Age: 63.0
Sex: F
Vaccine: FLU4, FLUC3
Symptoms: Ammonia increased, Anaemia, Anion gap, Anticoagulant therapy, Aspartate aminotransferase increased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By:  Verified By:  Encounter Info: Hospital, Inpatient, 03/26/23 -     * Final Report *        Chief Complaint   AMS  History of Present Illness/Subjective     Due to AMS, HPI is limited. 63 year old female with hx of liver cirrhosis s/p TIPS, HLD, hypothyroidism, presents to the ED. Patient was recently discharged from hospital on the 18th. She is now at a nursing facility and this morning she woke up and started walking around which is atypical for her. Staff reports she did not fall or hit her head. The patient was then reported to sleep all throughout the day which is also atypical for her. The staff then reassessed the patient at 1600 so they could also give her her lactulose, however they noticed she was AMS. The staff reports that the patient is usually conversant, but was only responding to her name and not question.   In the ED her ammonia was elevated at 93, patient was unable to follow commands or take po medications, therefore an NG tube was placed for lactulose administration. Patient also had an AKI and worsened anemia. CT abd pelvis did not demonstrate any acute findings. Additionally, she was sedated further with 5mg haldol and 1mg of Ativan for the facilitation of the ng tube placement.  Review of Systems     unable to assess due to AMS  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.4 °C (Axillary)  HR: 90 (Monitored)  RR: 16  BP: 132/63  SpO2: 100%  WT: 87.40 kg BMI: 27.6  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 2 (L/min)   Hemodynamics   Neurologic  Glasgow Coma Score: 11  Patient Weight  Current Daily Weight:    87.4 kg    03/27/23  BMI:    27.6    03/27/23    Overweight (BMI 25-29.9) Patient Height  Current Height:    178 cm    03/27/23        General: Well developed, well nourished. Appears comfortable  Head: Normocephalic, atraumatic.  Eyes: No acute pupillary or ocular movement abnormalities. Sclera are non-icteric and conjunctiva are pink bilaterally.  ENT: Oropharynx clear and without edema, injection nor exudate. The uvula is midline. There is no appreciable cervical lymphadenopathy. The neck is supple with full range of motion.  Respiratory: No respiratory distress. Lungs are clear to auscultation bilaterally with good air exchange.  CV: Regular rate and rhythm. No murmur, gallop or rub.  Abdomen: Soft, supple and non-distended. Diffuse abdominal tenderness. There is not any organomegaly, nor are any masses appreciated.  Neuro: Moving all extremities, sensation grossly intact, neuro tremulous. Arousable to verbal stimuli, but not answering questions or following commands.  Skin: Normal color. Warm and dry. Skin tear to posterior aspect of L forearm, no active bleeding.  Musculoskeletal/Extremities: No swollen or painful joints. No obvious deformities.  No lower extremity edema.  Psych: Not answering questions  Assessment/Plan      1. Hepatic encephalopathy   K72.90  Ammonia elevated at time of admission  Continue lactulose titrate to achieve 2-3 bowel movements per day  Continue rifaximin twice daily   2. UTI (urinary tract infection)   N39.0  continue Rocephin, follow urine culture, trend procalcitonin   3. Cirrhosis of liver   K74.60   4. S/P TIPS (transjugular intrahepatic portosystemic shunt)   Z95.828  Monitor LFTs  GI consult as needed   5. HFrEF (heart failure with reduced ejection fraction)   I50.20  Continue home medications as BP will allow   6. Hyperlipidemia   E78.5  Can obtain fasting lipid panel continue home medication   7. Hypothyroidism   E03.9  Obtain TFTs continue home medications   Orders:   buPROPion, 150 mg, Orally, Tab, Extended Rel, Daily, 03/27/23 9:00:00  ceftRIAXone, 1 GM, IVPB, Injection, Q24H, Indication: UTI, 03/27/23 19:00:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  furosemide, 40 mg, Orally, Tablet, Daily, 03/27/23 9:00:00  heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 03/27/23 1:00:00  influenza virus vaccine, inactivated, 0.5 mL, IM, Injection, ONCE, 03/27/23 9:00:00, 03/27/23 9:00:00  lactulose, 30 GM = 45 mL, nasoGASTRIC Tube, Syrup, TID, 03/27/23 9:00:00  levothyroxine, 50 mCg, Orally, Tablet, Before Breakfast, 03/27/23 6:00:00  loratadine, 10 mg, Orally, Tablet, Daily, 03/27/23 9:00:00  rifaXIMin, 550 mg, Orally, Tablet, BID, 03/27/23 9:00:00  spironolactone, 100 mg, Orally, Tablet, Daily, 03/27/23 9:00:00  Admit to Inpatient  aPTT Pl QN  Aspiration Precautions  Auto Diff  Bladder Scan  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  Call Urine Output  CBC w/Differential  Comp Metabolic Panel  Fall Precautions  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Nasogastric Tube  NPO  Phosphorus SerPl QN  PTINR  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  T4 Free Direct SerPl QN  Telemetry Class III 24hr Recommendation  TSH w FreeT4 reflex  Vital Signs  Weight   Code Status   Resuscitation Status - Ordered    -- 03/27/23 0:06:00, Full Code   Chronic Problem List    Abscess of left jaw  Anasarca  Anemia  Arthritis  Ascites  Bilateral ankle pain  Depression  Displaced fracture of right femoral neck  Distal radius fracture, right  Edema of both lower extremities  Edema of both lower extremities  Encounter for long-term (current) use of medications  Fatigue  Femoral neck fracture  Hepatic encephalopathy  HFrEF (heart failure with reduced ejection fraction)  Hyperglycemia  Hyperlipidemia  Hypothyroidism  Iron deficiency anemia  Jaw mass  Left femoral neck fracture  Liver cirrhosis secondary to nonalcoholic steatohepatitis  Liver cirrhosis secondary to nonalcoholic steatohepatitis  Long term use of drug  Mitral regurgitation  Mitral valve incompetence  Neck mass  Obstructive sleep apnea  Osteoarthritis  Pancreatic lesion  PVC (premature ventricular contraction)  Right hip pain  S/P TIPS (transjugular intrahepatic portosystemic shunt)  S/P umbilical hernia repair, follow-up exam  UTI (urinary tract infection)  Varicose veins of lower extremities  Procedure/Surgical History  ?bowel blockage repair cause by hernia (2019) ?Banding (2018) ?egd (08/16/2017) ?Colonoscopy (2012) ?Repair of umbilical hernia (2006) ?Left ovary tumor removed (2004) ?Cholecystectomy (2003) ?Splenectomy (2003) ?Hip replacement ?TIPS - Transjugular intrahepatic portosystemic shunt   Surgical History Internal  07/06/2020    EGD Diagnostic  06/11/2020    Central Line Insertion.  06/04/2020    Hip Hardware Removal  (Right)   05/21/2020    Transjugular Intraheptic Portosystemic S   05/20/2020    Hip Arthroplasty Hemi  (Right)   05/19/2020    US Drain      11/28/2019    Hernia Repair Umbilical   11/18/2019    Transjugular Intraheptic Portosystemic S   11/13/2019    Endoscopy Video Capsule Ingestion   07/15/2019    Hip Arthroplasty Hemi  (Left)    03/20/2019    EGD Ablt Tmr Polyp Lsn      10/17/2018    EGD Diagnostic     06/28/2018    EGD Ablt Tmr Polyp Lsn     01/24/2018    EGD Diagnostic     12/21/2017    EGD Diagnostic      10/04/2017    EGD Diagnostic    08/16/2017    EGD Diagnostic      06/14/2017    EGD Ablt Tmr Polyp Lsn     05/17/2017    EGD Diagnostic      04/19/2017    EG Variceal Banding      09/07/2016    EGD Ablt Tmr Polyp Lsn      01/13/2016    EGD Diagnostic      09/09/2015    EGD Diagnostic      05/27/2015    EGD Diagnostic      04/30/2014    EGD Control Bleeding      10/30/2013    EGD Control Bleeding      03/13/2013    EGD Diagnostic      12/12/2012    EGD Diagnostic      03/09/2012    EGD Diagnostic      11/04/2011    EGD Diagnostic      08/05/2011    EGD Ablt Tmr Polyp Lsn      05/02/2011    EGD Diagnostic      08/04/2009    EGD Diagnostic      12/05/2008    EGD Diagnostic      03/25/2004    Laparoscopic Salpingo Oophorectomy      Medications   Home Medications (16) Active  benzonatate 100 mg oral capsule 100 mg = 1 Capsule, PRN, Orally, TID  buPROPion 150 mg/24 hours (XL) oral tablet, extended release 150 mg = 1 Tablet, Orally, Daily  calcium (as carbonate)-vitamin D 500 mg-200 intl units oral tablet 1 Tablet, Orally, Daily  Clear Eyes CLR preserved ophthalmic solution 1 Drop, PRN, Eyes, Both, 5 Times Daily  diclofenac 1% topical gel 2 GM, PRN, Topical, 4 Times Daily  diphenhydrAMINE 25 mg oral tablet 50 mg = 2 Tablet, PRN, Orally, Q6H  fexofenadine 180 mg oral tablet 180 mg = 1 Tablet, Orally, Daily  furosemide 40 mg oral tablet See Instructions, TAKE 1 TABLET EVERY DAY  lactulose 10 GM/15 mL oral syrup 30 GM = 45 mL, Orally, TID  levothyroxine 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Before Breakfast  metoPROLOL succinate 25 mg oral capsule, extended release 12.5 mg, Orally, Daily, Appointment needed for further refills.  Mucinex Max Strength 1200 mg oral tablet, extended release 1,200 mg = 1 Tablet, PRN, Orally, Q12H  ondansetron 4 mg oral tablet, disintegrating 8 mg = 2 Tablet, Orally, TID  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, BID  rifaXIMin 550 mg oral tablet 550 mg = 1 Tablet, Orally, BID  spironolactone 100 mg oral tablet See Instructions, TAKE 1 TABLET EVERY DAY  Active Scheduled Inpatient Medications  buPROPion (buPROPion 24 hour extended release), Tab, Extended Rel, 150 mg, Orally, Daily, Start: 03/27/23 09:00:00  ceftRIAXone, Injection, 1 GM, IVPB, Q24H, Indication: UTI, Start: 03/27/23 19:00:00  furosemide, Tablet, 40 mg, Orally, Daily, Start: 03/27/23 09:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 03/27/23 01:00:00  influenza virus vaccine, inactivated (influenza virus vaccine, inactivated preservative-free quadrivalent IM suspension), Injection, 0.5 mL, IM, ONCE, Start: 03/27/23 09:00:00  lactulose (lactulose 10 GM/15 mL oral syrup), Syrup, 30 GM, nasoGASTRIC Tube, TID, Start: 03/27/23 09:00:00  levothyroxine, Tablet, 50 mCg, Orally, Before Breakfast, Start: 03/27/23 06:00:00  loratadine, Tablet, 10 mg, Orally, Daily, Start: 03/27/23 09:00:00  rifaXIMin, Tablet, 550 mg, Orally, BID, Start: 03/27/23 09:00:00  spironolactone, Tablet, 100 mg, Orally, Daily, Start: 03/27/23 09:00:00    One-Time Medications Given 03/26/23 00:00:00 TO 03/27/23 06:05:00  None Reported  PRN Medications (0600 - 0559) from 03/26 - 03/27  None Reported  Allergies   Infed (Cardiac Arrest)  nadolol (low b/p)  predniSONE (Nausea/Vomiting, stomach upset)  Seasonal Allergies (Runny nose)  iron dextran (Unknown)  oxyCODONE (unknown)  Social History    Alcohol - Denies Alcohol Use   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Work/School description: Disabled.   Home/Environment   Married, 2 children   Substance Abuse   Denies   Tobacco - Denies Tobacco Use   Tobacco Use: Never (less than 100 in lifetime).  Family History   Congestive heart failure..: Mother.  DM (diabetes mellitus)..: Mother.  Lung cancer..: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.7 k/cumm High (03/27/23 03:12:00)  RBC: 1.94 million/cumm Low (03/27/23 03:12:00)  Hgb: 7.8 GM/dL Low (03/27/23 03:12:00)  Hct: 23.1 % Low (03/27/23 03:12:00)  MCV: 119 fL High (03/27/23 03:12:00)  MCH: 40.2 pg High (03/27/23 03:12:00)  MCHC: 33.8 GM/dL (03/27/23 03:12:00)  RDW: 20.3 % High (03/27/23 03:12:00)  Platelet: 222 k/cumm (03/27/23 03:12:00)  MPV: 8.1 fL (03/27/23 03:12:00)  Neutrophils %: 55 % (03/27/23 03:12:00)  Lymphocytes %: 14 % (03/27/23 03:12:00)  Monocytes %: 24 % (03/27/23 03:12:00)  Eosinophils %: 7 % (03/27/23 03:12:00)  Basophils %: 1 % (03/27/23 03:12:00)  Absolute Neutrophil: 5.9 k/cumm (03/27/23 03:12:00)  Absolute Lymphocyte: 1.5 k/cumm (03/27/23 03:12:00)  Absolute Monocyte: 2.5 k/cumm High (03/27/23 03:12:00)  Absolute Eosinophil: 0.7 k/cumm High (03/27/23 03:12:00)  Absolute Basophil: 0.1 k/cumm (03/27/23 03:12:00)  Chemistry:  Sodium SerPl QN: 142 mmol/L (03/27/23 03:12:00)  Potassium SerPl QN: 4.2 mmol/L (03/27/23 03:12:00)  Chloride SerPl QN: 112 mmol/L High (03/27/23 03:12:00)  Carbon Dioxide SerPl QN: 25 mmol/L (03/27/23 03:12:00)  Anion Gap: 5 mmol/L (03/27/23 03:12:00)  BUN SerPl QN: 26 mg/dL High (03/27/23 03:12:00)  Creatinine SerPl QN: 1.71 mg/dL High (03/27/23 03:12:00)  Estimated GFR (CKD-EPI, no race): 33 mL/min/1.73m2 Low (03/27/23 03:12:00)  Estimated CRCL (CG): 40 mL/min Low (03/27/23 03:12:00)  Glucose SerPl QN: 80 mg/dL (03/27/23 03:12:00)  Calcium Total SerPl QN: 9.2 mg/dL (03/27/23 03:12:00)  Phosphorus SerPl QN: 3.5 mg/dL (03/27/23 03:12:00)  Alkaline Phos SerPl QN: 146 Units/L High (03/27/23 03:12:00)  ALT SerPl QN: 30 Units/L (03/27/23 03:12:00)  AST SerPl QN: 51 Units/L High (03/27/23 03:12:00)  Bilirubin Total SerPl QN: 6.1 mg/dL High (03/27/23 03:12:00)  Total Protein SerPl QN: 6.2 GM/dL Low (03/27/23 03:12:00)  Albumin SerPl QN: 1.9 GM/dL Low (03/27/23 03:12:00)  Magnesium SerPl QN: 2.2 mg/dL (03/27/23 03:12:00)  Lipase SerPl QN: 13 Units/L (03/26/23 16:41:00)  Troponin-I High Sensitivity: 14 ng/L High (03/26/23 17:52:00)  BNP Pl QN: 273 pg/mL High (03/26/23 16:41:00)  Ammonia Pl QN: 93 mCmol/L High (03/26/23 16:41:00)  Lactate Venous Pl QN: 1.9 mmol/L (03/26/23 16:41:00)  pH Bld Venous QN: 7.46 High (03/26/23 16:41:00)  PCO2 Bld Venous QN: 35 mmHg Low (03/26/23 16:41:00)  PO2 Bld Venous QN: 45 mmHg (03/26/23 16:41:00)  Base Excess Bld Venous: 1 mmol/L (03/26/23 16:41:00)  Bicarb Bld Venous Calc: 25 mmol/L (03/26/23 16:41:00)  O2 Sat Bld Venous Calc: 84 % (03/26/23 16:41:00)  Patient Temperature: 37 DegC (03/26/23 16:41:00)  TSH 3rd Gen SerPl QN: 5.02 mcU/mL High (03/27/23 03:12:00)  Urine Studies:  Color: Yellow (03/26/23 17:47:00)  Clarity: Slightly Cloudy (03/26/23 17:47:00)  Specific Gravity: 1.009 (03/26/23 17:47:00)  pH: 6 (03/26/23 17:47:00)  Protein: NEGATIVE (03/26/23 17:47:00)  Glucose: Normal (03/26/23 17:47:00)  Ketones: NEGATIVE (03/26/23 17:47:00)  Bilirubin: NEGATIVE (03/26/23 17:47:00)  Hgb Ur: NEGATIVE (03/26/23 17:47:00)  Nitrite: NEGATIVE (03/26/23 17:47:00)  Urobilinogen: Normal (03/26/23 17:47:00)  Leukocyte Esterase Ur: Large500 Abnormal (03/26/23 17:47:00)  WBC: 51-100 Abnormal (03/26/23 17:47:00)  RBC: 0-2 (03/26/23 17:47:00)  Bacteria: TRACE. (03/26/23 17:47:00)  Squamous Epithelial: Moderate (03/26/23 17:47:00)  Hyaline Casts: 0-2 (03/26/23 17:47:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (03/26/23 16:55:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (03/26/23 16:55:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 03/26/2023 19:43 - XR Chest PA or AP Portable  IMPRESSION:1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists.    03/26/2023 20:25 - CT Head W/o IV Contrast  IMPRESSION:  No CT evidence of acute intracranial abnormalities.    03/26/2023 20:25 - CT Abd/Pelvis W/O IV Contrast  IMPRESSION:1.  Limited exam due to lack of IV contrast and motion artifact. Noacute findings in the abdomen or pelvis.2.  Cirrhosis status post TIPS stent placement. Trace perihepaticfree fluid.3.  Diverticulosis4.  Stable 1.5 x 1.3 cm cyst in the distal body of the pancreas. Theknown pancreatic lesion is not well visualized. This was previouslyevaluated with MRI on 2/21/2023. Please refer to that report.5.  Diverticulosis6.  Left adnexal dermoid with measurements given aboveThank you for consulting our team of subspecialty radiologists.                Electronically Signed on 03/27/23 06:05  ________________________________________________________