Age: 88.0
Sex: M
Vaccine: PNC13
Symptoms: Blood thyroid stimulating hormone, Blood urea increased, Calcium ionised normal, Carbon dioxide normal, Cerebral small vessel ischaemic disease
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on October 22, 2024 17:50 EDT   Verified By: MD on October 22, 2024 17:50 EDT   Encounter Info: Hospital, Inpatient, 10/22/24 -     * Final Report *  Document Has Been Revised        Chief Complaint   Pallor  History of Present Illness/Subjective     Patient is an 88 year old man who presents to the ER with 10 to 11 days of pallor and weakness. Patient also endorses headache and decreased appetite. His daughter is worried that he is dehydrated. Upon arrival to the ER his vitals were stable. Labs were notable for a Hgb of 5.7 and WBC count of 2.3. Plts were 12. Cr was 1.5 which is around his baseline. CxR showed bilateral opacities c/f infection. CT head was negative. COVID-19 and flu were negative. Patient was given a unit of blood and admitted to the medicine service for further management.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours      Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  CTAB Cardiovascular:  Regular rate and rhythm, no MGR Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan      1. Pancytopenia   D61.818  -Heme/Onc consulted and recommends BM biopsy  -Transfuse for Hgb less than 7  -Transfuse for plts less than 10  -q8H CBC  -Initial lab w/u started in the ER      2. (HFpEF) heart failure with preserved ejection fraction   I50.30  -Euvolemic  -Continue home regimen      3. Diabetes   E11.9  -Sliding scale   -Continue home insulin regimen at reduced dose  -Carb controlled diet  -Hypoglycemia protocol  -Hold oral DM meds      4. CAD (coronary artery disease)   I25.10  -Hold ASA, plavix  -Continue atorvastatin and beta blocker      5. Hypertension   I10  -Continue home antihypertensive regimen      6. Hypothyroid   E03.9  -Continue home levothyroxine      7. Chronic renal failure   N18.9  -Serum creatinine is at baseline  -Renally dose medications  -Avoid nephrotoxic agents  -Monitor with daily CMP  -CKD stage 3    8. CAP -Urine legionella and strep Ag  -Procalcitonin to guide abx de-escalation  -CTX and doxycycline (1/5)  -COVID-19 negative     Code Status  DNR/DNI/Comprehensive   Chronic Problem List    (HFpEF) heart failure with preserved ejection fraction  Anxiety and depression  Aortic stenosis  B12 deficiency  BPH with urinary obstruction  CAD (coronary artery disease)  Chronic renal failure  Coronary sclerosis  Depression  Diabetes  Hyperlipidemia associated with type 2 diabetes mellitus  Hypertension  Hypothyroid  Irritable bowel  Long term use of drug  Lumbar pain  Lung nodule  Malaise  Osteoarthritis  Pancreatic cyst  S/P TAVR (transcatheter aortic valve replacement)  Severe aortic stenosis  Stenosis Of Abdominal Aorta  Procedure/Surgical History  ?Colonoscopy (04/23/2015) ?Appendectomy ?Coronary angioplasty with stenting ?Tonsillectomy   Surgical History Internal  09/23/2019    Transcatheter Aortic Valve Replacement    MD  Medications   Home Medications (13) Active  acetaminophen 500 mg oral tablet 1,000 mg = 2 Tablet, PRN, Orally, Q4H  ammonium lactate 10% topical cream 1 App, Topical, Daily  aspirin 81 mg oral tablet, delayed release 81 mg = 1 Tablet, Orally, Daily  atenolol 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  cyanocobalamin 1000 mCg/mL injectable solution 1,000 mCg = 1 mL, IM, Daily  Flomax 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily  levothyroxine 125 mCg (0.125 mg) oral tablet 125 mCg = 1 Tablet, Orally, Daily  losartan 25 mg oral tablet 12.5 mg = 0.5 Tablet, Orally, Daily  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  Plavix 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily  sodium bicarbonate 325 mg oral tablet 650 mg = 2 Tablet, Orally, QAM  Trulicity Pen 0.75 mg/0.5 mL subcutaneous solution 0.75 mg, Subcutaneous, Every Week  Zocor 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 10/21/24 00:00:00 TO 10/22/24 17:40:25  None Reported  PRN Medications (0600 - 0559) from 10/21 - 10/22  None Reported  Allergies   penicillins  traMADol (Vomiting, Nausea)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Work/School description: retired farmer.   Home/Environment   married 4 children   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Cancer: Mother.  Diabetes mellitus: Mother.  Heart attack: Father.   Deceased Family Member(s)  Relationship: Mother, Age: Unknown  Relationship: Father, Age: 52 Years, Cause: heart attack  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 2.3 k/cumm Low (10/22/24 14:22:00)  RBC: 1.75 million/cumm Low (10/22/24 14:22:00)  Hgb: 5.7 GM/dL Critical (10/22/24 14:22:00)  Hct: 16 % Critical (10/22/24 14:22:00)  MCV: 91 fL (10/22/24 14:22:00)  MCH: 32.3 pg (10/22/24 14:22:00)  MCHC: 35.5 GM/dL (10/22/24 14:22:00)  RDW: 17.2 % High (10/22/24 14:22:00)  Platelet: 12 k/cumm Critical (10/22/24 14:22:00)  MPV: 10.2 fL (10/22/24 14:22:00)  Neutrophils %: 48 % (10/22/24 14:22:00)  Lymphocytes %: 39 % (10/22/24 14:22:00)  Monocytes %: 6 % (10/22/24 14:22:00)  Eosinophils %: 7 % (10/22/24 14:22:00)  Basophils %: 0 % (10/22/24 14:22:00)  Absolute Neutrophil: 1.1 k/cumm Low (10/22/24 14:22:00)  Absolute Lymphocyte: 0.9 k/cumm Low (10/22/24 14:22:00)  Absolute Monocyte: 0.1 k/cumm (10/22/24 14:22:00)  Absolute Eosinophil: 0.2 k/cumm (10/22/24 14:22:00)  Absolute Basophil: 0 k/cumm (10/22/24 14:22:00)  Chemistry:  Lactate Bld Venous QN: 1.6 mmol/L (10/22/24 14:44:00)  Gluc-Strip Manual, POC: 277 mg/dL High (10/22/24 11:39:00)  Sodium, ePOC: 139 mmol/L (10/22/24 14:44:00)  Potassium, ePOC: 4.4 mmol/L (10/22/24 14:44:00)  Ionized Ca, ePOC: 1.29 mmol/L (10/22/24 14:44:00)  Chloride, ePOC: 105 mmol/L (10/22/24 14:44:00)  CO2-Tot, ePOC: 25 mmol/L (10/22/24 14:44:00)  Glucose, ePOC: 226 mg/dL High (10/22/24 14:44:00)  BUN, ePOC: 32 mg/dL High (10/22/24 14:44:00)  Creatinine, ePOC: 1.5 mg/dL High (10/22/24 14:44:00)  Anion Gap, ePOC: 15 mmol/L (10/22/24 14:44:00)  Estimated CRCL (CG), POC: 39 mL/min Low (10/22/24 14:44:00)  Estimated GFR (CKD-EPI, no race), POC: 45 mL/min/1.73m2 Low (10/22/24 14:44:00)  TSH 3rd Gen SerPl QN: 0.542 mcU/mL (10/22/24 14:22:00)  Coagulation:  D-Dimer Pl QN: <200 (10/22/24 14:22:00)  All Other Labs:  Specimen Type Occult Blood: Stool (10/22/24 15:47:00)  Occult Blood Stool: Negative (10/22/24 15:47:00)  ABO Rh: O Pos (10/22/24 15:06:00)  IAT Interp: Neg (10/22/24 15:06:00)  RBC Product Ready.: RBC Done (10/22/24 15:40:00)  COVID 19 Specimen Source: Nasopharyngeal (10/22/24 14:22:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (10/22/24 14:22:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (10/22/24 14:22:00)  Rapid Influenza A PCR: Not Detected (10/22/24 14:22:00)  Rapid Influenza B PCR: Not Detected (10/22/24 14:22:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 10/22/2024 14:42 - XR Chest PA or AP Portable  IMPRESSION:1.  New increased interstitial opacities in both lower lobessuspicious for atypical infection or aspiration.Thank you for consulting our team of subspecialty radiologists at Physicians Radiology. Please contact us XRAY with any questions.    10/22/2024 16:48 - CT Head W/o IV Contrast  IMPRESSION: 1.  No acute CT abnormality of the head. No acute intracranialhemorrhage , mass effect or hydrocephalus.2.  Mild-to-moderate chronic small vessel ischemic diseaseThank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at XRAY with any questions.             Signature Line Electronically Signed on 10/22/24 17:50 EDT ________________________________________________________ MD  Electronically Signed on 10/22/24 17:56 EDT ________________________________________________________ MD