Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Platelet count normal, Pleural effusion, Pneumonia, Procalcitonin, Protein total decreased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on December 08, 2023 18:28  Verified By: MD on December 08, 2023 18:28   Encounter Info: Hospital, Inpatient, 12/08/23 -     * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     Chief complaint:  shortness of breath and bloody vomitus   HPI:Patient is a 81-year-old male patient with history of COPD diabetes hyperlipidemia left renal mass, chronic right heart failure, coronary artery disease, anemia, history of GI bleed presented to emergency department with a chief complaint of vomiting.  Patient is accompanied by his wife who is the historian and who reports 1 episode of projectile bloody vomitus this morning.  She also brought in some samples of blood soaked mucus from the vomitus.  She reports that his shortness of breath has been slightly worse over the last couple of weeks since being diagnosed with pneumonia on November 10, 2023.  He has been on long course of antibiotics since then without any improvement.  Upon evaluation in the emergency room patient found to have a white count of 9.4 hemoglobin 8.6 which is lower than his baseline of about 10.  INR 1.22 D-dimer 600 which is age-appropriate BUN 44 creatinine 1.87 glucose 190 ALT AST 6 and 6 normal troponins BNP 62 lactate 2.4.  Chest x-ray was obtained that showed bilateral lower lobe interstitial and alveolar airspace disease right greater than left suspicious for multifocal pneumonia.  Probable small layering right pleural effusion since D-dimer was high CTA chest to rule out pulmonary embolism was obtained that showed patchy pneumonia in the right lower lobe with small volume right parapneumonic effusion negative for pulmonary embolism severe emphysema left upper pole renal mass measuring up to 7.3 cm similar in size since the prior study.  Patient also have multivessel coronary artery disease on the study.  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Physical Exam/Objective Vitals & Measurements most recent past 24 hours   Weight Result Pt Reported: 70.9 kg (12/08/23 08:34:00)    Temp Result C Pt Reported: 97.2 F (12/07/23 09:07:00)    Pulse Patient Reported: 104 bpm (12/07/23 09:00:00)    Oxygen Saturation Patient Reported: 91 % (12/07/23 08:59:00)    Systolic Result Patient Reported: 114 mmHg (12/07/23 09:00:00)    Diastolic Result Patient Reported: 54 mmHg (12/07/23 09:00:00)  Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported  Patient Reported Weight  Weight Result Pt Reported: 70.9 kg (12/08/23)    Weight Result Pt Reported: 71.7 kg (12/07/23)     General: Alert and oriented Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Rhonchi in bilateral lower lung fields, respirations labored symmetric expansion Cardiovascular: Normal rate, Regular rhythm. Gastrointestinal: Soft, Non-tender. Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect       Assessment/Plan       1. Sepsis   A41.9  Patient meets sepsis criteria secondary to having tachycardia tachypnea and infection in the lung.  -Patient has failed outpatient antibiotic therapy.  -Patient was given 1000 mL fluid bolus for sepsis.  -We will continue fluids at 150 mill an hour for next 6 to 7 hours since patient has history of chronic congestive heart failure and monitoring closely for fluid overload.  -Patient was also given cefepime and vancomycin in the emergency room.  -I will switch antibiotics to Zosyn and vancomycin.  -Follow-up on blood cultures Legionella procalcitonin and strep antigen.  -Repeat lactate in 6 hours.  -Check patient for COVID.    2. Pneumonia   J18.9   See management above.   3. Upper GI bleed   K92.2   Patient apparently have a history of a procedure bleed and I have asked the emergency room doctor to consult GI.  -No DVT prophylaxis at this time.  -Hemoglobin every 6 hours.  -Transfuse if hemoglobin less than 7.  -Protonix 40 mg IV twice daily.   4. Anemia   D64.9   Noted.  Patient has at least 1 episode of upper GI bleed today.  -Will monitor closely.   5. COPD (chronic obstructive pulmonary disease)   J44.9   Patient is tachypneic at the time of presentation likely secondary to sepsis.  Patient's oxygen saturation is 92% on 2 L nasal cannula which is his baseline.  -At this time no steroids are indicated.   6. Hyperlipidemia   E78.5   Noted.  Patient will be resumed on home medications.   7. Renal cell carcinoma of left kidney   C64.2   Noted.  Ongoing therapy outpatient.   8. Diabetes mellitus   E11.9   Patient's sugars are fairly well-controlled.  -CDU protocol no Lantus.   9. Chronic diastolic heart failure   I50.32   Noted.  Fluid overload closely.    Code Status   None Recorded   Chronic Problem List    Anemia  CAD (coronary artery disease)  Chronic diastolic heart failure  Chronic respiratory failure  Chronic right heart failure  Colonic polyp  COPD (chronic obstructive pulmonary disease)  Diabetes mellitus  Elevated PSA  End stage COPD  Erectile dysfunction  GERD (gastroesophageal reflux disease)  Hx of CABG  Hyperlipidemia  Hypogammaglobulinemia  Iron deficiency anemia  Left renal mass  Low testosterone  Major depression in remission  Melena  OAB (overactive bladder)  Polypharmacy  Pulmonary nodules  Renal cell carcinoma of left kidney  Renal cyst  Tubular adenoma  Urgency of urination  Vasomotor rhinitis  Procedure/Surgical History  ?EGD (esophagogastroduodenoscopy) and closure of duodenal fistula (05/12/2023) ?Port placement (03/30/2023) ?Colonoscopy (09/12/2022) ?Colonoscopy (09/18/2017) ?Prostate biopsy needle (2016) ?PFT (08/06/2013) ?Surgery (2010) ?Left ear drum patched (1986) ?Hernia repair (1966) ?CABG x 3 - Coronary artery bypass grafts x 3 ?Capsule endoscopy ?Cataract extraction   Surgical History Internal  05/12/2023    EGD Diagnostic    MD  03/30/2023    Portacath Insertion     MD  09/12/2022    Colonscpy Bx    MD  09/18/2017    Colonscpy Diagnostic/Screen     MD  Medications   Home Medications (37) Active  acyclovir 400 mg oral tablet 400 mg = 1 Tablet, Orally, Daily  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H  aspirin 81 mg, Orally, Daily  atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily  azithromycin 250 mg oral tablet 250 mg = 1 Tablet, Orally, Every Mon Wed Fri  cholecalciferol (vitamin D3) 25 mCg (1,000 intl units) oral capsule 25 mCg = 1 Capsule, Orally  Cymbalta 60 mg oral delayed release capsule 60 mg = 1 Tablet, Orally, Daily  Daliresp 500 mCg oral tablet 500 mCg = 1 Tablet, Orally, Daily  DULOXetine 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, Daily  Dymista 137 mCg-50 mCg/inh nasal spray 1 Spray, Nostrils, Both, BID, Prime before initial use and when it has not been used for 14 or more days.  Flomax 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily  Gemtesa 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily  guaiFENesin 400 mg oral tablet See Instructions, 1 Tablet Orally BID, then increase to 4 tablets/day PRN  ipratropium nasal 42 mCg/spray See Instructions, USE 2 SPRAYS IN EACH NOSTRIL THREE TIMES DAILY  Marinol 2.5 mg oral capsule 2.5 mg = 1 Capsule, Orally, BID  metFORMIN 850 mg oral tablet 850 mg = 1 Tablet, Orally, BID  metoPROLOL tartrate 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  MiraLax oral powder for reconstitution 17 GM, PRN, Orally, Daily, dissolve in water before taking  morphine 10 mg/5 mL oral solution 5 mg = 2.5 mL, PRN, Orally, Q4H  OneTouch Delica Lancets Check daily, Other, Unscheduled, Dispense QS 90 days  OneTouch Verio Meter Not Applicable, Other, Unscheduled  OneTouch Verio Test Strips Test blood sugar 1 times daily, Other, Unscheduled, Dispense QS for 90 days  predniSONE 10 mg oral tablet See Instructions, 6 tab x 3 days, then 5 tab x 3 days, then 4 tab x 3 days, then 3 tab x 3 days, then 2 tab x 3 days, then 1 tablet x 3 days  predniSONE 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  Prevacid 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, Daily  ProAir RespiClick 90 mCg/inh inhalation powder 1 Puff, PRN, Inhalation, Q4H  Proscar 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  Reglan 10 mg oral tablet 10 mg = 1 Tablet, Orally, TID, Take 1/2 hour before meals.  Remeron 30 mg oral tablet 30 mg = 1 Tablet, Orally, At Bedtime  senna 8.6 mg oral tablet 17.2 mg = 2 Tablet, PRN, Orally, BID, Senna 187 mg = 8.6mg Sennosides  torsemide 20 mg oral tablet See Instructions, Take 1 tablet by mouth in AM and 3 tablets in PM  Trelegy Ellipta 100 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  Vitamin B12 2500 mCg sublingual tablet 2,500 mCg = 1 Tablet, Sublingually, QAM  Vitamin C See Instructions, Take 4,000 mg in AM, 10,000 mg PM  Xanax 0.25 mg oral tablet 0.25 mg = 1 Tablet, PRN, Orally, TID  Xiidra 5% ophthalmic solution 1 Drop, Eyes, Both, BID  Zyrtec 10 mg oral tablet 10 mg = 1 Tablet, Orally, QAM  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 12/07/23 00:00:00 TO 12/08/23 18:28:07  None Reported  PRN Medications (0600 - 0559) from 12/07 - 12/08  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Work/School description: police officer.   Home/Environment   lives at home with wife and son, Lives with Spouse. Home equipment: Oxygen, nebulizer .   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. 5 packs per day. Started age 16.0 Years. Stopped age 61 Years.  Family History   Asthma: Daughter.  COPD: Brother.  Diabetes mellitus type 1: Brother.  Encephalitis: Daughter.  Heart disease..: Brother.  Hypertension..: Mother.  Prostate cancer..: Father.  Seizure..: Daughter.  Stroke..: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.4 k/cumm (12/08/23 14:40:00)  RBC: 2.87 million/cumm Low (12/08/23 14:40:00)  Hgb: 8.6 GM/dL Low (12/08/23 14:40:00)  Hct: 26.6 % Low (12/08/23 14:40:00)  MCV: 93 fL (12/08/23 14:40:00)  MCH: 30.1 pg (12/08/23 14:40:00)  MCHC: 32.4 GM/dL (12/08/23 14:40:00)  RDW: 20.1 % High (12/08/23 14:40:00)  Platelet: 218 k/cumm (12/08/23 14:40:00)  MPV: 6.6 fL Low (12/08/23 14:40:00)  Neutrophils %: 89 % (12/08/23 14:40:00)  Lymphocytes %: 2 % (12/08/23 14:40:00)  Monocytes %: 9 % (12/08/23 14:40:00)  Eosinophils %: 0 % (12/08/23 14:40:00)  Basophils %: 0 % (12/08/23 14:40:00)  Absolute Neutrophil: 8.4 k/cumm High (12/08/23 14:40:00)  Absolute Lymphocyte: 0.2 k/cumm Low (12/08/23 14:40:00)  Absolute Monocyte: 0.8 k/cumm (12/08/23 14:40:00)  Absolute Eosinophil: 0 k/cumm (12/08/23 14:40:00)  Absolute Basophil: 0 k/cumm (12/08/23 14:40:00)  Chemistry:  Sodium SerPl QN: 141 mmol/L (12/08/23 14:40:00)  Potassium SerPl QN: 3.8 mmol/L (12/08/23 14:40:00)  Chloride SerPl QN: 98 mmol/L (12/08/23 14:40:00)  Carbon Dioxide SerPl QN: 35 mmol/L High (12/08/23 14:40:00)  Anion Gap: 8 mmol/L (12/08/23 14:40:00)  BUN SerPl QN: 44 mg/dL High (12/08/23 14:40:00)  Creatinine SerPl QN: 0.87 mg/dL (12/08/23 14:40:00)  Estimated GFR (CKD-EPI, no race): 87 mL/min/1.73m2 (12/08/23 14:40:00)  Estimated CRCL (CG): 68 mL/min (12/08/23 14:40:00)  Glucose SerPl QN: 190 mg/dL High (12/08/23 14:40:00)  Calcium Total SerPl QN: 8.9 mg/dL (12/08/23 14:40:00)  Alkaline Phos SerPl QN: 42 Units/L (12/08/23 14:40:00)  ALT SerPl QN: 6 Units/L Low (12/08/23 14:40:00)  AST SerPl QN: 6 Units/L Low (12/08/23 14:40:00)  Bilirubin Total SerPl QN: 0.2 mg/dL (12/08/23 14:40:00)  Total Protein SerPl QN: 6.2 GM/dL Low (12/08/23 14:40:00)  Albumin SerPl QN: 3.5 GM/dL (12/08/23 14:40:00)  Troponin-I High Sensitivity: 8 ng/L (12/08/23 15:36:00)  BNP Pl QN: 62 pg/mL (12/08/23 14:40:00)  Lactate Venous Pl QN: 2.4 mmol/L High (12/08/23 16:27:00)  Coagulation:  PT: 13.8 seconds High (12/08/23 14:40:00)  INR: 1.22 (12/08/23 14:40:00)  D-Dimer Pl QN: 600 ng/mL DDU High (12/08/23 14:40:00)  All Other Labs:  ABO Rh: B Pos (12/08/23 16:27:00)  IAT Interp: Neg (12/08/23 16:27:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 12/08/2023 15:23 - XR Chest PA or AP Portable  IMPRESSION:1.  Bilateral lower lobe interstitial and alveolar airspace disease,right greater than left, suspicious for multifocal pneumonia.2.  Probable small layering right pleural effusion.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    12/08/2023 17:29 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for pulmonary embolism.2.  Patchy pneumonia in the right lower lobe with small volume rightparapneumonic effusion.3.  Severe emphysema.4.  Left upper pole renal mass measures up to 7.3 cm, similar in sizesince the prior study.5.  Multivessel coronary artery disease.Results were communicated and receipt was documented in the Primordial Results Reporting System.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 12/08/23 18:28 EST ________________________________________________________ MD  Electronically Signed on 12/09/23 08:33 EST ________________________________________________________ MD