Nicolich

Patient seen and examined at the bedside this morning. No acute events overnight. POD 2 s/p sacral
ulcer debridement without complications and pain well controlled. Patient has no other complaints.
Denies fever/chills, SOB, abdominal pain, diarrhea/constipation.

Gen: NAD, pleasant, comfortable in bed

HEENT: NCAT, MMM
Cardio: RRR, +S1, S2, no murmurs appreciated
Lungs: CTA B/L, exam performed in anterior lung fields only
Abd: soft, NT/ND, +BSx4
GU: foley present. Clear output.
Ext: non-edematous lower extremities
neuro: aaox3, no focal deficits.

76 y/o with PMHx of HTN, HLD, Hypothyroid, rheumatoid arthritis, MDR urosepsis, gout, stage IV sacral
decub ulcers followed up wound care and a recent admission to WUH for MSSA bacteremia (likely from
a pulmonary source given +flu and pneumonia) with course complicated by PE, septic right ankle, acute
respiratory failure requiring intubation and anemia of unclear source (family was not amenable to a GI
workup) presenting with lethargy, decreased urine output and discoloration of urine

Impression:
- septic shock 2/2 E. coli bacteremia from a urinary source, now resolved
- OM of coccyx extending to distal sacrum noted on pelvic MRI, s/p surgical debridement
- AKI now resolved
- Anemia of Chronic dx requiring one unit of PRBC's, Hb currently stabilized

Plan:
-wound cx: ngtd day 1, upon d/c long term abx IV vs PO
-given history of recurrently UTI, will get CT abd/pelvis to r/o underlying pathology
- Re-started on home metoprolol 25mg BID
- repeat ucx negative, initial cultures growing pansensitive E. Coli
- continue with meropenem (10/11-) + PO minocycline
- Post-op day 2,wound debridement on 10/16, daily dakins dressing changes for sacral decub.
- Will consider re-starting benazepril, lasix and amlodipine if patient is hypertensive.
-Echo from may 18th disclosed EF of 45-50% and grade I diastolic dysfunction. Patient has been
normotensive after midodrine has been tapered
- creatinine normalized, the initial insult was likely prerenal. Avoid nephrotoxics
- Patient refused texas catheter placement after surgery, and instead requested to continue using his
foley. Attempted to remove foley (10/9 inserted) but patient has continuously refused as he states he is
incontinent and will get messy
- c/w Levothyroxine 100mcg
- psych consult for depression found patient to not be depressed, and to be dealing appropriately with
his wife's death.

Cardiac Diet
SCDs
Foley
Full Code
HCP: BOB 303-926-9226