Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Urine analysis abnormal, Urine ketone body absent, Urine leukocyte esterase, Urobilinogen urine, Vomiting
Clinical narrative: Encounter Info: 02/07/23-   Chief Complaint   He presented septic with high fever and tachycardia as well as hypoxia, COVID test was positive. Chief Complaint   s/p fall  History of Present Illness/Subjective  71-year-old male with a past medical history of CAD, diabetes, BPH, bipolar disorder, cirrhosis of the liver, GERD, HLD, HTN presents to the ED at Bedford Hospital with a chief complaint status post fall.  His neighbors found him on the ground and vomit and called EMS.  Patient states that he has had fever over the past few days  Document Type: History and Physical   Document Subject: History & Physical Note   Performed:  on February 08, 2023 09:13 EST   Verified on February 08, 2023 09:13 EST   Encounter Info:  Hospital, Inpatient, 02/07/23 -  * Final Report *  Chief Complaint   s/p fall  History of Present Illness/Subjective  71-year-old male with a past medical history of CAD, diabetes, BPH, bipolar disorder, cirrhosis of the liver, GERD, HLD, HTN presents to the ED at Hospital with a chief complaint status post fall.  His neighbors found him on the ground and vomit and called EMS.  Patient states that he has had fever over the past few days with cough and endorses nausea.  He is confused and unable to state the year month or what he was doing earlier today and HPI is limited due to his being a poor historian.   He presented septic with high fever and tachycardia as well as hypoxia, COVID test was positive.  He is significantly improved after receiving a liter of fluids, Tylenol, 2 L nasal cannula O2, and IV antibiotics in the ED.  Review of Systems unable to assess due to patient's AMS  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.5 (37-37.5)  Temp (FAHR) 99.5 (98.6-99.5), BP 122/76 (103-132)/(63-76), HR 77 (77-89), RR 18 (18-18), O2Sat 97 (96-97) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    118.2 kg    02/08/23  Previous Daily Weight:    118.2 kg    02/08/23  BMI:    40.8    02/08/23    Morbid Obesity (BMI > = 40) Patient Height  Current Height:    170.2 cm    02/08/23        Constitutional:  No acute distress,  well-nourished, fatigued-appearing Eyes:  PERRL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB, no resp distress Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, distended, Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary: Pale-appearing, 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. Sepsis     2. Pneumonia due to COVID-19 virus    follow cx, cont cap coverage for bacterial superimposed pneumonia  start dexamethasone 6mg qd  start remdesivir, trend renal fxn  resp assessment and duonebs, supplemental o2 prn  isolation precautions     3. Hyponatremia   likely 2/2 dehydration, cont to monitor  monitor I/O's     4. CHF (congestive heart failure)       5. CAD in native artery    6. HTN (hypertension)   7. HLD (hyperlipidemia)  noted. cont home medications. 8. Diabetes   iss, poc glucose checks, ADA diet, blood glucose goal is 140-180 while inpatient  9. BPH (benign prostatic hyperplasia)   bladder scans prn 10. Cirrhosis    noted. ct did not demonstrate ascites, no abd pain. Allergic rhinitis   Ordered: loratadine, 10 mg, Orally, Tablet, Daily, 02/08/23 9:00:00 EST Chronic GERD    Ordered:  pantoprazole, 40 mg, Orally, Tab, Delayed Rel, BID, 02/08/23 9:00:00 EST Constipation  Ordered: docusate, 100 mg, Orally, Capsule, TID, 02/08/23 9:00:00 EST Depression  Ordered: FLUoxetine, 20 mg, Orally, Capsule, Daily, 02/08/23 9:00:00 EST Disequilibrium   R42  Ordered: loratadine, 10 mg, Orally, Tablet, Daily, 02/08/23 9:00:00 EST Hyperlipidemia    Ordered: atorvastatin, 80 mg, Orally, Tablet, Daily, 02/08/23 9:00:00 EST carvedilol, 25 mg, Orally, Tablet, BID, 02/08/23 9:00:00 EST cycloBENZaprine, 10 mg, Orally, Tablet, BID, 02/08/23 9:00:00 EST dexamethasone, 6 mg, IV Push, Injection, Q24H, 02/07/23 23:00:00 EST, for 10 Days, 02/16/23 23:00:00 EST donepezil, 10 mg, Orally, Tablet, At Bedtime, 02/08/23 21:00:00 EST doxycycline, 100 mg, IVPB, Injection, Q12H, Indication: First dose inpatient initiation, 02/08/23 0:00:00 EST, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100 enoxaparin, 40 mg, Subcutaneous, Injection, Q12, Routine, 02/07/23 23:00:00 EST famotidine, 20 mg, IV Push, Injection, Q12H, 02/07/23 23:00:00 EST hydroCODONE-acetaminophen, 1 Tablet, Orally, Tablet, TID, PRN, Pain, Moderate to Severe, 02/08/23 6:53:00 EST isosorbide mononitrate, 60 mg, Orally, Tab, Extended Rel, Daily, 02/08/23 9:00:00 EST metoPROLOL, 100 mg, Orally, Tab, Extended Rel, Daily, 02/08/23 9:00:00 EST piperacillin-tazobactam, 3.375 GM, IVPB, Injection, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), 02/08/23 3:00:00 EST, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50 polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation, 02/08/23 7:02:00 EST pregabalin, 100 mg, Orally, Capsule, BID, 02/08/23 9:00:00 EST remdesivir, 100 mg, IVPB, Injection, At Bedtime, 02/08/23 21:00:00 EST, for 4 Doses, 02/11/23 21:00:00 EST, 500 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 250 sacubitril-valsartan, 2 Tablet, Orally, Tablet, BID, 02/08/23 9:00:00 EST spironolactone, 25 mg, Orally, Tablet, Daily, 02/08/23 9:00:00 EST tamsulosin, 0.4 mg, Orally, Capsule, Daily, 02/08/23 9:00:00 EST zolpidem, 5 mg, Orally, Tablet, At Bedtime, PRN, Sleep, 02/08/23 6:54:00 EST 180 gm Carb per day Diet  All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 11.4 k/cumm High (02/08/23 03:37:00)  RBC: 4.98 million/cumm (02/08/23 03:37:00)  Hgb: 14.1 GM/dL (02/08/23 03:37:00)  Hct: 43.1 % (02/08/23 03:37:00)  MCV: 86 fL (02/08/23 03:37:00)  MCH: 28.4 pg (02/08/23 03:37:00)  MCHC: 32.8 GM/dL (02/08/23 03:37:00)  RDW: 15 % High (02/08/23 03:37:00)  Platelet: 78 k/cumm Low (02/08/23 03:37:00)  MPV: 9.4 fL (02/08/23 03:37:00)  Neutrophils %: 92 % (02/08/23 03:37:00)  Lymphocytes %: 1 % (02/08/23 03:37:00)  Monocytes %: 7 % (02/08/23 03:37:00)  Eosinophils %: 0 % (02/08/23 03:37:00)  Basophils %: 0 % (02/08/23 03:37:00)  Absolute Neutrophil: 10.4 k/cumm High (02/08/23 03:37:00)  Absolute Lymphocyte: 0.2 k/cumm Low (02/08/23 03:37:00)  Absolute Monocyte: 0.7 k/cumm (02/08/23 03:37:00)  Absolute Eosinophil: 0 k/cumm (02/08/23 03:37:00)  Absolute Basophil: 0 k/cumm (02/08/23 03:37:00)  Chemistry:  Sodium SerPl QN: 132 mmol/L Low (02/08/23 03:37:00)  Potassium SerPl QN: 4.5 mmol/L (02/08/23 03:37:00)  Chloride SerPl QN: 97 mmol/L Low (02/08/23 03:37:00)  Carbon Dioxide SerPl QN: 27 mmol/L (02/08/23 03:37:00)  Anion Gap: 8 mmol/L (02/08/23 03:37:00)  BUN SerPl QN: 20 mg/dL (02/08/23 03:37:00)  Creatinine SerPl QN: 1.01 mg/dL (02/08/23 03:37:00)  Estimated GFR (CKD-EPI, no race): 80 mL/min/1.73m2 (02/08/23 03:37:00)  Estimated CRCL (CG): 82 mL/min (02/08/23 03:37:00)  Glucose SerPl QN: 159 mg/dL High (02/08/23 03:37:00)  Calcium Total SerPl QN: 8.8 mg/dL (02/08/23 03:37:00)  Alkaline Phos SerPl QN: 20 Units/L Low (02/08/23 03:37:00)  ALT SerPl QN: 24 Units/L (02/08/23 03:37:00)  AST SerPl QN: 63 Units/L High (02/08/23 03:37:00)  Bilirubin Total SerPl QN: 1 mg/dL (02/08/23 03:37:00)  Total Protein SerPl QN: 6.3 GM/dL Low (02/08/23 03:37:00)  Albumin SerPl QN: 3.8 GM/dL (02/08/23 03:37:00)  CK SerPl QN: 126 Units/L (02/07/23 15:57:00)  Troponin-I High Sensitivity: 9 ng/L (02/07/23 15:57:00)  BNP Pl QN: 1141 pg/mL High (02/07/23 19:01:00)  Lactate Venous Pl QN: 1.9 mmol/L (02/07/23 19:30:00)  Gluc-Strip, POC: 205 mg/dL High (02/07/23 15:47:00)  Urine Studies:  Color: Yellow (02/07/23 17:58:00)  Clarity: Clear (02/07/23 17:58:00)  Specific Gravity: <=1.005 (02/07/23 17:58:00)  pH: 5.5 (02/07/23 17:58:00)  Protein: 30 Abnormal (02/07/23 17:58:00)  Glucose: >=1000 Abnormal (02/07/23 17:58:00)  Ketones: NEGATIVE (02/07/23 17:58:00)  Bilirubin: NEGATIVE (02/07/23 17:58:00)  Hgb Ur: MODERATE. Abnormal (02/07/23 17:58:00)  Nitrite: NEGATIVE (02/07/23 17:58:00)  Urobilinogen: NormalUro (02/07/23 17:58:00)  Leukocyte Esterase Ur: NEGATIVE (02/07/23 17:58:00)  WBC: 0-5 (02/07/23 17:58:00)  RBC: 0-2 (02/07/23 17:58:00)  Bacteria: TRACE. (02/07/23 17:58:00)  Squamous Epithelial: NONE (02/07/23 17:58:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/07/23 15:50:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (02/07/23 15:50:00) Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/07/23 15:50:00)  Rapid Influenza A PCR: Not Detected (02/07/23 15:50:00)  Rapid Influenza B PCR: Not Detected (02/07/23 15:50:00)   Admit to Inpatient   Aspiration Precautions  Auto Diff  Bladder Scan  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Oxygen Need Greater Than  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  CBC w/Differential  Comp Metabolic Panel  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Fall Precautions  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Oxygen Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  Level of Care  Lipid Panel SerPl QN  Medical Service  No NSAIDS (includes COX-2 Inhibitors)  Patient Isolation  Peripheral IV Insertion  Procalcitonin  PT Evaluation and Treatment  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Strep pneumoniae Ag Urine  Telemetry Class III 24hr Recommendation  Titrate FiO2 to Keep O2 Sat  Vital Signs  Vital Signs  Weight  Weight Code Status   Resuscitation Status - Ordered    -- 02/07/23 22:22:00 EST, Full Code  Surgical History Internal  01/06/2021    Tooth Extraction.  12/27/2018    Lumbar Laminectomy    12/06/2018    Lumbar Laminectomy Minimally Invasive  (Right)   Medications Active Scheduled Inpatient Medications  aspirin, Tab, Delayed Rel, 81 mg, Orally, Daily, Start: 02/08/23 09:00:00  atorvastatin, Tablet, 80 mg, Orally, Daily, Start: 02/08/23 09:00:00  carvedilol, Tablet, 25 mg, Orally, BID, Start: 02/08/23 09:00:00  cycloBENZaprine (cycloBENZaprine 10 mg oral tablet), Tablet, 10 mg, Orally, BID, Start: 02/08/23 09:00:00  dexamethasone, Injection, 6 mg, IV Push, Q24H, Start: 02/07/23 23:00:00  docusate (docusate sodium), Capsule, 100 mg, Orally, TID, Start: 02/08/23 09:00:00  donepezil (Aricept), Tablet, 10 mg, Orally, At Bedtime, Start: 02/08/23 21:00:00  doxycycline, Injection, 100 mg, IVPB, Q12H, Indication: First dose inpatient initiation, Start: 02/08/23 00:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, Q12, Start: 02/07/23 23:00:00  famotidine (famotidine inj), Injection, 20 mg, IV Push, Q12H, Start: 02/07/23 23:00:00  fenofibrate, Tablet, 160 mg, Orally, Daily, Start: 02/08/23 09:00:00  FLUoxetine (Prozac), Capsule, 20 mg, Orally, Daily, Start: 02/08/23 09:00:00  isosorbide mononitrate (isosorbide mononitrate extended release), Tab, Extended Rel, 60 mg, Orally, Daily, Start: 02/08/23 09:00:00  loratadine (Claritin), Tablet, 10 mg, Orally, Daily, Start: 02/08/23 09:00:00  metoPROLOL (metoPROLOL succinate), Tab, Extended Rel, 100 mg, Orally, Daily, Start: 02/08/23 09:00:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, BID, Start: 02/08/23 09:00:00  piperacillin-tazobactam, Injection, 3.375 GM, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 02/08/23 03:00:00  pregabalin (Lyrica), Capsule, 100 mg, Orally, BID, Start: 02/08/23 09:00:00  remdesivir, Injection, 100 mg, IVPB, At Bedtime, Start: 02/08/23 21:00:00  sacubitril-valsartan (Entresto 49 mg-51 mg oral tablet), Tablet, 2 Tablet, Orally, BID, Start: 02/08/23 09:00:00  spironolactone, Tablet, 25 mg, Orally, Daily, Start: 02/08/23 09:00:00  tamsulosin, Capsule, 0.4 mg, Orally, Daily, Start: 02/08/23 09:00:00    One-Time Medications Given 02/07/23 00:00:00 TO 02/08/23 09:12:39  remdesivir, Injection, 200 mg, IVPB, ONCE, (1 DOSE 02/07/23 23:40:00)  PRN Medications (0600 - 0559) from 02/07 - 02/08  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, TID, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   zolpidem, 5 mg, Orally, At Bedtime, 0  Dose(s)     Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Use, within last 90 days. Type: Cannabinoid Infused. Started At Age: 70.0 Years.   Nutrition/Health   Caffeine intake amount: 3 servings per day.   Substance Abuse   Prescription medications   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Cancer: Brother.  Cancer of colon: Father.  Diabetes mellitus type 2: Brother.  High blood pressure..: Father and Grandfather.  Lymphoma: Brother.