Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Monocyte count normal, Monocyte percentage increased, Neutrophil count normal, Neutrophil percentage, Nitrite urine absent
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on March 12, 2022 10:08 EST   Verified By: MD on March 12, 2022 10:08 EST   Encounter Info: Inpatient, 03/12/22 - 03/23/22    * Final Report *  Document Has Been Revised        Chief Complaint    Hemoptysis  History of Present Illness/Subjective      77-year-old male with past medical history of hypertension, diabetes mellitus, BPH, GERD, CAD status post CABG came to the ED with complaints of hemoptysis started yesterday. Had some cough with mild blood-tinged sputum couple of weeks ago but it got better he did not seek any attention. Yesterday evening around 3 PM he started having cough with bright red blood associated with chest pain came to the ED. complained of intermittent chest pain the last couple of weeks.  Initially attributed to acid reflux symptoms and PCP started on PPI which kind of improved his pain.  Complained of vague pain in the lower chest/ epigastric area & no aggravating or relieving factors.  on my evaluation he said there was no pain at this time He has been feeling short of breath with activities and decreased exercise tolerance for couple of weeks and concerned that he has something wrong. He had difficulty swallowing hard solid food since he had a CABG 3 years ago.  He feels like sometimes stuck in the throat but no issues with liquids. felt little bit worsening symptoms but no quite serious any episodes, Denies any hemoptysis.  Denied any nausea, vomiting, diarrhea, constipation.  Had chronic urinary complaints with sometimes difficulty urination and sometimes cannot hold due to his prostate issues. Denied any hematuria.  Denied any recent weight loss or weight gain or loss of appetite. Lives with wife and independent of ADL/IDL good functions capacity. Retired worked in stone quary before.  ED course:  afebrile, blood pressure 174/94, heart rate 78, respiratory 26, satting well on room air  Labs showed normal white cell count.PT/INR within normal limits, BMP showed normal K 3.3, creatinine elevated 1.21 baseline around 1. normal liver functions, troponin negative,  UA showed glucose, small hemoglobin  CT chest with contrast: showed 6.6 X 6.3X 7cm aggressive appearing lobulated mass on the left renal pole concern for renal cancer, multiple lung nodular opacities involving left upper lobe associated with pericardial nodes. there is a large subcarinal  heterogeneously enhancing with necrotic center metastatic deposit measuring up to 3.3 cm displacing esophagus posteriorly and compressed esophagus invasion is not excluded the proximal esophagus, concern for lymphatic spread of tumor versus postobstructive pneumonia, several small pulmonary nodules in the lower lobes bilaterally.  Transferred to Hospital for admission  Review of Systems     12 point ROS negative except above  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.5 (36.5-36.8)  Temp (FAHR) 97.7 (97.7-98.2), BP 185/89 (185-188)/(89-91), HR 68 (68-70), RR 19 (19-24), O2Sat 97 (95-97) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    78.2 kg    03/12/22  BMI:    22.8    03/12/22    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    185.4 cm    03/12/22         Present on Admission    Physical Exam General: Alert, in no acute cardiopulmonary distress. Mental Status: Oriented to person, place and time. Normal affect. Head: Normocephalic. Eyes: Pupils are equal, round and reactive to light. Extraocular muscles intact. Ear, Nose and Throat: Oropharynx clear, mucous membranes moist. Ears and nose without masses, lesions or deformities. Tympanic membranes clear bilaterally. Trachea midline. Neck: Supple, Full range of motion. Respiratory: Clear to auscultation and percussion. No wheezing, rales or rhonchi. Cardiovascular: Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops. Gastrointestinal: Abdomen soft, non-tender, non-distended. Normal bowel sounds. . No hepatosplenomegaly. Genitourinary: No costovertebral angle tenderness. Neurologic: Cranial nerves II-XII grossly intact. No focal neurological deficits. Flexor plantar response. Moves all extremities spontaneously. Sensation intact bilaterally. Skin: No rashes or lesions. No petechiae or purpura. No edema. Musculoskeletal: No cyanosis or clubbing. No gross deformities. Normal range of motion. Lymphatics: Palpation of neck reveals no swelling or tenderness of neck nodes. Palpation of groin reveals no swelling or tenderness of groin nodes.  Assessment/Plan       Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 03/12/22 7:59:00 EST  atorvastatin, 20 mg, Orally, Tablet, Daily, 03/12/22 9:00:00 EST  benzonatate, 100 mg, Orally, Capsule, TID, 03/12/22 9:00:00 EST  carvedilol, 3.125 mg, Orally, Tablet, BID, 03/12/22 9:00:00 EST  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 03/12/22 8:03:00 EST, PRN - See Comments  fluticasone-vilanterol, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 03/12/22 9:00:00 EST  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 03/12/22 8:03:00 EST  glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 03/12/22 8:03:00 EST  hydrALAZINE, 25 mg, Orally, Tablet, TID, 03/12/22 9:00:00 EST  insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 03/12/22 8:03:00 EST  lisinopril, 40 mg, Orally, Tablet, Daily, 03/12/22 9:00:00 EST  nitroGLYCerin, 0.4 mg, Sublingually, Tablet, Q5min, PRN, Chest Pain, 03/12/22 8:00:00 EST  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 03/12/22 7:59:00 EST  pantoprazole, 40 mg, Orally, Tab, Delayed Rel, Daily, 03/12/22 9:00:00 EST  piperacillin-tazobactam, 3.375 GM, IVPB, Injection, Q6H, 03/12/22 9:00:00 EST, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 03/12/22 7:59:00 EST  Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 03/12/22 8:55:00 EST, 75 mL/hr, Clinical Weight  tamsulosin, 0.4 mg, Orally, Capsule, Daily, 03/12/22 9:00:00 EST  2000 mg Sodium, 225 gm Carb, 20 gm Saturated Fat Diet  Admit to Inpatient  Call (Specify)  Call Blood Glucose  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  CT Abd/Pelvis W/IV Contrast  Fluid Intake Requirement  Gluc-Strip POC  Hgb A1C HPLC Bld QN  HS Snack with 15 gm Carb  Initiate (Specify)  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Level of Care  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  Notify Provider  Notify Provider  Notify Provider  Peripheral IV Insertion  Resuscitation Status  Sequential Compression Device  Telemetry Class II 48hr Recommendation  Vital Signs  Weight   77-year-old male with past medical history of CAD status post CABG, hypertension, diabetes mellitus, BPH, GERD came to the ED with complaints of hemoptysis. CT scan noted to have concern for metastatic renal cell cancer with pulmonary mets lymph node enlargement and adrenal deposit.  #Hemoptysis:   #postobstructive pneumonia  Could be from lung mets cannot rule out infection  we will hold on aspirin Plavix for the time being  Start on cough medications  start Zosyn, doxycycline  We will obtain sputum cultures, trend pro-Cal  follow blood cultures  monitor   #Concern for metastatic renal cell cancer with pulmonary mets lymph node enlargement and adrenal deposit:   Discussed with urology recommended CT abdomen pelvis for evaluation  Will obtain CT abdomen tomorrow as he just received contrast this morning after discussion with radiology  discussed with Dr verbally recommended discussing with IR for biopsy whatever possible after CT scan  #Left renal vein thrombus;  discussed likely from tumor burden. with hemoptysis does not recommended anticoagulation at this time.  #Dysphagia:   Having some problems with swallow with solid food sometimes.  It is going on since CABG in 3 years ago  CT chest concern for esophageal compression  discussed with the GI does  not recommended any intervention at this time  discussed with patient about diet modification   #Hypertension: blood pressure elevated  Continue hydralazine, lisinopril  Hold on hydrochlorothiazide with just received contrast  Change metoprolol to Coreg twice daily  Keep clonidine as needed  Monitor blood pressure  #Diabetes mellitus on Jardiance, glipizide at home  No recent A1c  Fingerstick glucose in 200s  Hold on oral medications   monitor fingerstick glucose and continue sliding scale insulin  #Hyperlipidemia: continue statin   #CAD status post CABG: Aspirin/ Plavix hold with hemoptysis   continue goal-directed medical therapy  follows with Dr.    #GERD continue PPI   #BPH continue tamsulosin   Diet carb controlled low-salt diet   VTE prophylaxis SCDs with bleeding   CODE STATUS full code but does not want to be on a long-term ventilator  I spent 75 minuets in evaluation and management of this patient with more than 50% time spent counselling and coordinating care. I discussed with the patient about the findings and differential diagnosis, my assessment and plan.?????  Code Status   Resuscitation Status - Ordered    -- 03/12/22 7:59:00 EST, Full Code   Chronic Problem List    BPH without urinary obstruction  Diabetes mellitus  Hx of CABG  Hyperlipidemia  Procedure/Surgical History  ?CABG (05/27/2018) ?Rectal Fissures 15 yrsago   Medications   Home Medications (15) Active  aspirin 81 mg oral tablet   atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  cloNIDine 0.1 mg oral tablet 0.1 mg = 1 Tablet, PRN, Orally, BID, PRN for systolic blood presure above 180  glimepiride 4 mg oral tablet 4 mg = 1 Tablet, Orally, Daily  hydrALAZINE 25 mg oral tablet   hydroCHLOROthiazide 25 mg oral tablet , TAKE 1 TABLET BY MOUTH EVERY DAY  Jardiance 25 mg oral tablet   Jardiance 25 mg oral tablet , QAM  lisinopril 40 mg oral tablet , TAKE 1 (ONE) TABLET DAILY FOR BLOOD PRESSURE  metoPROLOL Tartrate 50 mg oral tablet , TAKE 1 TABLET BY MOUTH TWICE A DAY  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  pantoprazole 40 mg oral delayed release tablet , Daily  Plavix 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily  Symbicort 160 mCg-4.5 mCg/inh inhalation aerosol , BID  tamsulosin 0.4 mg oral capsule , TAKE 1 CAPSULE BY MOUTH EVERY DAY  Active Scheduled Inpatient Medications  atorvastatin, Tablet, 20 mg, Orally, Daily, Start: 03/12/22 09:00:00  benzonatate (Tessalon Perles), Capsule, 100 mg, Orally, TID, Start: 03/12/22 09:00:00  carvedilol (Coreg), Tablet, 3.125 mg, Orally, BID, Start: 03/12/22 09:00:00  fluticasone-vilanterol (fluticasone-vilanterol 200 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 03/12/22 09:00:00  hydrALAZINE, Tablet, 25 mg, Orally, TID, Start: 03/12/22 09:00:00  lisinopril, Tablet, 40 mg, Orally, Daily, Start: 03/12/22 09:00:00  pantoprazole (pantoprazole 40 mg oral delayed release tablet), Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 03/12/22 09:00:00  Zosyn, Injection, 3.375 GM, IVPB, Q6H, Start: 03/12/22 09:00:00  tamsulosin (Flomax), Capsule, 0.4 mg, Orally, Daily, Start: 03/12/22 09:00:00  Dextrose 10% in Water 500 mL IV PRN - See Comments     Sodium Chloride 0.9%  1,000 mL IV  75 mL/hr       One-Time Medications Given 03/11/22 00:00:00 TO 03/12/22 09:40:51  None Reported  PRN Medications (0600 - 0559) from 03/11 - 03/12  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   nitroGLYCerin, 0.4 mg, Sublingually, Q5min, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   Aleve  Keflex  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse.   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   brother with some cancern  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 5.2 k/cumm (03/12/22 00:05:00)  RBC: 4.79 million/cumm (03/12/22 00:05:00)  Hgb: 14.4 GM/dL (03/12/22 00:05:00)  Hct: 42.1 % (03/12/22 00:05:00)  MCV: 88 fL (03/12/22 00:05:00)  MCH: 30.1 pg (03/12/22 00:05:00)  MCHC: 34.2 GM/dL (03/12/22 00:05:00)  RDW: 12.6 % (03/12/22 00:05:00)  Platelet: 231 k/cumm (03/12/22 00:05:00)  MPV: 7.2 fL (03/12/22 00:05:00)  Neutrophils %: 70 % (03/12/22 00:05:00)  Lymphocytes %: 15 % (03/12/22 00:05:00)  Monocytes %: 11 % (03/12/22 00:05:00)  Eosinophils %: 4 % (03/12/22 00:05:00)  Basophils %: 1 % (03/12/22 00:05:00)  Absolute Neutrophil: 3.6 k/cumm (03/12/22 00:05:00)  Absolute Lymphocyte: 0.8 k/cumm Low (03/12/22 00:05:00)  Absolute Monocyte: 0.6 k/cumm (03/12/22 00:05:00)  Absolute Eosinophil: 0.2 k/cumm (03/12/22 00:05:00)  Absolute Basophil: 0 k/cumm (03/12/22 00:05:00)  Chemistry:  Sodium SerPl QN: 137 mmol/L (03/12/22 00:05:00)  Potassium SerPl QN: 3.3 mmol/L Low (03/12/22 00:05:00)  Chloride SerPl QN: 102 mmol/L (03/12/22 00:05:00)  Carbon Dioxide SerPl QN: 24 mmol/L (03/12/22 00:05:00)  Anion Gap: 11 mmol/L (03/12/22 00:05:00)  BUN SerPl QN: 16 mg/dL (03/12/22 00:05:00)  Creatinine SerPl QN: 1.21 mg/dL (03/12/22 00:05:00)  Estimated GFR (CKD-EPI): 57 mL/min/1.73m2 Low (03/12/22 00:05:00)  Estimated CRCL (CG): 58 mL/min Low (03/12/22 00:05:00)  Glucose SerPl QN: 214 mg/dL High (03/12/22 00:05:00)  Calcium Total SerPl QN: 8.9 mg/dL (03/12/22 00:05:00)  Alkaline Phos SerPl QN: 64 Units/L (03/12/22 00:05:00)  ALT SerPl QN: 12 Units/L (03/12/22 00:05:00)  AST SerPl QN: 13 Units/L (03/12/22 00:05:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (03/12/22 00:05:00)  Total Protein SerPl QN: 6.8 GM/dL (03/12/22 00:05:00)  Albumin SerPl QN: 4.3 GM/dL (03/12/22 00:05:00)  Troponin-I High Sensitivity: 10 ng/L (03/12/22 01:25:00)  BNP Pl QN: 95 pg/mL (03/12/22 00:05:00)  Lactate Venous Pl QN: 1 mmol/L (03/12/22 00:05:00)  pH Bld Venous QN: 7.44 (03/12/22 00:05:00)  Patient Temperature: 37 DegC (03/12/22 00:05:00)  Coagulation:  PT: 12.1 seconds (03/12/22 00:05:00)  INR: 1 (03/12/22 00:05:00)  aPTT: 27.9 seconds (03/12/22 00:05:00)  D-Dimer Pl QN: <200 (03/12/22 00:05:00)  Urine Studies:  Color: Yellow (03/12/22 01:20:00)  Clarity: Clear (03/12/22 01:20:00)  Specific Gravity: 1.010 (03/12/22 01:20:00)  pH: 6.0 (03/12/22 01:20:00)  Protein: NEGATIVE (03/12/22 01:20:00)  Glucose: >=1000 Abnormal (03/12/22 01:20:00)  Ketones: NEGATIVE (03/12/22 01:20:00)  Bilirubin: NEGATIVE (03/12/22 01:20:00)  Hgb Ur: SMALL. Abnormal (03/12/22 01:20:00)  Nitrite: NEGATIVE (03/12/22 01:20:00)  Urobilinogen: NormalUro (03/12/22 01:20:00)  Leukocyte Esterase Ur: NEGATIVE (03/12/22 01:20:00)  WBC: 0-5 (03/12/22 01:20:00)  RBC: None Seen (03/12/22 01:20:00)  Bacteria: NONE (03/12/22 01:20:00)  Squamous Epithelial: NONE (03/12/22 01:20:00)  Micro - Last 7 days  Coronavirus SARS Ag FIA: Not Detected (03/12/22 00:37:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 03/12/2022 00:47 - XR Chest PA or AP Portable  IMPRESSION: 1.  No obvious infiltrate or effusion.Template Version: Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the department. For after-hours or emergency department cases, pleasecall    03/12/2022 01:51 - CT Chest W/ IV Contrast  IMPRESSION:1.  Multiple findings concerning for left renal cell carcinoma withmetastatic disease to the left adrenal gland, bilateral lungs, andmediastinal nodes as discussed in detail above.2.  Left upper lobe postobstructive pneumonia versus lymphangiticspread of tumor with near occlusion of the left upper lobe bronchus,possibly by tumor.3.  Large centrally necrotic metastatic deposits in the subcarinalregion with compression of the adjacent esophagus. No evidence ofobstruction at this time. Invasion of the esophagus cannot beexcluded.4.  No pulmonary embolism.5.  Left renal vein thrombus nonocclusive image 119 of series 2.6.  Cholelithiasis without evidence of acute cholecystitis.7.  Critical Findings were discussed by Dr. Per with Dr. of the Emergency Services at 3/12/2022 2:20 AM Template Version: Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the ER. Lumbar 2nd                Signature Line Electronically Signed on 03/12/22 10:08 EST ________________________________________________________ MD  Electronically Signed on 03/12/22 15:08 EST ________________________________________________________ MD