Age: 81.0
Sex: F
Vaccine: FLU4, VARZOS
Symptoms: Pneumonia, Pneumonia influenzal, Protein total normal, Protein urine, Rales
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 29, 2022 17:01   Verified By: MD on November 29, 2022 17:57   Encounter Info: Inpatient, 11/29/22 -     * Final Report *          History of Present Illness/Subjective      Chief Complaint: weakness HPI: Patient is an 80-year-old female presented to Emergency Department via EMS complaining of back pain that started 2 days ago additionally have been having some vomiting since yesterday oxygen saturation in 80s when EMS arrived at scene.  Patient is now on 4 L oxygen and saturating in high 90s  Patient's confused HPI is limited due to the altered mental state. Patient presented with a temperature of 101.5 heart rate monitor to respirations in high 20s to low 30s presenting blood pressure 219/88.  Briefly she was given nicardipine in the emergency room and her blood pressure gradually improved temperature dropped to 99.7 and respirations continue to be high.  Laboratory data was unremarkable except patient's troponin was 68 BNP 820 urinalysis showing moderate amount of hemoglobin rapid influenza positive: Negative.  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  Vital Signs (most recent and range for last 24 hours)  None reported this timeframe     Patient Weight    Patient Height  None Reported     General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. basilar crackles Cardiovascular: Normal rate, Regular rhythm. s1 s2 positive Gastrointestinal: Soft, Non-tender. BS present all 4 quadrants Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact    Assessment/Plan       1. Sepsis   A41.9   Patient meets sepsis criteria secondary to high temperature tachycardia tachypnea and chest x-ray showing pneumonia.  -Patient has been started on broad-spectrum antibiotics  -We will gently hydrate the patient since patient's BNP is elevated to almost 1000.  -Monitor for fluid overload.   2. Pneumonia   J18.9   Follow-up on culture data, procalcitonin.  -If procalcitonin level is less than 0.25 discontinue antibiotics she is likely having influenza pneumonia.   3. Altered mental state   R41.82   See problem 1 and 2   4. Influenza   J11.1   Patient will be given Tamiflu twice daily for 5 days.  -Keep in droplet isolation.   5. Hypertensive urgency   I16.0  Patient was briefly on nicardipine drip bp improved.  will give metoprolol pushes if needed on the floor otherwise start home meds.   6. Elevated brain natriuretic peptide (BNP) level   R79.89   Patient does not appear to be fluid overloaded but her BNP is sufficiently elevated.  -Obtain 2D echocardiogram   7. Elevated troponin   R77.8   Likely demand related.  -Repeat troponin.   8. Lacunar infarction   I63.81   This appears to be an old infarct but I am not certain since patient is having altered mental state I would like to get an MRI of her brain to rule out any acute problems.   9. Ascending aortic aneurysm   I71.21   This is also quite large chest at the verge and patient might need repair.  -We will refer this to primary care doctor for outpatient follow-up.   10. Hypokalemia   E87.6   This will be monitored daily patient is mildly hypokalemic.  -We will replace.   11. DM (diabetes mellitus), type 2   E11.9   Diabetes appears to be fairly well controlled.  -No need for Lantus.  -Continue with sliding scale insulin and low-carb diet.  -Hypoglycemia protocol.   12. Hyperlipidemia   E78.5   Resume statins   13. Morbid obesity   E66.01   Counseling will be provided once patient is more alert and awake.    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 52 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    Abnormal gait  Arthralgia of multiple joints  BMI 37.0-37.9, adult  DM (diabetes mellitus), type 2  Heart murmur  Hyperlipidemia  Hypertension  Left-sided chest wall pain  Long term use of drug  Morbid obesity  Osteoarthritis  Right knee DJD  Procedure/Surgical History  ?Colonoscopy (08/22/2007) ?Ankle fracture ?Eye surgery     Medications   Home Medications (11) Active  amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Blood Glucose Meter Not Applicable, Other, Unscheduled  Blood Glucose Test Strips Check daily, Other, Unscheduled, E11.65Z79.4  DME Walker (ONCE) Not Applicable, Other, Unscheduled, standard walker  DME Wheelchair Not Applicable, Other, Unscheduled  ibuprofen 200 mg oral capsule 200 mg = 1 Capsule, Orally, Q4H  Lancet Device Not Applicable, Other, Unscheduled  Lancets 1 Box, Other, Unscheduled, Use as needed to check blood sugars  lisinopril-hydroCHLOROthiazide 20 mg-12.5 mg oral tablet 1 Tablet, Orally, Daily  Misc Supplies See Instructions, Toilet seat riser with arms  Active Scheduled Inpatient Medications  niCARdipine PREMIX + Sodium Chloride 0.9% PREMIX IV Titrate - See Comments 5 mg/hr      One-Time Medications Given 11/28/22 00:00:00 TO 11/29/22 17:01:20  None Reported  PRN Medications (0600 - 0559) from 11/28 - 11/29  None Reported  Allergies   NKA  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Diabetes mellitus type 2: Mother.  Heart disease..: Mother.  High blood pressure..: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 5.8 k/cumm (11/29/22 11:50:00)  RBC: 4.14 million/cumm (11/29/22 11:50:00)  Hgb: 11.8 GM/dL Low (11/29/22 11:50:00)  Hct: 35.5 % (11/29/22 11:50:00)  MCV: 86 fL (11/29/22 11:50:00)  MCH: 28.5 pg (11/29/22 11:50:00)  MCHC: 33.2 GM/dL (11/29/22 11:50:00)  RDW: 14.3 % (11/29/22 11:50:00)  Platelet: 302 k/cumm (11/29/22 11:50:00)  MPV: 7.8 fL (11/29/22 11:50:00)  Neutrophils %: 87 % (11/29/22 11:50:00)  Lymphocytes %: 6 % (11/29/22 11:50:00)  Monocytes %: 7 % (11/29/22 11:50:00)  Eosinophils %: 0 % (11/29/22 11:50:00)  Basophils %: 0 % (11/29/22 11:50:00)  Absolute Neutrophil: 5 k/cumm (11/29/22 11:50:00)  Absolute Lymphocyte: 0.3 k/cumm Low (11/29/22 11:50:00)  Absolute Monocyte: 0.4 k/cumm (11/29/22 11:50:00)  Absolute Eosinophil: 0 k/cumm (11/29/22 11:50:00)  Absolute Basophil: 0 k/cumm (11/29/22 11:50:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (11/29/22 11:50:00)  Potassium SerPl QN: 3.4 mmol/L Low (11/29/22 11:50:00)  Chloride SerPl QN: 95 mmol/L Low (11/29/22 11:50:00)  Carbon Dioxide SerPl QN: 31 mmol/L High (11/29/22 11:50:00)  Anion Gap: 10 mmol/L (11/29/22 11:50:00)  BUN SerPl QN: 15 mg/dL (11/29/22 11:50:00)  Creatinine SerPl QN: 0.71 mg/dL (11/29/22 11:50:00)  Estimated GFR (CKD-EPI, no race): 85 mL/min/1.73m2 (11/29/22 11:50:00)  Estimated CRCL (CG): 70 mL/min (11/29/22 11:50:00)  Glucose SerPl QN: 167 mg/dL High (11/29/22 11:50:00)  Calcium Total SerPl QN: 9.9 mg/dL (11/29/22 11:50:00)  Alkaline Phos SerPl QN: 77 Units/L (11/29/22 11:50:00)  ALT SerPl QN: 11 Units/L (11/29/22 11:50:00)  AST SerPl QN: 15 Units/L (11/29/22 11:50:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (11/29/22 11:50:00)  Total Protein SerPl QN: 7.7 GM/dL (11/29/22 11:50:00)  Albumin SerPl QN: 4.3 GM/dL (11/29/22 11:50:00)  Troponin-I High Sensitivity: 68 ng/L High (11/29/22 11:50:00)  BNP Pl QN: 820 pg/mL High (11/29/22 11:50:00)  Lactate Venous Pl QN: 1.2 mmol/L (11/29/22 11:50:00)  pH Bld Venous QN: 7.37 (11/29/22 11:50:00)  PCO2 Bld Venous QN: 56 mmHg (11/29/22 11:50:00)  PO2 Bld Venous QN: 40 mmHg (11/29/22 11:50:00)  Base Excess Bld Venous: 6 mmol/L High (11/29/22 11:50:00)  Bicarb Bld Venous Calc: 32 mmol/L High (11/29/22 11:50:00)  O2 Sat Bld Venous Calc: 73 % (11/29/22 11:50:00)  Patient Temperature: 37 DegC (11/29/22 11:50:00)  Urine Studies:  Color: Yellow (11/29/22 14:01:00)  Clarity: Clear (11/29/22 14:01:00)  Specific Gravity: 1.020 (11/29/22 14:01:00)  pH: 6.0 (11/29/22 14:01:00)  Protein: 100 Abnormal (11/29/22 14:01:00)  Glucose: NEGATIVE (11/29/22 14:01:00)  Ketones: NEGATIVE (11/29/22 14:01:00)  Bilirubin: NEGATIVE (11/29/22 14:01:00)  Hgb Ur: MODERATE. Abnormal (11/29/22 14:01:00)  Nitrite: NEGATIVE (11/29/22 14:01:00)  Urobilinogen: 1.0. (11/29/22 14:01:00)  Leukocyte Esterase Ur: NEGATIVE (11/29/22 14:01:00)  WBC: 0-5 (11/29/22 14:01:00)  RBC: 3-5 Abnormal (11/29/22 14:01:00)  Bacteria: Few Abnormal (11/29/22 14:01:00)  Squamous Epithelial: Few (11/29/22 14:01:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (11/29/22 11:34:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/29/22 11:34:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (11/29/22 13:46:00)  Rapid Influenza A PCR: Detected Abnormal (11/29/22 13:46:00)  Rapid Influenza B PCR: Not Detected (11/29/22 13:46:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/29/2022 12:24 - CTA Chest WO/W IV Contrast  IMPRESSION:1.  No evidence of aortic dissection.2.  Dilatation of ascending thoracic aorta measuring up to 4.9 cm.3.  Moderate to severe atherosclerosis with moderate/severe ostialstenosis of the celiac artery and mild ostial stenosis of the SMA.4.  Patchy consolidative opacities in the right middle lobe and medial right lung base, likely infectious in etiology.5.  Other ancillary findings as above. Thank you for consulting our team of subspecialty radiologists Radiology. Healthcare providers wishing to discuss this case further can contact.     11/29/2022 12:24 - CTA Abd/Pelvis WO/W IV Contrast  IMPRESSION:1.  No evidence of aortic dissection.2.  Dilatation of ascending thoracic aorta measuring up to 4.9 cm.3.  Moderate to severe atherosclerosis with moderate/severe ostialstenosis of the celiac artery and mild ostial stenosis of the SMA.4.  Patchy consolidative opacities in the right middle lobe and medial right lung base, likely infectious in etiology.5.  Other ancillary findings as above. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss this case further can contact the Hospital. For after-hours or emergency department cases.    11/29/2022 12:24 - CT Head W/o IV Contrast  IMPRESSION:  1.  No CT evidence of acute intracranial hemorrhage, mass effect orhydrocephalus.2.  Age indeterminate lacunar infarct in the right corpus striatum with background of chronic microvascular ischemic disease and chronic cortical infarct in the left frontal lobe.3.  Features of acute right maxillary sinusitis. Thank you for consulting our team of subspecialty Radiology. Healthcare providers wishing to discuss this case further can contact the hospital. For after-hours or emergency department cases.                Signature Line Electronically Signed on 11/29/22 17:57  ________________________________________________________ MD