Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Craniocerebral injury, Creatinine renal clearance decreased, Crepitations, Dehydration, Diarrhoea
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on December 04, 2022 18:57   Verified By: NP on December 04, 2022 18:57   Encounter Info: Hospital, Observation, 12/04/22 - 12/04/22    * Final Report *          History of Present Illness/Subjective     18:50 December 04, 2022 18:50:59 67 year old with a History of diabetes, hyperlipidemia, hypertension presents with 6 days of fever, chills, vomiting, diarrhea, weakness. He fell yesterday and hit his head, he was out of a short while.  on interview,pt endorsed having black water stool x 6 days. occult blood is positive in the ER.  And hemoglobin has been stable.  No hematemesis, hematuria, chest pain, headache, fever, nausea or vomiting.  Patient appears severely dehydrated and very tired, on auscultation by the NP, upper lobe wheezing and lower lobe crackles noted.  In the ER  Vital signs-blood pressure 117/45, heart rate 77, SPO2 95% on room air Labs  WBC 7.8, hemoglobin 11.6, neutrophils 85% platelet 183  D-dimer 628, sodium 130, chloride 95, bicarb 20, anion gap 15, BUN/creatinine 53/2.12, glucose 251, calcium 8.3, ALT 51, AST 87, T bili 0.6, troponin 44, ketones negative  Lactate 2.0  Venous blood gas-pH 7.33, PCO2 39, bicarb 21, O2 sat 40  COVID-negative  Flu a positive  occult blood positive Imaging Chest x-ray-Bilateral interstitial opacities with a focal opacity in the left  lower lung findings which may represent pneumonia and/or edema.  CT PE-Bilateral patchy ground glass opacities, which may be seen in setting  of multifocal pneumonia  CT head-no acute intracranial process  CT cervical spine-no acute fracture      Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.9 (36.9-36.9)  Temp (FAHR) 98.4 (98.4-98.4), BP 145/63 (117-154)/(34-71), HR 79 (74-90), RR 20 (2-23), O2Sat 97 (94-97)     Patient Weight  Current Daily Weight:    130.1 kg    12/04/22  Previous Daily Weight:    131.7 kg    12/04/22  Difference from Previous:    -1.600000 kg  BMI:    44.9    12/04/22    Morbid Obesity (BMI > = 40) Patient Height  Current Height:    170.2 cm    12/04/22        Constitutional:  + Mild distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs Bilateral bases with expiratory crackles and Bilteral upper lobes expiratory wheezing Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan     Assessment/Plan 67 year old presents with 6 days of fever, chills, vomiting, diarrhea, weakness and a fall.  admitted for multiple problems 1. Influenza A   J10.1  Positive for flu a  -We will give Tamiflu 75 mg twice daily for 5 days.  Antibiotics to cover for possible bacterial superinfection.  We will give ceftriaxone and doxycycline  -Airborne precaution   2. GI bleeding  Patient endorsed passing watery black stool for the past 6 days, Last  episode this am.  Also appears very dehydrated on exam.  Vital signs have been stable, and hemoglobin is currently stable. baseline hemoglobin is between 10 and 11.  Occult blood positive  We will monitor patient's closely and if patiently acutely decompensates i.e  tachycardic, hypotensive or has a large black bowel movement, will consult GI urgently overnight for urgent endoscopy  -In the meantime, will start IV PPI twice daily  -N.p.o. except medication  -Hb Q4 hr and notify provider if downtrending  -Ensure adequate IV access. ensure fluid hydration  -Transfuse as needed to keep Hb >7g/dl  -Will notify GI  -Telemetry  2. Hyperglycemia   R73.9  Elevated blood sugars noted  -Insulin ISS  -Monitor BGM's with ACH S  -Get A1c  3. Elevated troponin   R77.8  Troponin is 44, no current chest pain.  Trend to peak  -We will get EKG to rule out ST changes  -Place patient on telemetry  4. Hyponatremia   E87.1  Sodium of 130 and chloride of 95.  Symptomatic  Likely hypovolemic hyponatremia.  We will send sodium labs and give IV hydration  -Trend sodium daily  AKI (acute kidney injury)   N17.9  BUN/creatinine higher than baseline.  Likely prerenal given dehydration.  Will give IV fluid hydration and trend creatinine daily, if not downtrending will get renal ultrasound and consult nephrologist  Closed head injury   S09.90XA  History of fall yesterday, with head CT negative for acute intracranial process resulting from fall.  -We will continue to monitor mental status  -Ensure pain control  Fall at home   W19.XXXA  Pneumonia   J18.9  Seen on chest imaging.  Likely secondary to influenza A.  We will treat as listed above  Sinusitis   J32.9   Orders:   acetaminophen, 1,000 mg, Orally, Tablet, Q8H, PRN, Pain Mild PO (1-3 out of 10), 12/04/22 18:46:00   ceftRIAXone, 1 GM, IVPB, Injection, Q24H, 12/04/22 19:00:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 12/04/22 18:46:00, PRN - See Comments, Clinical Weight  doxycycline, 100 mg, IVPB, Injection, Q12H, 12/04/22 19:00:00, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 12/04/22 18:46:00   glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 12/04/22 18:46:00   hydroCODONE-acetaminophen, 1 Tablet, Orally, Tablet, Q8H, PRN, Pain Moderate PO (4-6 out of 10), 12/04/22 18:46:00   insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 12/04/22 18:46:00   labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 12/04/22 18:46:00   ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 12/04/22 18:46:00   oseltamivir, 75 mg, Orally, Capsule, BID, 12/04/22 21:00:00   pantoprazole, 40 mg, IV Push, Injection, BID, 12/04/22 21:00:00   Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 12/04/22 18:46:00, 150 mL/hr, Clinical Weight  Admit to Inpatient   Call (Specify)  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  Cardiac Monitor  Care Management Consult  CBC w/Differential  Comp Metabolic Panel  Electrocardiogram  Fluid Intake Requirement  Gluc-Strip POC  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Level of Care  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  Nasal Cannula  Notify Provider  Notify Provider  Notify Provider  OT Evaluation and Treatment  Peripheral IV Insertion  PT Evaluation and Treatment  Reason for Not Ordering Long-acting Insulin  Reason for Not Ordering Medication Prophylaxis  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Vital Signs  Weight   Code Status   Resuscitation Status - Ordered    -- 12/04/22 18:46:00, Full Code   Chronic Problem List    AKI (acute kidney injury)  Closed head injury  Diabetes mellitus  Fall at home  Hyperlipidemia  Hypertension  Pneumonia  Severe obesity  Sinusitis  Procedure/Surgical History  ?None     Medications   Home Medications (11) Active  alfuzosin 10 mg oral tablet, extended release 10 mg = 1 Tablet, Orally, Daily  amitriptyline 25 mg, Orally, At Bedtime  citalopram 20 mg, Orally, Daily  finasteride 5 mg, Orally, Daily  Lantus (insulin glargine) 100 units/mL subcutaneous solution See Instructions, 60 units in morning  Lipitor 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  losartan 25 mg, Orally, TID  metFORMIN 1,000 mg, Orally, Daily  metoPROLOL tartrate , Orally, BID  NovoLOG Mix 70/30 subcutaneous suspension See Instructions, 40 units BID  Ozempic 2 mg/1.5 mL (0.25 mg or 0.5 mg dose) subcutaneous solution 2 mg, Subcutaneous, Every Saturday  Active Scheduled Inpatient Medications  ceftRIAXone, Injection, 1 GM, IVPB, Q24H, Start: 12/05/22 13:00:00  doxycycline, Injection, 100 mg, IVPB, Q12H, Start: 12/04/22 19:00:00  influenza virus vaccine, inactivated (influenza virus vaccine, inactivated preservative-free quadrivalent IM suspension), Injection, 0.5 mL, IM, ONCE, Start: 12/04/22 21:00:00  oseltamivir (Tamiflu), Capsule, 75 mg, Orally, BID, Start: 12/04/22 21:00:00  pantoprazole, Injection, 40 mg, IV Push, BID, Start: 12/04/22 21:00:00  Sodium Chloride 0.9%  1,000 mL IV  150 mL/hr     Dextrose 10% in Water 500 mL IV PRN - See Comments       One-Time Medications Given 12/03/22 00:00:00 TO 12/04/22 18:56:40  Zithromax, Injection, 500 mg, IVPB, ONCE, (1 DOSE 12/04/22 12:55:00)  ceftRIAXone, Injection, 2 GM, IV Push, ONCE, (1 DOSE 12/04/22 12:55:00)  pantoprazole, Injection, 40 mg, IV Push, ONCE, (1 DOSE 12/04/22 10:16:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 12/04/22 10:16:00)  PRN Medications (0600 - 0559) from 12/03 - 12/04  acetaminophen, 1,000 mg, Orally, Q8H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q8H, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   labetalol, 10 mg, IV Push, Q6H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Past   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.8 k/cumm (12/04/22 09:44:00)  RBC: 3.84 million/cumm Low (12/04/22 09:44:00)  Hgb: 11.6 GM/dL Low (12/04/22 09:44:00)  Hct: 33.2 % Low (12/04/22 09:44:00)  MCV: 87 fL (12/04/22 09:44:00)  MCH: 30.2 pg (12/04/22 09:44:00)  MCHC: 34.9 GM/dL (12/04/22 09:44:00)  RDW: 14.1 % (12/04/22 09:44:00)  Platelet: 183 k/cumm (12/04/22 09:44:00)  MPV: 7.2 fL (12/04/22 09:44:00)  Neutrophils %: 85 % (12/04/22 09:44:00)  Lymphocytes %: 10 % (12/04/22 09:44:00)  Monocytes %: 5 % (12/04/22 09:44:00)  Eosinophils %: 0 % (12/04/22 09:44:00)  Basophils %: 0 % (12/04/22 09:44:00)  Absolute Neutrophil: 6.6 k/cumm (12/04/22 09:44:00)  Absolute Lymphocyte: 0.8 k/cumm Low (12/04/22 09:44:00)  Absolute Monocyte: 0.4 k/cumm (12/04/22 09:44:00)  Absolute Eosinophil: 0 k/cumm (12/04/22 09:44:00)  Absolute Basophil: 0 k/cumm (12/04/22 09:44:00)  Chemistry:  Sodium SerPl QN: 130 mmol/L Low (12/04/22 09:44:00)  Potassium SerPl QN: 4.1 mmol/L (12/04/22 09:44:00)  Chloride SerPl QN: 95 mmol/L Low (12/04/22 09:44:00)  Carbon Dioxide SerPl QN: 20 mmol/L Low (12/04/22 09:44:00)  Anion Gap: 15 mmol/L High (12/04/22 09:44:00)  BUN SerPl QN: 53 mg/dL High (12/04/22 09:44:00)  Creatinine SerPl QN: 2.12 mg/dL High (12/04/22 09:44:00)  Estimated GFR (CKD-EPI, no race): 33 mL/min/1.73m2 Low (12/04/22 09:44:00)  Estimated CRCL (CG): 44 mL/min Low (12/04/22 09:44:00)  Glucose SerPl QN: 251 mg/dL High (12/04/22 09:44:00)  Calcium Total SerPl QN: 8.3 mg/dL Low (12/04/22 09:44:00)  Alkaline Phos SerPl QN: 74 Units/L (12/04/22 09:44:00)  ALT SerPl QN: 51 Units/L (12/04/22 09:44:00)  AST SerPl QN: 87 Units/L High (12/04/22 09:44:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (12/04/22 09:44:00)  Total Protein SerPl QN: 7.1 GM/dL (12/04/22 09:44:00)  Albumin SerPl QN: 3.8 GM/dL (12/04/22 09:44:00)  Troponin-I High Sensitivity: 44 ng/L High (12/04/22 09:44:00)  Ketones SerPl QN: Negative (12/04/22 09:44:00)  Lactate Venous Pl QN: 2 mmol/L (12/04/22 09:44:00)  pH Bld Venous QN: 7.33 Low (12/04/22 09:44:00)  PCO2 Bld Venous QN: 39 mmHg Low (12/04/22 09:44:00)  PO2 Bld Venous QN: <35 Low (12/04/22 09:44:00)  Base Excess Bld Venous: -5 mmol/L Low (12/04/22 09:44:00)  Bicarb Bld Venous Calc: 21 mmol/L Low (12/04/22 09:44:00)  O2 Sat Bld Venous Calc: 40 % (12/04/22 09:44:00)  Patient Temperature: 37 DegC (12/04/22 09:44:00)  Coagulation:  D-Dimer Pl QN: 698 ng/mL DDU High (12/04/22 09:44:00)  All Other Labs:  Specimen Type Occult Blood: Stool (12/04/22 09:43:00)  Occult Blood Stool: Positive Abnormal (12/04/22 09:43:00)  COVID 19 Specimen Source: Nasopharyngeal (12/04/22 09:27:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (12/04/22 09:27:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/04/22 09:27:00)  Rapid Influenza A PCR: Detected Abnormal (12/04/22 09:27:00)  Rapid Influenza B PCR: Not Detected (12/04/22 09:27:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/04/2022 11:26 - CT Head W/o IV Contrast  IMPRESSION: 1.  No acute intracranial hemorrhage or midline shift.2.  Mild cerebral and cerebellar atrophy.3.  Intracranial atherosclerosis.4.  Partial opacification of the paranasal sinuses findings whichrepresent sinusitis.    12/04/2022 11:26 - CT Cervical Spine W/o IV Contrast  IMPRESSION:1.  No acute fracture or malalignment.2.  Mild degenerative changes as described above.    12/04/2022 11:27 - XR Chest PA or AP Portable  IMPRESSION:1.  Bilateral interstitial opacities with a focal opacity in the leftlower lung findings which may represent pneumonia and/or edema.    12/04/2022 15:21 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:Limited evaluation demonstrating no lobar or definite segmentalpulmonary embolism. Bilateral patchy ground glass opacities, which may be seen in settingof multifocal pneumonia. Clinically correlate.Coronary calcifications.                Signature Line Electronically Signed on 12/04/22 18:57  ________________________________________________________ NP  Electronically Signed on 12/05/22 18:29  ________________________________________________________ MD