Age: 44.0
Sex: M
Vaccine: COVID19
Symptoms: Pericardial effusion, Peripheral swelling, Platelet count increased, Pneumonia, Protein total decreased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on October 11, 2024 06:11 EDT   Verified By: DO on October 11, 2024 06:11 EDT   Encounter Info: Hospital, Inpatient, 10/11/24 -     * Final Report *  Document Has Been Revised        Chief Complaint   arm and leg swelling, DOE  History of Present Illness/Subjective     48 year old male presents to the ED via private vehicle complaining of extremity swelling. The patient reports he was seen in the ED 2 days ago and left AMA. He endorses severe numbness and swelling in his extremities of unknown onset which is why he came to the ED the first time. He reports tonight he realized that he should have listened to the advice of the physician who saw him the first time, so he came back. He also reports yesterday morning he woke up and started walking around, and could hardly walk secondary to weakness and dyspnea. He now also endorses severe right shoulder pain and diaphoresis. The patient endorses history of smoking and alcohol use. He also tested positive for methamphetamine. He states he cannot lay down flat without getting short of breath.  Patient denies chest pain.   His labs are significant for white blood cell count of 12.1, hemoglobin 14.6, platelet of 494.  CHEM panel shows sodium 135, potassium of 4.0, BUN 17, creatinine 0.88.  ALT and AST mildly elevated at 64 and 55 respectively alk phos was normal, initial troponin was 50, repeat troponin was 46, BNP was 46.  Urinalysis was benign.   His labs are significant for white blood cell count of 12.1, hemoglobin 14.6, platelet of 494.  CHEM panel shows sodium 135, potassium of 4.0, BUN 17, creatinine 0.88.  ALT and AST mildly elevated at 64 and 55 respectively alk phos was normal, initial troponin was 50, repeat troponin was 46, BNP was 46.  Urinalysis was benign. Chest XR showed focal confluent opacity in the left upper lobe, previously seen on CT from October 9, 2024 and again suggestive of pneumonia as well as mild central vascular congestion.     Patient had a Chest CTA on October 9 and it showed the following:  1.  Negative for pulmonary embolism in the central, lobar or  segmental levels. Limited assessment of the subsegmental branches.  2.  Focal peripheral left upper lobe consolidation, likely related to  pneumonia in the right clinical setting. Recommend follow-up to  resolution to exclude the possibility of underlying malignancy.  3.  Scattered pulmonary nodules measuring up to 5 mm. Please see  below for follow-up recommendations.  4.  Moderate cardiomegaly with mild to moderate pericardial effusion.  Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI.???????  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.8 °C (Oral)  BP: 113/70  HR: 105 (Monitored)  RR: 16  SpO2: 94%  Oxygen Therapy: Room air  WT: 113.90 kg (WFC)    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    113.9 kg    10/11/24    Patient Height  Current Height:    167 cm    10/11/24         Constitutional:  No acute distress Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  fine crackles b/l, no wheezes, adequate inspirations, b/l chest rise Cardiovascular:  Regular rate and rhythm, laterally displaced PMI Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal: Edema in all extremities 3+ in LE b/l 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      1. Acute heart failure   I50.9   2. Elevated troponin   R79.89   3. Peripheral edema   R60.0  #pericardial effusion   -pericardial effusion present on cta chest, will reach out to Dr. for recs, but may also improve with diruesis  Likely due to methamphetamine use versus hypertensive heart disease, will start Lasix drip and obtain stat echocardiogram.  Will likely obtain cardio consultation in the morning after echocardiogram. Continue sodium and fluid restricted diet, daily weights, strict in and out analysis. Continue telemetry and potassium supplementation as appropriate.  PT/OT and outpatient follow up with cardiac HF clinic.  Maximize goal directed management as dictate by clinical course and tolerance to titration.   4. Pneumonia   J18.9   Stop azithromycin given prolonged QTc, start doxycycline and continue Rocephin, urine antigens, MRSA swab, respiratory culture, SVNs as needed respiratory assessment protocol  No??????? evidence of sepsis.   5. Right shoulder pain   M25.511   Unclear etiology, shoulder x-ray 2 days ago did not show any acute etiology, continue to monitor   6. Tobacco use   Z72.0   Counseled on cessation of use, nicotine replacement therapy as needed   7. Methamphetamine use   F15.10  Social work consult, counseled on cessation of use   8. Elevated transaminase level   R74.01  Mild, continue to trend and monitor if increasing will consider obtaining right upper quadrant ultrasound   I spent greater than 75 minutes in the evaluation and management of this patient with more than 50% of the time spent counseling and/or coordinating care.  I counseled the patient and/or family about the findings, differential diagnoses, my assessment, recommendations, and plan.  I coordinated care with the multidisciplinary healthcare team.  Code Status   None Recorded   Chronic Problem List    Tobacco use       Medications   Home Medications (5) Active  Augmentin 875 mg-125 mg oral tablet 1 Tablet, Orally, Q12H  doxycycline monohydrate 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  methocarbamol 500 mg oral tablet   No Active Home Meds   Active Scheduled Inpatient Medications  ondansetron, Injection, 4 mg, IV Push, ONCE, prn, Nausea/Vomiting IV - Use First, Start: 10/11/24 01:30:00    One-Time Medications Given 10/10/24 00:00:00 TO 10/11/24 06:11:45  azithromycin, Injection, 500 mg, IVPB, ONCE, (1 DOSE 10/11/24 02:59:00)  ceftRIAXone, Injection, 2 GM, IV Push, ONCE, (1 DOSE 10/11/24 02:43:00)  furosemide, Injection, 40 mg, IV Push, ONCE, (1 DOSE 10/11/24 01:28:00)  HYDROmorphone (HYDROmorphone Inj ED (1 mg/mL)), Injection, 1 mg, IV Push, ONCE, (1 DOSE 10/11/24 01:38:00)  PRN Medications (0600 - 0559) from 10/10 - 10/11  HYDROmorphone, 1 mg, IV Push, Q10min, 1  Dose(s)   Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: 5-9 cigarettes (between 1/4 to 1/2 pack)/day in last 30 days.    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12.1 k/cumm High (10/11/24 01:30:00)  RBC: 4.99 million/cumm (10/11/24 01:30:00)  Hgb: 14.6 GM/dL (10/11/24 01:30:00)  Hct: 43.8 % (10/11/24 01:30:00)  MCV: 88 fL (10/11/24 01:30:00)  MCH: 29.2 pg (10/11/24 01:30:00)  MCHC: 33.2 GM/dL (10/11/24 01:30:00)  RDW: 15 % High (10/11/24 01:30:00)  Platelet: 494 k/cumm High (10/11/24 01:30:00)  MPV: 7.9 fL (10/11/24 01:30:00)  Neutrophils %: 64 % (10/11/24 01:30:00)  Lymphocytes %: 26 % (10/11/24 01:30:00)  Monocytes %: 6 % (10/11/24 01:30:00)  Eosinophils %: 5 % (10/11/24 01:30:00)  Basophils %: 0 % (10/11/24 01:30:00)  Absolute Neutrophil: 7.7 k/cumm High (10/11/24 01:30:00)  Absolute Lymphocyte: 3.2 k/cumm (10/11/24 01:30:00)  Absolute Monocyte: 0.7 k/cumm (10/11/24 01:30:00)  Absolute Eosinophil: 0.6 k/cumm High (10/11/24 01:30:00)  Absolute Basophil: 0 k/cumm (10/11/24 01:30:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (10/11/24 01:30:00)  Potassium SerPl QN: 4 mmol/L (10/11/24 01:30:00)  Chloride SerPl QN: 105 mmol/L (10/11/24 01:30:00)  Carbon Dioxide SerPl QN: 25 mmol/L (10/11/24 01:30:00)  Anion Gap: 5 mmol/L (10/11/24 01:30:00)  BUN SerPl QN: 17 mg/dL (10/11/24 01:30:00)  Creatinine SerPl QN: 0.88 mg/dL (10/11/24 01:30:00)  Estimated GFR (CKD-EPI, no race): >90 (10/11/24 01:30:00)  Estimated CRCL (CG): >120 (10/11/24 01:30:00)  Glucose SerPl QN: 91 mg/dL (10/11/24 01:30:00)  Calcium Total SerPl QN: 9.5 mg/dL (10/11/24 01:30:00)  Phosphorus SerPl QN: 3 mg/dL (10/11/24 01:30:00)  Alkaline Phos SerPl QN: 92 Units/L (10/11/24 01:30:00)  ALT SerPl QN: 64 Units/L High (10/11/24 01:30:00)  AST SerPl QN: 55 Units/L High (10/11/24 01:30:00)  Bilirubin Direct SerPl QN: 0.1 mg/dL (10/11/24 01:30:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (10/11/24 01:30:00)  Total Protein SerPl QN: 6.2 GM/dL Low (10/11/24 01:30:00)  Albumin SerPl QN: 3.2 GM/dL Low (10/11/24 01:30:00)  Magnesium SerPl QN: 1.7 mg/dL (10/11/24 01:30:00)  Troponin-I High Sensitivity: 46 ng/L High (10/11/24 03:42:00)  BNP Pl QN: 46 pg/mL (10/11/24 01:30:00)  Blood Gas Comment: venous (10/11/24 01:30:00)  pH Bld Venous QN: 7.44 (10/11/24 01:30:00)  PCO2 Bld Venous QN: 37 mmHg (10/11/24 01:30:00)  PO2 Bld Venous QN: 68 mmHg High (10/11/24 01:30:00)  Base Excess Bld Venous: 1 mmol/L (10/11/24 01:30:00)  Bicarb Bld Venous Calc: 25 mmol/L (10/11/24 01:30:00)  O2 Sat Bld Venous Calc: 94 % (10/11/24 01:30:00)  Patient Temperature: 37 DegC (10/11/24 01:30:00)  Urine Studies:  Color: Colorless (10/11/24 02:15:00)  Clarity: Clear (10/11/24 02:15:00)  Specific Gravity: 1.008 (10/11/24 02:15:00)  pH: 6 (10/11/24 02:15:00)  Protein: NEGATIVE (10/11/24 02:15:00)  Glucose: Normal (10/11/24 02:15:00)  Ketones: NEGATIVE (10/11/24 02:15:00)  Bilirubin: NEGATIVE (10/11/24 02:15:00)  Hgb Ur: NEGATIVE (10/11/24 02:15:00)  Nitrite: NEGATIVE (10/11/24 02:15:00)  Urobilinogen: Normal (10/11/24 02:15:00)  Leukocyte Esterase Ur: NEGATIVE (10/11/24 02:15:00)  Toxicology:  Amphetamine Urine Scn QL: Positive Abnormal (10/11/24 02:15:00)  Methamphetamine Urine Scn QL: Positive Abnormal (10/11/24 02:15:00)  Barbiturates Urine Scn QL: Negative (10/11/24 02:15:00)  Benzodiazepines Urine Scn QL: Negative (10/11/24 02:15:00)  Cannabinoid Urine Scn QL: Negative (10/11/24 02:15:00)  Cocaine Urine Scn QL: Negative (10/11/24 02:15:00)  Opiates Urine Scn QL: Negative (10/11/24 02:15:00)  PCP Urine Scn QL: Negative (10/11/24 02:15:00)  Methadone Urine Scn QL: Negative (10/11/24 02:15:00)  Oxycodone Urine Scn QL: Negative (10/11/24 02:15:00)  Buprenorphine Urine Scn QL: Negative (10/11/24 02:15:00)  Tricyclic Antid Urine Scn QL: Negative (10/11/24 02:15:00)  Drugs of Abuse Comment: See Comment (10/11/24 02:15:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 10/11/2024 01:12 - POC US Cardiac       10/11/2024 02:01 - XR Chest PA or AP Portable  IMPRESSION:1.  Faintly visualized focal confluent opacity in the left upperlobe, previously seen on CT from 10/9/2024 and again suggestive ofpneumonia.2.  Mild central vascular congestion. Thank you for consulting our team of radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 10/11/24 06:11 EDT ________________________________________________________ DO  Electronically Signed on 10/11/24 06:54 EDT ________________________________________________________ DO