Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Cerebral infarction, Coma scale, Computerised tomogram abdomen abnormal, Computerised tomogram thorax abnormal, Condition aggravated
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Performed By: NP on August 20, 2023 15:23   Verified By: NP on August 20, 2023 15:23   Encounter Info: Hospital, Inpatient, 08/15/23 -     * Final Report *  Document Contains Addenda        Subjective     76 year old female, history of breast adenocarcinoma, arrhythmia, a-fib, cerebral embolism w/ cerebral infarction left side hemiplegia, CHF, COPD, CVA, HLD, and HTN, anticoagulated on Apixaban, who presents to the ED via EMS from  ECF for evaluation of fatigue and altered LOC. History is limited and was obtained from EMS in its entirety. Per EMS, the patient was recently admitted for sepsis 5-6 days ago and was discharged 4 days ago. Since discharge, she has generally declined and developed a fever today. Patient is febrile upon arrival with temperature of 100.7 degrees Fahrenheit axillary.   ???????Upon ER evaluation her heart rate was elevated at 104, respiratory rate was elevated at 23, blood pressure was low at 91/75.  Temperature was 37.4.  Lab work revealed an elevated white blood cell count of 13.9, hemoglobin was 11.5, renal function was slightly reduced with a GFR of 62, alkaline phos was elevated at 323 lipase was 13, troponin was 19 with repeat being 18, lactate was 0.9, urinalysis revealed evidence of a UTI, COVID-19 testing was negative, CT abdomen pelvis showed mild wall thickening of the urinary bladder CT of the chest with IV contrast completed showed bibasilar atelectasis trace left pleural effusion and moderate cardiomegaly.  While in the ER she received Zosyn.  Patient will be brought into MedSurg for further evaluation management of sepsis, UTI.   8/16 x ray shows possible radial head fracture, cultures still pending, we had ortho see her, ordered shoulder and wrist xray, no acute finding will put arm in sling, MRI pending although her ms is better today than yesterday but not back to baseline.   8/17:MRI Brain W/O IV Contrast     1. No evidence of acute infarct, recent hemorrhage, or significant  intracranial mass effect.  2. Finding suggestive of a chronic right MCA infarct, associated  with wallerian degeneration.  3. Age-related volume loss findings suggestive moderate chronic  microvascular ischemic change.   Pt still c/o arm pain, awaiting candida result prior to sending back to NH. Family at bedside.   8/18: candida auris still pending, Family and POA decided to make pt comfort only and start hospice when she goes back. Candida still pending. Pt having a lot of r arm pain and we increased comfort meds, added xanax   8/19: Pt is much more comfortable today with xanax. Passing gas, no complaints, awaiting candida auris result prior to sending back to NH.   8/20 Still awaiting candida, apparently the first swab sent said Sample inhibitory to PCR assay. Suggest reorder and recollection. 8/18/2023 14:28:04   We have resent but cannot send pt back until this has resulted, remains comfortable with family at bedside  Doing well with xanax, used norco x 1 today  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 37.0 °C (Oral)  BP: 121/67  HR: 11 (Monitored)  RR: 20  SpO2: 94%  Oxygen Therapy: Room air  Oxygen Flow Rate: 0 (L/min)  WT: 91.1 kg    Hemodynamics   Neurologic  Glasgow Coma Score: 13  Patient Weight  Current Daily Weight:    91.1 kg    08/20/23  Previous Daily Weight:    85.8 kg    08/16/23  Difference from Previous:    5.300 kg  Weight for Nutrition:    85.8 kg    08/16/23  BMI:    33.5    08/16/23    Obese (BMI 30-39.9) Patient Height  Current Height:    160 cm    08/20/23     Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 08/19 - 08/20  Total Intake 120.00 mL    Total Output 900.00 mL     Balance -780.00 mL     Physical Exam     Physical Exam Constitutional:  No acute distress,  well nourished Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Skin:  Intact, warm, dry no rashes Neurologic:  mod cognitive impairment,  no focal deficits  Assessment/Plan      1. Sepsis   A41.9   resolved, blood and urine cultures are negative, stop abx.  2. UTI (urinary tract infection)   N39.0    As above  3. Infectious encephalopathy   G93.49   -resolved  -wanted to r/u another CVA since pt is not moving her r arm much as of 2 weeks ago, carotid doppler less than 50% stenosis  -MRI brain no acute findings  4. Adenocarcinoma of breast   C50.919    Noted patient to continue to follow-up oncology as an outpatient  5. Atrial fibrillation   I48.91    Continue  carvedilol, diltiazem  stopped apixaban , pt now comfort measurses 6. Chronic diastolic heart failure   I50.32     7. History of CVA in adulthood   Z86.73    Noted, left side hemiplegia  8. Hyperlipidemia   E78.5      9. Hypertension   I10  10. Hypothyroidism   E03.9      11. Elevated LFTs   R79.89   monitor daily  Orders:   Urine CX 1. Right shoulder pain   M25.511   no acute finding on shoulder or wrist xray of r arm, elbow xr shows possible radial neck fracture, orthos consulted. Will fit pt for sling and have her follow up as an outpt with ortho  PT at NH   ???????Patient is a no CODE STATUS now comfort measures   1. Right shoulder pain   M25.511    2. AMS (altered mental status)   R41.82    History of CVA (cerebrovascular accident)   Z86.73    Right wrist pain   M25.531     Code Status  Resuscitation Status - Ordered    -- 08/18/23 12:58:00, DNR/Comfort Measures   Medications   Active Scheduled Inpatient Medications  ALprazoLAM (Xanax), Tablet, 0.25 mg, Orally, TID, Start: 08/18/23 15:00:00  aripiprazole (Abilify), Tablet, 10 mg, Orally, Daily, Start: 08/16/23 10:00:00  carvedilol, Tablet, 12.5 mg, Orally, BID, Start: 08/15/23 10:00:00  diltiaZEM (diltiaZEM (Eqv-Cardizem CD) 180 mg/24 hours oral capsule, extended release), Cap, Extended Rel, 360 mg, Orally, Daily, Start: 08/16/23 10:00:00  gabapentin, Capsule, 400 mg, Orally, TID, Start: 08/17/23 21:00:00  OXcarbazepine, Tablet, 300 mg, Orally, BID, Start: 08/16/23 21:00:00  polyethylene glycol 3350, Powder, 17 GM, Orally, Daily, Start: 08/16/23 09:00:00  topiramate (Topamax), Tablet, 50 mg, Orally, BID, Start: 08/16/23 10:00:00  venlafaxine (venlafaxine extended release), Cap, Extended Rel, 150 mg, Orally, Daily, Start: 08/16/23 09:00:00  Sodium Chloride 0.9%  1,000 mL IV Continuous  20 mL/hr       One-Time Medications Given 08/19/23 00:00:00 TO 08/20/23 15:23:05  None Reported  PRN Medications (0600 - 0559) from 08/19 - 08/20  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   cycloBENZaprine, 10 mg, Orally, At Bedtime, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q6H, 1  Dose(s)   labetalol, 10 mg, IV Push, Q6H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   Lab Results      Micro - Last 7 days  L pneumo Urine Ag QL: Not Detected (08/16/23 02:40:00)  L pneumo Urine Ag QL Interp: L pneumo Urine Ag QL Interp (08/16/23 02:40:00)  Strep pneumo Ag Ur: GeneXpert NOT DETECTED (08/16/23 02:40:00)  Strep pneumo Ag Ur Interp: GeneXpert 46 (08/16/23 02:40:00)  Urine CX: NEG (08/15/23 18:24:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.             Signature Line Electronically Signed on 08/20/23 15:23  ________________________________________________________ NP     Addendum by MD on August 20, 2023 15:38:18 (Verified)    General: Alert and oriented Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. Cardiovascular: Normal rate, Regular rhythm. Gastrointestinal: Soft, Non-tender. Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect       I saw and evaluated the patient in addition to the APP. I provided a substantive portion of the care for this patient. I personally performed in its entirety examfor this encounter. I have reviewed and verified this documentation and it accurately reflects our care.     MD   Hospital Medicine   Signature Line Electronically Signed on 08/20/23 15:38  ________________________________________________________ MD