Age: 88.0
Sex: F
Vaccine: COVID19
Symptoms: Hiatus hernia, Hip fracture, Injury, Klebsiella infection, Leukocytosis
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on December 07, 2022 16:03 EST   Verified By: MD on December 07, 2022 16:03 EST   Encounter Info: Hospital, Inpatient, 12/07/22 -     * Final Report *          History of Present Illness/Subjective     90-year-old woman past medical history of anemia, CKD stage III, peripheral vascular disease, hypertension, hyperlipidemia, coronary artery disease, diabetes mellitus, hypothyroidism, and GERD. She presented after a fall, now with multiple fractures.  Orthopedic surgery consulted, no surgical intervention. was being treated for Klebsiella uti with ceftriaxone. blood cultures were negative  she was at Paoli Hospital, pending placement, today during rounds, she was found to be not feeling well and looked slightly pale and cyanotic.  Although bedside saturation was normal .  troponin EKG and chest x-ray was ordered.  Her troponin were found to be elevated.  She did not complain of chest pain or heaviness.  EKG did not show any dynamic changes in comparison to the previous ekgs.  the patient was started on NSTEMI treatment.  Cardiology on board  I do not see any previous cardiac work-up or stress testing in the charts   Patient has slight leukocytosis, chronic stable anemia resolving AKI on CKD, troponin of 2699.   Review of Systems     13 point review of system negative except for whats mentioned in my HPI   Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  None reported this timeframe     Patient Weight    Patient Height  None Reported     Constitutional:  pale   Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB 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, Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. NSTEMI (non-ST elevated myocardial infarction)   I21.4  - trend trops Q6,  - Serial ekg q6  -heparin drip  -s/l aspirin and Plavix loading  - aspirin and plavix daily  - cardiology consult  -nitroglycerin prn  - pain control if needed   Orders:   Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 12/07/22 9:48:00 EST, for 1 Days, 12/08/22 9:47:00 EST, 42 mL/hr, Clinical Weight  Bed Request (Decision to Admit)  Electrocardiogram  Level of Care  Troponin-I High Sensitivity  1. Sepsis secondary to UTI   A41.9  Ceftriaxone for one more day  for klebsiella UTI  2. Fall with injury   W19.XXXA   3. Hip fracture, left   S72.002A   Conservative management,     Per Ortho on call, Dr, "I reviewed the images. Would recommend non operative treatment with protective weight bearing  with walker and pain control. Would repeat X-ray of pelvis and inlet/outlet view in 7-10 days. Can't see her old dexa results but some vit d and calcium would help for insufficiency type fractures"  - restarted anticoagulation  -Calcium and vitamin D have been added to patient's regimen .   4. Left acetabular fracture   S32.402A   no surgical intervention per ortho  for DC to rehab After resolution of acute issues  5. Fracture of left inferior pubic ramus   S32.592A   no surgical intervention per ortho  for DC to rehab After resolution of acute issues  6. Anemia   D64.9   chronic and stable, normocytic, no active signs of bleeding, continue to trend  7. CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min   N18.30   Stable relative to baseline, avoid nephrotoxins as possible and continue to trend   8. PVD (peripheral vascular disease)   I73.9  on Xarelto, but currently on heparin drip for NSTEMI.  9. HTN (hypertension)   I10   Relatively normotensive and stable, continue to trend, continue home regimen with titration as appropriate  10. HLD (hyperlipidemia)   E78.5   stable on current statin regimen, screening lipid profile pending  11. Coronary artery disease   I25.10  H/o of CAD  12. DM2 (diabetes mellitus, type 2)   E11.9   Continue subcutaneous sliding scale and carb controlled diet for tight glycemic control.  Initiate baseline basal/bolus regimen as indicated by home clinical course with appropriate titration  13. Hypothyroidism   E03.9   continue home dosing of levothyroxine     Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent  35-70 minutes minutes of critical care time directly and personally managing the patient. This critical care time included obtaining a history, examining the patient, pulse oximetry, ordering and reviewing the studies, arranging urgent treatment with development of a management plan, evaluation of the patient?s response to treatment, frequent reassessment, and discussions with other clinicians. The critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see the MDM section and the rest of this note for further information on patient assessment and treatment.  Code Status   None Recorded   Chronic Problem List    Atherosclerosis of artery of left upper extremity  Shoulder arthritis  Shoulder strain  Subclavian artery stenosis  Procedure/Surgical History  ?Bone density scan (12/31/2018) ?Pressure relieved in eye (2011) ?Pressure relieved in eye (2009) ?Repair of hole in retina (2006) ?EGD with biopsy (09/08/2005) ?Colonoscopy (07/13/2004) ?Gallbladder (2004) ?Hip replacement (2001) ?Stents in heart (2001) ?Cataract (1999) ?Cesarean section (1961) ?Cesarean section (1958) ?Cesarean section (1954) ?Carotid Stent     Medications   Home Medications (19) Active  atorvastatin 20 mg, Orally, Daily  clopidogrel 75 mg, Orally, Daily  Colace 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  furosemide 20 mg, Orally, Daily  gabapentin 100 mg oral capsule 100 mg = 1 Capsule, Orally, Daily  gemfibrozil 600 mg, Orally, BID  isosorbide mononitrate 60 mg, Orally, QAM  Lantus (glucostabilizer) 38 Units, Subcutaneous, At Bedtime, 38-40 units  levothyroxine 112 mCg, Orally, Daily  Nitrostat 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  Novolog See Instructions, 14 units in morning, 15 at noon, 4-6 in evening  oxybutynin 5 mg, Orally, Daily  pantoprazole. 40 mg, Orally, Daily  Refresh 1 Drop, Eyes, Both, BID  Restasis   Restasis 0.05% ophthalmic emulsion 1 Bottle, Eyes, Both, Q12H, 1 drop each eye  sodium bicarbonate 325 mg, Orally, BID  Xarelto 2.5 mg oral tablet 2.5 mg = 1 Tablet, Orally, BID  Zioptan 0.0015% ophthalmic solution 1 Drop, Eyes, Both, Every PM  Active Scheduled Inpatient Medications  Dextrose 10% in Water 500 mL IV PRN - See Comments     Sodium Chloride 0.9%  1,000 mL IV  42 mL/hr     Heparin PREMIX + Sodium Chloride 0.45% IV Per Nomogram 1,514.7059 Units/kg/hr      One-Time Medications Given 12/06/22 00:00:00 TO 12/07/22 16:03:03  None Reported  PRN Medications (0600 - 0559) from 12/06 - 12/07  None Reported  Allergies   TRENtal  sulfa drugs  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Alone.   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: 12.2 k/cumm High (12/07/22 15:12:00)  RBC: 2.41 million/cumm Low (12/07/22 15:12:00)  Hgb: 7.7 GM/dL Low (12/07/22 15:12:00)  Hct: 23.2 % Low (12/07/22 15:12:00)  MCV: 96 fL (12/07/22 15:12:00)  MCH: 31.9 pg (12/07/22 15:12:00)  MCHC: 33.1 GM/dL (12/07/22 15:12:00)  RDW: 14.1 % (12/07/22 15:12:00)  Platelet: 311 k/cumm (12/07/22 15:12:00)  MPV: 7.5 fL (12/07/22 15:12:00)  Neutrophils %: 90 % (12/07/22 06:13:00)  Lymphocytes %: 2 % (12/07/22 06:13:00)  Monocytes %: 6 % (12/07/22 06:13:00)  Eosinophils %: 1 % (12/07/22 06:13:00)  Basophils %: 1 % (12/07/22 06:13:00)  Absolute Neutrophil: 10.1 k/cumm High (12/07/22 06:13:00)  Absolute Lymphocyte: 0.2 k/cumm Low (12/07/22 06:13:00)  Absolute Monocyte: 0.6 k/cumm (12/07/22 06:13:00)  Absolute Eosinophil: 0.2 k/cumm (12/07/22 06:13:00)  Absolute Basophil: 0.1 k/cumm (12/07/22 06:13:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (12/07/22 06:13:00)  Potassium SerPl QN: 4.1 mmol/L (12/07/22 06:13:00)  Chloride SerPl QN: 105 mmol/L (12/07/22 06:13:00)  Carbon Dioxide SerPl QN: 20 mmol/L Low (12/07/22 06:13:00)  Anion Gap: 11 mmol/L (12/07/22 06:13:00)  BUN SerPl QN: 42 mg/dL High (12/07/22 06:13:00)  Creatinine SerPl QN: 1.39 mg/dL High (12/07/22 06:13:00)  Estimated GFR (CKD-EPI, no race): 36 mL/min/1.73m2 Low (12/07/22 06:13:00)  Estimated CRCL (CG): 24 mL/min Low (12/07/22 06:13:00)  Glucose SerPl QN: 74 mg/dL (12/07/22 06:13:00)  Calcium Total SerPl QN: 9.2 mg/dL (12/07/22 06:13:00)  Alkaline Phos SerPl QN: 116 Units/L (12/07/22 06:13:00)  ALT SerPl QN: 10 Units/L (12/07/22 06:13:00)  AST SerPl QN: 22 Units/L (12/07/22 06:13:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (12/07/22 06:13:00)  Total Protein SerPl QN: 6.1 GM/dL Low (12/07/22 06:13:00)  Albumin SerPl QN: 3 GM/dL Low (12/07/22 06:13:00)  Troponin-I High Sensitivity: 2699 ng/L High (12/07/22 12:50:00)  Gluc-Strip, POC: 72 mg/dL (12/07/22 11:28:00)  Coagulation:  aPTT: 24 seconds (12/07/22 15:12:00)  Micro - Last 7 days  Blood CX: NEG (12/01/22 23:17:00)  Blood CX: NEG (12/01/22 23:17:00)  Urine CX: POS Critical (12/01/22 16:46:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/07/2022 15:50 - XR Chest PA or AP Portable  Impression: There is mild vascular congestion and possibly edema.There is large hiatal hernia.Visualized cardiac silhouette size appears enlarged, accentuated bylow lung volumes. Pericardial effusion is not excluded.                Signature Line Electronically Signed on 12/07/22 16:03 EST ________________________________________________________ MD