DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES: Impairment of mobility and activities of daily living requiring inpatient rehabilitation; peripheral vascular disease, status post left below-the-knee amputation; history of right below-the-knee amputation; bacteremia; pneumonia; Clostridium difficile enterocolitis; end-stage renal disease, on hemodialysis; diabetes mellitus; diabetic peripheral neuropathy; blindness with retinal detachment; atrial fibrillation, status post pacemaker insertion; coronary artery disease; hypertension; anemia with chronic renal disease.
DISCHARGE DIAGNOSES: Impairment of mobility and activities of daily living requiring inpatient rehabilitation; peripheral vascular disease, status post left below-the-knee amputation; history of right below-the-knee amputation; bacteremia; pneumonia; Clostridium difficile enterocolitis; end-stage renal disease, on hemodialysis; diabetes mellitus; diabetic peripheral neuropathy; blindness with retinal detachment; atrial fibrillation, status post pacemaker insertion; coronary artery disease; hypertension; anemia with chronic renal disease; left shoulder pain, likely bursitis.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who was readmitted here. The patient was admitted initially after the left below-the-knee amputation. The patient was in need of rehabilitation at the time and the patient was admitted. The patient was also being treated for pneumonia during that hospitalization with hemodialysis for end-stage renal disease. The patient was doing well and progressing well until MM/DD/YYYY when he became lethargic and became hypoxemic.
The patient was readmitted back with a diagnosis of new pneumonia. The patient was treated with antibiotics. The patient was getting better but the patient still has significant amount of bacteremia as well as Clostridium difficile enterocolitis. Appropriate medical treatments were initiated. Obviously, the patient became quite a bit more deconditioned and was having significant difficulty with self-care activities and mobility due to the recent BKA with a history of right below-the-knee amputation in the past. The patient required moderate to maximal assistance for mobility and was not ambulatory at all. The patient required similar assistance for self-care activities and the patient was quite deconditioned.
The patient obviously was in need of comprehensive inpatient rehabilitation care. The patient’s case was reviewed at the preadmission meeting here. It was determined that the patient would benefit from comprehensive inpatient rehabilitation and was an excellent candidate. Therefore, the patient was admitted. This hospitalization was reasonable and medically necessary. The patient will continue to require close monitoring of his medical condition as well as his functional condition.
HOSPITAL COURSE: The patient received comprehensive inpatient rehabilitation care. The patient received physiatric care for rehabilitation and medical intervention. The patient was also followed for nephrology management. Overall, the patient remained medically stable. The patient was continued on oral vancomycin due to persistently positive Clostridium difficile toxin. The patient had intermittent diarrhea as well. The patient continued to receive hemodialysis three times a week. The latest BUN was 42 and creatinine was 4.2. Potassium was 4 and sodium was 134.
Anemia was stable with hemoglobin of 9.6 and hematocrit of 29.4. The patient was continued on insulin and also Aranesp for his anemia. The left stump was healing well. There were some scabs, but there was no evidence of infection. Gentle wrapping was done but stump shrinker was not used in view of incomplete healing at the time of discharge. The patient has evidence of pleural effusion. The chest x-ray showed some pleural effusion and possible right basilar infiltrate. Nephrology followed the patient very closely. The patient was able to participate in the rehabilitation program as fully as he possibly could do. Discharge planning was done.
FUNCTIONAL STATUS: The patient required minimal assistance for bed mobility and minimal to moderate assistance for functional transfers using right prosthesis. The patient was obviously nonweightbearing at the left lower extremity due to recent BKA. The patient was not ambulatory. The patient also required assistance for wheelchair mobility due to blindness. The patient required supervision for eating and grooming and upper body dressing, minimal assistance for lower body dressing, maximal to total assistance for bathing and toileting. Extensive family training was done.
DISCHARGE MEDICATIONS: Betoptic S one drop each eye at bedtime; Lasix 40 mg p.o. daily; Lantus insulin 20 units subcutaneously at bedtime, one month’s supply; Xalatan ophthalmic solution one drop to each eye at bedtime; Protonix 40 mg p.o. daily; Zoloft 50 mg p.o. at bedtime; Nephro-Vite one p.o. daily; vancomycin orally 250 mg q. 6 hours x1 month; and Vicodin one p.o. t.i.d. p.r.n., #60.
FOLLOWUP: The patient will have followup with Nephrology on next hemodialysis day. The patient will also have followup with Dr. John Doe. The patient will be followed here in about four weeks. The patient was referred to outpatient physical therapy here two times a week for four weeks and these are to be done on nonhemodialysis days. The patient will continue with preprosthetic training and stump wrapping.
DISCHARGE DIET: A 2000-calorie ADA with renal diet.
DISCHARGE EQUIPMENT: The patient already has a front-wheel walker, wheelchair, bedside commode, and shower chair. Sliding board was ordered.
DISCHARGE CONDITION: Medically stable.
DISPOSITION: The patient is being discharged home with wife and family assistance.
