Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Substance use, Tachycardia, Thrombocytopenia, Tobacco user, Toxic encephalopathy
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on July 08, 2024 18:07    Verified By: MD on July 08, 2024 18:07    Encounter Info: Hospital, Inpatient, 07/08/24 -     * Final Report *        Chief Complaint   Abd pain  History of Present Illness/Subjective     Patient is a 60 year old woman who presents to the ER w/ abd pain. Patient reports pain in her upper abdomen for the last 24 hours. She denied any N/V however upon arrival to the ICU she was retching. She denies any aggravating or alleviating factors. She states that her last BM was 2 days ago. Isn't sure if she is passing gas or not. She is still actively using meth. Her most recent EF was 16% in Feb of this year. Upon arrival to the Facility she was normotensive and tachycardic at 107. Labs were notable for a Hgb of 10 and plts of 141. T Bili was 3.8. UA was unremarkable. Blood cx are pending. Lactate was 3.2 and repeat was the same. Trop was 37. EKG showed no acute ischemic changes. CxR showed no focal consolidations. CTA abd/pelvis showed moderate ascites but no other concerning findings. Bedside US was attempted in the ER but there was not a large enough pocket to safely tap so this was aborted. She was empirically treated for SBP. Upon arrival to the ICU here she is agitated and confused at times. She reports pain in her abdomen but otherwise has no complaints. Her HR remains elevated in the 110s and EKG showed sinus tach. Na is 132 and Cr is 1.24 up from a normal baseline. BNP was 2732.     Review of Systems     Unable to obtain due to patient's mental status.      Physical Exam/Objective Vitals & Measurements most recent past 24 hours        Constitutional:  No acute distress,  well-nourished Eyes: scleral icterus ENMT:  Moist oral mucosa Respiratory:  CTAB Cardiovascular:  tachycardic, no MGR Gastrointestinal:  distended, pain to palpation of R lower quadrant Musculoskeletal:  intact ROM Integumentary:  stage 2 pressure ulcer on L knee Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan     Patient is a 60 year old woman admitted w/ sepsis.       1. Sepsis   A41.9  -POA  -Sources possibly SBP  -Zosyn for now  -No more fluids as she is already volume overloaded and has an EF of 16%  -F/u blood cx  -Repeat lactate now      2. HFrEF (heart failure with reduced ejection fraction)   I50.20  -TTE  -Most recent EF of 16%  -Strict I/Os, daily weights  -Acute on chronic  -Telemetry      3. Toxic metabolic encephalopathy   G92.8  -Due to sepsis  -Ammonia, VBG, TSH, B12  -Head CT now      4. Abdominal pain   R10.9  -No clear cause but will repeat lactate now and if uptrending may repeat CT scan  -CTA abd/pelvis was negative for a cause  -Possibly SBP so covering empirically w/ Zosyn  -Will assess w/ bedside US and consider diagnostic and possibly therapeutic tap later this evening      5. Ascites   R18.8  -Likely related CHF as patient has no known h/o cirrhosis  -Hep panel now      6. Hyperbilirubinemia   E80.6  -Due to liver dysfunction  -Monitor for now      7. Elevated troponin   R79.89  -Likely demand ischemia  -Serial troponin  -Telemetry  -TTE       8. Thrombocytopenia   D69.6  -Likely due to synthetic dysfunction in the setting of liver failure  -Monitor for now      9. Elevated lactic acid level   R79.89  -Likely d/t poor hepatic clearance and sepsis  -Holding off on further fluids as her EF is 16% and she is already volume overloaded  -Repeat lactate now      10. AKI (acute kidney injury)   N17.9  -Likely cardiorenal and/or hepatorenal  -Renally dose meds  -PVR urine  -Lasix 40mg IV q12H for now      11. Hyponatremia   E87.1  -Hypervolemic in nature  -Lasix as above  -1500cc/day fluid restriction      12. Tobacco use   Z72.0  -Encourage cessation  -Nicotine patch PRN      13. CAD (coronary artery disease)   I25.10  -Continue DAPT and beta blocker      14. Diabetes mellitus   E11.9  -CDA in place  -Carb controlled diet  -Hypoglycemia protocol  -Hold oral DM meds      15. Anemia   D64.9  -The patient presents with anemia chronic and normocytic due to other chronic disease at present is stable.  Continue to trend serial analysis as appropriate with nutritional or blood product supplementation as required.  ???????   16. Illicit drug use   F19.90  -Patient is still actively using meth  -Repeat UDS now  -SW consult       Code Status   Resuscitation Status - Ordered    -- 07/08/24 17:59:00 EDT, Full Code   Chronic Problem List    Acute on chronic heart failure with reduced ejection fraction and diastolic dysfunction  CAD (coronary artery disease)  CHF (congestive heart failure)  Chronic pain in right foot  Diabetes mellitus  Illicit drug use  Sepsis  Tobacco use  Procedure/Surgical History  ?back ?BKA, left ?choleycystectomy ?Hernia repair ?Total Knee Replacement ?Tubal Ligation   Medications   Home Medications (17) Active  albuterol (Eqv-ProAir HFA) 90 mCg/inh inhalation aerosol 1 Puff, PRN, Inhalation, Q6H  aspirin 81 mg, Orally, Daily  carvedilol 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, BID  clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Daily  empagliflozin 10 mg oral tablet 2 tablets, Orally, QAM  estradiol topical 0.1 mg/gm cream , APPLY PEA SIZED AMOUNT NIGHTLY 2 TIMES PER WEEK.  Farxiga 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  furosemide 20 mg oral tablet 40 mg = 2 Tablet, Orally, QAM  HumaLOG (insulin lispro) 100 units/mL injection , sliding scale with morning and evening meals  Incruse Ellipta 62.5 mCg inhalation powder , PRN, Inhalation  Lasix 20 mg, Orally, Every PM  midodrine 10 mg oral tablet   nortriptyline 25 mg oral capsule , TAKE 1 CAPSULE BY MOUTH AT BEDTIME  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  Stiolto Respimat 2.5 mCg-2.5 mCg inhalation aerosol   Toujeo (insulin glargine) SoloStar Pen (CONCENTRATED) 300 units/mL subcutaneous solution   Trulicity Pen 1.5 mg/0.5 mL subcutaneous solution , INJECT ONE AUTOINJECTOR PEN UNDER THE SKIN 1 (ONE) TIME PER WEEK.  Active Scheduled Inpatient Medications  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 07/08/24 18:00:00  furosemide (Lasix), Injection, 40 mg, IV Push, BID, Start: 07/09/24 09:00:00  Dextrose 10% in Water  500 mL IV Continuous  Per Core Diabetes App - See Comments       One-Time Medications Given 07/07/24 00:00:00 TO 07/08/24 18:00:37  None Reported  PRN Medications (0600 - 0559) from 07/07 - 07/08  glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Core Diabetes App , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Per Core Diabetes App , Subcutaneous, Unscheduled, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   promethazine, 12.5 mg, IVPB, Q6H, 0  Dose(s)   Allergies   morphine (Rash)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: 5-9 cigarettes (between 1/4 to 1/2 pack)/day in last 30 days.  Family History   Unable to obtain due to patient's mental status.   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.4 k/cumm (07/08/24 09:52:00)  RBC: 4.48 million/cumm (07/08/24 09:52:00)  Hgb: 10.1 GM/dL Low (07/08/24 09:52:00)  Hct: 32.2 % Low (07/08/24 09:52:00)  MCV: 72 fL Low (07/08/24 09:52:00)  MCH: 22.5 pg Low (07/08/24 09:52:00)  MCHC: 31.4 GM/dL Low (07/08/24 09:52:00)  RDW: 26.8 % High (07/08/24 09:52:00)  Platelet: 141 k/cumm Low (07/08/24 09:52:00)  MPV: 9.6 fL (07/08/24 09:52:00)  Neutrophils %: 73 % (07/08/24 09:52:00)  Lymphocytes %: 15 % (07/08/24 09:52:00)  Monocytes %: 10 % (07/08/24 09:52:00)  Eosinophils %: 0 % (07/08/24 09:52:00)  Basophils %: 1 % (07/08/24 09:52:00)  Absolute Neutrophil: 5.2 k/cumm (07/08/24 09:52:00)  Absolute Lymphocyte: 1.1 k/cumm (07/08/24 09:52:00)  Absolute Monocyte: 0.7 k/cumm (07/08/24 09:52:00)  Absolute Eosinophil: 0 k/cumm (07/08/24 09:52:00)  Absolute Basophil: 0.1 k/cumm (07/08/24 09:52:00)  RBC Morphology: See Comment. (07/08/24 09:52:00)  Codocyte: Few (1+). (07/08/24 09:52:00)  Hypochromasia: Slight. (07/08/24 09:52:00)  Microcyte: Moderate (2+), (07/08/24 09:52:00)  Schistocyte: None Seen. (07/08/24 09:52:00)  Platelet Estimate: Decreased. (07/08/24 09:52:00)  Chemistry:  Sodium SerPl QN: 132 mmol/L Low (07/08/24 09:52:00)  Potassium SerPl QN: 4.3 mmol/L (07/08/24 09:52:00)  Chloride SerPl QN: 94 mmol/L Low (07/08/24 09:52:00)  Carbon Dioxide SerPl QN: 27 mmol/L (07/08/24 09:52:00)  Anion Gap: 11 mmol/L (07/08/24 09:52:00)  BUN SerPl QN: 32 mg/dL High (07/08/24 09:52:00)  Creatinine SerPl QN: 1.24 mg/dL High (07/08/24 09:52:00)  Estimated GFR (CKD-EPI, no race): 50 mL/min/1.73m2 Low (07/08/24 09:52:00)  Estimated CRCL (CG): 49 mL/min Low (07/08/24 09:52:00)  Glucose SerPl QN: 138 mg/dL High (07/08/24 09:52:00)  Calcium Total SerPl QN: 9 mg/dL (07/08/24 09:52:00)  Alkaline Phos SerPl QN: 122 Units/L (07/08/24 09:52:00)  ALT SerPl QN: 14 Units/L (07/08/24 09:52:00)  AST SerPl QN: 28 Units/L (07/08/24 09:52:00)  Bilirubin Total SerPl QN: 3.8 mg/dL High (07/08/24 09:52:00)  Total Protein SerPl QN: 6.5 GM/dL (07/08/24 09:52:00)  Albumin SerPl QN: 3.3 GM/dL Low (07/08/24 09:52:00)  Lipase SerPl QN: 10 Units/L (07/08/24 09:52:00)  Troponin-I High Sensitivity: 37 ng/L High (07/08/24 09:52:00)  BNP Pl QN: 2732 pg/mL High (07/08/24 09:52:00)  Lactate Venous Pl QN: 3.2 mmol/L High (07/08/24 11:32:00)  pH Bld Venous QN: 7.31 Low (07/08/24 17:40:00)  PCO2 Bld Venous QN: 54 mmHg High (07/08/24 17:40:00)  PO2 Bld Venous QN: 37 mmHg (07/08/24 17:40:00)  Base Excess Bld Venous: 0 mmol/L (07/08/24 17:40:00)  Bicarb Bld Venous Calc: 27 mmol/L (07/08/24 17:40:00)  O2 Sat Bld Venous Calc: 64 % (07/08/24 17:40:00)  Patient Temperature: 37 DegC (07/08/24 17:40:00)  Urine Studies:  Color: Yellow (07/08/24 13:30:00)  Clarity: Clear (07/08/24 13:30:00)  Specific Gravity: 1.020 (07/08/24 13:30:00)  pH: 6.0 (07/08/24 13:30:00)  Protein: 30 Abnormal (07/08/24 13:30:00)  Glucose: NEGATIVE (07/08/24 13:30:00)  Ketones: NEGATIVE (07/08/24 13:30:00)  Bilirubin: SC Small Abnormal (07/08/24 13:30:00)  Hgb Ur: NEGATIVE (07/08/24 13:30:00)  Nitrite: NEGATIVE (07/08/24 13:30:00)  Urobilinogen: 1.0. (07/08/24 13:30:00)  Leukocyte Esterase Ur: NEGATIVE (07/08/24 13:30:00)  WBC: None Seen (07/08/24 13:30:00)  RBC: None Seen (07/08/24 13:30:00)  Bacteria: Many Abnormal (07/08/24 13:30:00)  Squamous Epithelial: Many (07/08/24 13:30:00)  Hyaline Casts: 0-2 (07/08/24 13:30:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 07/08/2024 09:59 - XR Chest PA or AP Portable  IMPRESSION:  Mediastinal contour and heart size are stable, with cardiacprominence similar to previous. Curvilinear interface along the rightconvexity compatible with skinfold. No focal consolidation, pulmonaryedema, pneumothorax, or significant pleural effusion.  No new acutecardiopulmonary abnormalities since the previous examination.  Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the EmergencyRadiology reading room.    07/08/2024 11:30 - CTA Abd/Pelvis W/IV Contrast  IMPRESSION:1.  No acute vascular findings in the abdomen or pelvis.2.  Moderate to large volume ascites and diffuse body wall edema.3.  Chronic, degenerative postoperative findings as described.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.             Signature Line Electronically Signed on 07/08/24 18:07 EDT ________________________________________________________ MD