Age: 61.0
Sex: M
Vaccine: COVID19
Symptoms: Crystal urine present, Culture wound, Differential white blood cell count, Drug screen, Encephalopathy
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 14, 2023 15:42   Verified By: MD on February 14, 2023 15:42   Encounter Info: Hospital, Inpatient, 02/14/23 -     * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     This is a 62-year-old male who was brought in by the EMS from ECF for confusion and fever.  In the ECF the patient was noted to have 1 or 2.9 °F temperature this morning and was confused.  On my evaluation the patient was alert and oriented x0 and agitated, in pain.In the ED patient was hypotensive, received for 3 L of fluid.  Blood pressure stable now but has been persistently tachycardic since then it is sinus tachycardia with incomplete right bundle branch block.  Labs were significant for leukocytosis  anemia of 11.5, sedimentation rate of 111, dimers 5254, elevated C-reactive protein, patient has left leg wound x-ray was done which did not show erosive changes on the bone ultrasound left lower extremity did not show any DVT.  CTA was done but cannot rule out PE because of motion.  Patient's x-ray shows some pulmonary edema he is saturating 96% on room air but the leg is visibly swollen and erythematous.  He is also noted to have AKI on CKD stage III.  Review of Systems     In point review of system was not possible due to patient's orientation  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  , O2Sat 94 (94-94)     Patient Weight    Patient Height  None Reported     Constitutional:  acute distress  Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  crepts Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  left lower leg, swollen, unable to open the bandage, he wouldnt let me Integumentary:  Intact, warm, dry no rashes Neurologic: Alert but confused Psychiatric:  agitated    Assessment/Plan       1. Sepsis with acute hypoxic respiratory failure   A41.9  - broad spectrum antibiotics  - Follow lactate and procal  - blood culture  - acute resp failure secondary to pna, fluid overload, needs sleep study outpatient   2. Encephalopathy   G93.40  - likely due to acute infective process  - follow b12, tsh, ammonia  - drug screen  - Meningis is one of the differentials, given history of hallucinations, but there is a source of infection already   3. PNA (pneumonia)   J18.9  - on broad spectrum due to PNA  - de escalate once stablizes  - f/u pna workup   4. Pulmonary edema   J81.1  - mild pulmonary edema,  - unable to diurese, at the moment due to severe sepsis   5. Left leg cellulitis   L03.116  - xray not suggestive of osteo,  - u/s lower ext: no dvt  - continue broad spectrum antibiotics   6. Left renal stone   N20.0  - out patient urology   7. Hypokalemia   E87.6  - replete as per protocol   8. AKI (acute kidney injury)   N17.9  - avoid nephrotoxins.  - gentle hydration   9. Sinus tachycardia   R00.0  - sinus, likely due to pain,  -follow TSH,   10. Elevated d-dimer   R79.89  - acute phase reactant, also other inflammatory markers elevated, including c reactive and esr  - cta was non conclusive, will preemptively treat for PE , well - SCORE moderate risk and repeat cta WHEN MORE ALERT   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/14/23 14:59:00   azithromycin, 500 mg, IVPB, Injection, Q24H, Indication: Pneumonia - CAP, 02/15/23 15:00:00, for 3 Doses, 02/17/23 15:00:00, 250 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 250  cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), 02/14/23 23:00:00, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 02/14/23 14:59:00  Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 02/14/23 14:59:00, for 1 Days, 02/15/23 14:58:00, 100 mL/hr, Clinical Weight  magnesium sulfate, 4 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 02/14/23 15:33:00, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  metroNIDAZOLE, 500 mg, IVPB, Infusion, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), 02/14/23 23:00:00, 100 mL/hr, Infuse Over 60 minutes, Total Volume (mL) = 100  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 02/14/23 14:59:00   potassium chloride, 30 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 02/14/23 15:33:00   potassium chloride, 40 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 02/14/23 15:33:00   sodium phosphate, 28 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 02/14/23 15:33:00, 37.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 150  sodium phosphate, 21 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 02/14/23 15:33:00, 50 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 150  sodium phosphate, 21 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 02/14/23 15:33:00, 50 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 150  traMADOL, 50 mg, Orally, Tablet, Q6H, PRN, Pain Moderate PO (4-6 out of 10), 02/14/23 15:41:00   Admit to Inpatient CAH  Ammonia Pl QN  Basic Metabolic Panel  Basic Metabolic Panel  Blood CX  Blood CX  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  CBC w/Differential  CBC w/Differential  Collect Specimen  Collect Specimen  Collect Specimen  Comp Metabolic Panel  Comp Metabolic Panel  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Drug Screen-Expanded, Urine  Dysphagia Screen by RN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  L pneumophila Ag Ur QL  L pneumophila Ag Ur QL  Lactate Pl Arterial QN  Level of Care  Message to Nursing  Nasal Cannula  Notify Provider  Notify Provider  Notify Provider  Notify Provider  NPO Advance as Tolerated  OT Evaluation and Treatment  Pain Assessment  Peripheral IV Insertion  Pharmacy Dosing Consult  Procalcitonin  Procalcitonin  PT Evaluation and Treatment  PTINR  Resp Evaluation or Assessment  Resuscitation Status  Strep pneumoniae Ag Urine  Titrate FiO2 to Keep O2 Sat  TSH 3rd Gen SerPl QN  Vancomycin Pharmacy Dosing Consult  Vital Signs  Vital Signs  Vitamin B12 SerPl QN  Weight  Wound CX + Stn   Code Status   Resuscitation Status - Ordered    -- 02/14/23 14:59:00, Full Code   Chronic Problem List    Adult BMI 30+  Allergic reaction  Bilateral chronic knee pain  Colonoscopy refused  Hypertension  Immunization refused  Morbid obesity  Obesity  Osteoarthritis of right hip  Osteoarthritis, chronic  Prediabetes  Procedure/Surgical History  ?None     Medications   Home Medications (14) Active  Aldactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  allopurinol 100 mg oral tablet 200 mg = 2 Tablet, Orally, Daily  atenolol 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  lisinopril 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  meloxicam 15 mg oral tablet 15 mg = 1 Tablet, Orally, Daily  metFORMIN 500 mg oral tablet, extended release See Instructions, TAKE 1 TABLET BY MOUTH TWICE A DAY  Pravachol 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Probiotic Formula 1 Capsule, Orally, Daily  Silvadene 1% cream 1 App, Topical, Daily  traMADOL 50 mg oral tablet 50 mg = 1 Tablet, Orally, TID  Tylenol Extra Strength 500 mg oral tablet 1,000 mg = 2 Tablet, Orally, Unscheduled, Tylenol Extra Strength (500MG Tablet, 1 Oral as needed) Active.  Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q6H  Vitamin D3 (cholecalciferol)   Active Scheduled Inpatient Medications  azithromycin, Injection, 500 mg, IVPB, Q24H, Indication: Pneumonia - CAP, Start: 02/15/23 15:00:00  cefePIME, Injection, 1 GM, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 02/14/23 23:00:00  metroNIDAZOLE, Infusion, 500 mg, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 02/14/23 23:00:00  Lactated Ringers  1,000 mL IV  100 mL/hr       One-Time Medications Given 02/13/23 00:00:00 TO 02/14/23 15:42:43  None Reported  PRN Medications (0600 - 0559) from 02/13 - 02/14  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   labetalol, 10 mg, IV Push, Q6H, 0  Dose(s)   magnesium sulfate, 4 GM, IVPB, Q12H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   potassium chloride, 30 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 40 mEq, Orally, Unscheduled, 0  Dose(s)   sodium phosphate, 21 mmol, IVPB, Unscheduled, 0  Dose(s)   sodium phosphate, 28 mmol, IVPB, Unscheduled, 0  Dose(s)   traMADOL, 50 mg, Orally, Q6H, 0  Dose(s)   Allergies   Peanuts/Peanut Butter (Anaphylaxis)  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   home health, Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Family history is negative  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12.5 k/cumm High (02/14/23 03:52:00)  RBC: 4.11 million/cumm Low (02/14/23 03:52:00)  Hgb: 11.5 GM/dL Low (02/14/23 03:52:00)  Hct: 35.1 % Low (02/14/23 03:52:00)  MCV: 85 fL (02/14/23 03:52:00)  MCH: 27.9 pg (02/14/23 03:52:00)  MCHC: 32.7 GM/dL (02/14/23 03:52:00)  RDW: 14.7 % High (02/14/23 03:52:00)  Platelet: 224 k/cumm (02/14/23 03:52:00)  MPV: 7.9 fL (02/14/23 03:52:00)  Neutrophils %: 96 % (02/14/23 03:52:00)  Lymphocytes %: 2 % (02/14/23 03:52:00)  Monocytes %: 2 % (02/14/23 03:52:00)  Eosinophils %: 0 % (02/14/23 03:52:00)  Basophils %: 0 % (02/14/23 03:52:00)  Absolute Neutrophil: 12.1 k/cumm High (02/14/23 03:52:00)  Absolute Lymphocyte: 0.2 k/cumm Low (02/14/23 03:52:00)  Absolute Monocyte: 0.2 k/cumm (02/14/23 03:52:00)  Absolute Eosinophil: 0 k/cumm (02/14/23 03:52:00)  Absolute Basophil: 0 k/cumm (02/14/23 03:52:00)  Band: 14 % (02/14/23 03:52:00)  Neutrophil: 81 % (02/14/23 03:52:00)  Lymphocyte: 4 % (02/14/23 03:52:00)  Monocyte: 1 % (02/14/23 03:52:00)  RBC Morphology: Normal, (02/14/23 03:52:00)  Sed Rate: 111 mm/hr High (02/14/23 03:52:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (02/14/23 03:52:00)  Potassium SerPl QN: 2.9 mmol/L Critical (02/14/23 03:52:00)  Chloride SerPl QN: 101 mmol/L (02/14/23 03:52:00)  Carbon Dioxide SerPl QN: 20 mmol/L Low (02/14/23 03:52:00)  Anion Gap: 14 mmol/L High (02/14/23 03:52:00)  BUN SerPl QN: 50 mg/dL High (02/14/23 03:52:00)  Creatinine SerPl QN: 1.71 mg/dL High (02/14/23 03:52:00)  Estimated GFR (CKD-EPI, no race): 45 mL/min/1.73m2 Low (02/14/23 03:52:00)  Estimated CRCL (CG): 61 mL/min (02/14/23 03:52:00)  Glucose SerPl QN: 173 mg/dL High (02/14/23 03:52:00)  Calcium Total SerPl QN: 8.7 mg/dL (02/14/23 03:52:00)  Alkaline Phos SerPl QN: 74 Units/L (02/14/23 03:52:00)  ALT SerPl QN: 28 Units/L (02/14/23 03:52:00)  AST SerPl QN: 63 Units/L High (02/14/23 03:52:00)  Bilirubin Direct SerPl QN: 0.3 mg/dL High (02/14/23 03:52:00)  Bilirubin Total SerPl QN: 1 mg/dL (02/14/23 03:52:00)  Total Protein SerPl QN: 6.9 GM/dL (02/14/23 03:52:00)  Albumin SerPl QN: 3.4 GM/dL Low (02/14/23 03:52:00)  Lipase SerPl QN: 12 Units/L (02/14/23 03:52:00)  Lactate Venous Pl QN: 1.8 mmol/L (02/14/23 03:52:00)  pH Bld Venous QN: 7.45 (02/14/23 03:52:00)  PCO2 Bld Venous QN: 30 mmHg Low (02/14/23 03:52:00)  PO2 Bld Venous QN: 51 mmHg High (02/14/23 03:52:00)  Base Excess Bld Venous: -2 mmol/L (02/14/23 03:52:00)  Bicarb Bld Venous Calc: 21 mmol/L Low (02/14/23 03:52:00)  O2 Sat Bld Venous Calc: 88 % (02/14/23 03:52:00)  Patient Temperature: 37 DegC (02/14/23 03:52:00)  C-Reactive Prot SerPl QN: 49 mg/dL High (02/14/23 03:52:00)  Coagulation:  D-Dimer Pl QN: 5254 ng/mL DDU High (02/14/23 03:52:00)  Urine Studies:  Color: Yellow (02/14/23 04:14:00)  Clarity: Clear (02/14/23 04:14:00)  Specific Gravity: 1.025 (02/14/23 04:14:00)  pH: 5.5 (02/14/23 04:14:00)  Protein: 100 Abnormal (02/14/23 04:14:00)  Glucose: NEGATIVE (02/14/23 04:14:00)  Ketones: NEGATIVE (02/14/23 04:14:00)  Bilirubin: NEGATIVE (02/14/23 04:14:00)  Hgb Ur: SMALL. Abnormal (02/14/23 04:14:00)  Nitrite: NEGATIVE (02/14/23 04:14:00)  Urobilinogen: NormalUro (02/14/23 04:14:00)  Leukocyte Esterase Ur: NEGATIVE (02/14/23 04:14:00)  WBC: 0-5 (02/14/23 04:14:00)  RBC: 0-2 (02/14/23 04:14:00)  Bacteria: TRACE. (02/14/23 04:14:00)  Squamous Epithelial: Few (02/14/23 04:14:00)  Mucous: PRESENT. (02/14/23 04:14:00)  Granular Casts: 3-5 Abnormal (02/14/23 04:14:00)  Amorphous Crys Ur: PRESENT. (02/14/23 04:14:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (02/14/23 03:55:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/14/23 03:55:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/14/23 03:55:00)  Rapid Influenza A PCR: Not Detected (02/14/23 03:55:00)  Rapid Influenza B PCR: Not Detected (02/14/23 03:55:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/14/2023 05:30 - XR Chest PA or AP Portable  IMPRESSION:1.  Question mildly increased interstitial opacities. This could berelated to poor penetration. Mild edema/vascular congestion oratypical infection is in the differential.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    02/14/2023 07:10 - XR Tibia/Fibula Left  Impression:1. Extensive soft tissue swelling of the foot. No underlying acutebony process seen.    02/14/2023 08:07 - Venous Duplex Scan LE Left  IMPRESSION:1. Limited study due to overlying edema, with the deep calf veins notcompletely evaluated. No deep or superficial venous thrombosisevident in the visualized veins.2. Left inguinal lymphadenopathy.3. Diffuse soft tissue catheter edema..    02/14/2023 08:43 - CTA Chest Pulm Embolism W/IV Contrast  Impression:1. Nondiagnostic study for evaluation of pulmonary embolus due toextensive respiratory patient motion artifact and diminished overallenhancement of the pulmonary arteries. Pulmonary emboli would not beable to be excluded.2. No acute pulmonary process seen.3. Incidentally noted is a nonobstructing upper pole left renalcalyceal calculus.                Signature Line Electronically Signed on 02/14/23 15:42  ________________________________________________________ MD  Electronically Signed on 02/14/23 17:02  ________________________________________________________ MD