placed and was also started on anticoagulation therapy due to DVT in his upper extremity.
He was transferred to this hospital where he was treated for postacute care and mechanical ventilator weaning. Since his hospitalization here, he was weaned from the ventilator and is currently decannulated. He has persistent impairments, including a right residual hemiparesis from his prior cerebrovascular accident and global weakness and poor endurance due to medical deconditioning from his acute hospital course and medical deconditioning.
Additionally, he has anemia with a recent H&H of 7.5 and 21 and has an abdominal and right groin wound as well as some redness of a stage I decubitus on his sacral area, as well as ongoing issues with hypertension.
ALLERGIES: He is allergic to Betadine and tape.
CURRENT MEDICATIONS: Include albuterol and Atrovent hand-held nebulizers, metoprolol, Flagyl, Prevacid, Fragmin and SAF-Gel to the wounds.
PAST MEDICAL AND SURGICAL HISTORY: Hypertension, coronary artery disease, status post coronary artery bypass graft, COPD, benign prostatic hypertrophy, status post TURP, history of peptic ulcer disease, status post Billroth I, history of pancreatitis, hyperlipidemia, status post cholecystectomy, history of inguinal hernia repair and history of splenectomy. He has a history of skin cancer.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: The patient is tired. He does complain of diarrhea. He denies any headaches, dizziness or blurred vision. He denies any nausea, vomiting or constipation. He denies any chest pain or shortness of breath. He denies any fevers, chills or sweats. He is incontinent of bladder. Does have some diarrhea with occasional incontinence of this. He does have residual right-sided weakness and reddened area on his backside as well as wounds on his abdomen and groin. He has a nonproductive cough.
SOCIAL AND FUNCTIONAL HISTORY: He was independent prior to his current hospitalization. He is at this point planing on selling his home. He is aware that he may need further convalescence, and if so, he intends to go to a nursing home.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 140/66, temperature is 97.8 degrees, heart rate 78, respirations 22, height is 5 feet 7 inches and weight is 165-1/2 pounds. GENERAL: He is a pleasant, elderly male, in no acute distress. HEENT: Pupils are equal, round and reactive to light. EOMs are intact. He does have arcus senilis. Oropharynx is moist and pink. His dentition actually is in fairly good shape. NECK: Supple. No bruits. LUNGS: He does have a nonproductive cough. Lungs are otherwise clear to auscultation. No rales, wheezes or rhonchi. CARDIOVASCULAR: Notable for regular rate and rhythm without any murmurs, rubs or gallops. ABDOMEN: Soft, nontender and nondistended with normoactive bowel sounds. He does have an abdominal wound measuring 4.5 x 1.5 cm with approximately 1 cm depth. The wound itself has got beefy, red granulation tissue without any significant drainage. On his right groin, he has also another wound approximately 4 x 2 x 1 cm in depth, also with good granulation tissue on the wound bed and no significant drainage. SKIN: Of note, his skin has significant actinic keratosis over the scalp and face. He also has a fairly large seborrheic keratosis over his left upper arm. EXTREMITIES: No joint pain, deformity, range of motion impairment or laxity with the exception that he has external rotation of his right hip. We think it is, at least in part, related to some tightness in his external rotators on that side. He has decreased range of motion, which is at least in part related to decreased strength on his right foot. We are able to get him to range to neutral for ankle dorsiflexion. NEUROLOGIC: He is awake, alert and oriented x4. Speech is fluent and intelligible. His fund of knowledge is intact. His short-term and long-term memory is intact. Sensation is intact. He does have a trace to 1+ edema of his right ankle and foot. Motor strength is notable for 4+ to 5-/5 strength on the left side with proximal greater than distal weakness. He does not get full range of motion for shoulder abduction on that right side, and he has 4/5 to 4-/5 for deltoids, 4+ to 5- distally in that right upper extremity. For right hip flexor, he is 4-/5. Quadriceps, 3+ to 4-/5. He has very minimal resistance distally for his ankle dorsiflexion and plantarflexion, extensor hallucis longus. Gait is not tested.
IMPRESSION AND PLAN: The patient is (XX)-year-old male with multiple medical comorbidities and is currently medically deconditioned with residual right hemiparesis due to remote cerebrovascular accident but with significant medical deconditioning following a catastrophic illness.
1. Medical deconditioning. Engage OT, PT, TR.
2. Pulmonary, status post respiratory failure. His tracheostomy stoma is healing well. We will continue with hand-held nebulizers q.4 hours. Also, to consider cardiopulmonary rehab for endurance training and strengthening.
3. Cardiovascular and hypertension. He does have a history of coronary artery disease, status post coronary artery bypass graft. We will continue with metoprolol, monitor blood pressure and cardiac response to therapies.
4. Deep venous thrombosis, status post Greenfield filter placement. We will continue with treatment dosing of Fragmin and monitor. Plan to get bilateral knee-high TED hose.
5. Infectious disease. The patient initially with an abscess. Status post 42 days of antibiotics. Did have recent Clostridium difficile colitis. His most recent stool culture, however, was negative. We will continue with additional 5 days of Flagyl. We will monitor bowels. We may need to get a followup Clostridium difficile toxin evaluation on his stools depending on his amount of diarrhea.
6. Anemia. We will check followup CBC today. We may need to transfuse depending on how low he goes, and we will monitor for signs and symptoms of anemia at rest.
7. Wounds. Currently looks clean with good evidence of granulation tissue. We plan to ask wound care nurse to consult, and we will continue SAF-Gel for now.
8. Nutrition. We will continue with a regular diet, mechanical, soft, with thin liquids. We will check albumin and prealbumin.
9. Skin, actinic keratosis, history of skin cancer. We think he can follow up as an outpatient. We will watch for this so as to see that he does not have any abnormal skin, that is more concerning than the actinic keratosis.
10. Mood. Stable.
11. Disposition. We think he has an intact plan for domestic disposition, eventually, if not in the short term.
CODE STATUS. Full.
GOALS. The goals are for him to be at a modified independent level for ADLs and self-care. Probably will need wheelchair for long distance mobility. Cognitively, we think he is going to be intact, will not require supervision or cognitive assistance from rehab standpoint.
