Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Haemoglobin normal, Head injury, Infection, Influenza A virus test negative, Influenza B virus test
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on October 13, 2023 19:05 EDT   Verified By: MD on October 13, 2023 19:05 EDT   Encounter Info: Hospital, Inpatient, 10/13/23 -     * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     This is an 87-year-old female with past medical history of allergic rhinitis presents to the emergency department following a fall.  The patient was seen in the emergency department yesterday for for nasal congestion and sore throat, she was feeling fine and labs were pretty normal, had some diarrhea.  And x-ray did not show any infiltrates she was discharged home.  Today she presents with a fall.  The patient was receiving her daughter on the gait.  At that time she her daughter was standing right in front of her and witnessed the fall.  The patient fell backwards straight on the floor hitting her head.  The daughter was by the bedside in the ED told me that she briefly jerked a bit, protruded her tongue.  At first she thought that the mother was dead but then thought her abdomen moving and called 911.  The patient had a similar fall about 4 weeks ago when she was putting dishes in the dishwasher.  The patient herself was alert and oriented x3 right now to does not recall the syncopal event.  She has chronic diarrhea.  And her daughter brought her electrolyte drinks today just because she thought the patient was dehydrated.    she  is vitally stable in the ED the Labs are suggestive of a normal white count, AKI on CKD stage III, mild elevation of bilirubin.  Urine analysis a day ago showed UTI.  Urine culture growing E. coli . the patient is COVID-positive.  CT scan of the head shows posterior parafalcine subdural hematoma as well as a probable small subdural hematoma overlying the right frontoparietal convexity.  Patchy subarachnoid hemorrhage in the bilateral frontoparietal cortical Salibi and probably in the right temporal occipital cortical sulci.  These findings were discussed by Dr. in the ED with Dr. who is a neurosurgeon.  He he said the patient can be admitted to Hospital and we just need to monitor with a repeat CT scan in the morning and keep the blood pressure systolic under 160.  Review of Systems     13 point review systems negative except for what is mentioned above  Physical Exam/Objective Vitals & Measurements most recent past 24 hours   Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress,  Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus  ENMT:  Moist oral mucosa  Neck:  Supple, non-tender, intact range of motion  Respiratory:  Lungs CTAB  Cardiovascular:  Regular rate and rhythm  Gastrointestinal:  Soft, non-tender, non-distended  Musculoskeletal:  No joint swelling, no deformity, intact ROM  Integumentary:  Intact, warm, dry no rashes  Neurologic: Alert & Oriented   Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Subdural bleeding   I62.00   CT scan in the AM,   - systolic blood pressure < 160   - SCD  -  NephroCheck q2,   - orthostatic vitals,   - gentle hydration   -no compression effect at the moment  - ED discussed wit Dr    2. Subarachnoid bleed   I60.9   problems 1    3. COVID   U07.1   - no Rx indicated, on room air,    4. AKI (acute kidney injury)   N17.9   - likely pre renal in etiology, continue hydration    5. UTI (urinary tract infection)   N39.0   - ceftriaxone 1gm daily for 5 days   - follow urine culture for sensitivities    6. Fall   W19.XXXA   - this falls looks like its from acute infection, weakness,   - orthostatic,vitals , telemtry, repeat head ct in the morning.    7. Chronic diarrhea   K52.9   - noted, i dont see any GI Consultation, will admit and monitor her bowel movement for now, family tells me it is always like that. may be need a colonoscopy outpatient    Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent  40 minutes of critical care time directly and personally managing the patient. This critical care time included obtaining a history, examining the patient, pulse oximetry, ordering and reviewing the studies, arranging urgent treatment with development of a management plan, evaluation of the patient?s response to treatment, frequent reassessment, and discussions with other clinicians. The critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see the MDM section and the rest of this note for further information on patient assessment and treatment.  Code Status   None Recorded   Chronic Problem List    Allergic rhinitis due to pollen  COVID  Deviated nasal septum  Hypertrophy of both inferior nasal turbinates  Multinodular goiter  Right thyroid nodule  Snoring  Procedure/Surgical History  ?Appendectomy ?Gallbladder ?Total hysterectomy     Medications   Home Medications (10) Active  allopurinol   dextromethorphan-promethazine 15 mg-6.25 mg/5 mL oral syrup 5 mL, PRN, Orally, Q6H  fluticasone HFA 44 mCg/inh 2 Puff, Inhalation, Q12H  hydroCHLOROthiazide , Orally, Daily  ketoROLAC   metoPROLOL tartrate 75 mg oral tablet 75 mg = 1 Tablet, Orally, BID  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  Paxlovid 150 mg-100 mg (300 mg-100 mg Dose) oral tablet 3 Tablet, Orally, BID  traMADOL , Orally  Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, TID  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 10/12/23 00:00:00 TO 10/13/23 19:03:33  None Reported  PRN Medications (0600 - 0559) from 10/12 - 10/13  None Reported  Allergies   No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.8 k/cumm (10/13/23 17:49:00)  RBC: 5.17 million/cumm (10/13/23 17:49:00)  Hgb: 15 GM/dL (10/13/23 17:49:00)  Hct: 46.3 % (10/13/23 17:49:00)  MCV: 89 fL (10/13/23 17:49:00)  MCH: 29 pg (10/13/23 17:49:00)  MCHC: 32.5 GM/dL (10/13/23 17:49:00)  RDW: 14.9 % High (10/13/23 17:49:00)  Platelet: 185 k/cumm (10/13/23 17:49:00)  MPV: 8.5 fL (10/13/23 17:49:00)  Neutrophils %: 59 % (10/13/23 17:49:00)  Lymphocytes %: 28 % (10/13/23 17:49:00)  Monocytes %: 12 % (10/13/23 17:49:00)  Eosinophils %: 0 % (10/13/23 17:49:00)  Basophils %: 1 % (10/13/23 17:49:00)  Absolute Neutrophil: 4 k/cumm (10/13/23 17:49:00)  Absolute Lymphocyte: 1.9 k/cumm (10/13/23 17:49:00)  Absolute Monocyte: 0.8 k/cumm (10/13/23 17:49:00)  Absolute Eosinophil: 0 k/cumm (10/13/23 17:49:00)  Absolute Basophil: 0 k/cumm (10/13/23 17:49:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (10/13/23 17:49:00)  Potassium SerPl QN: 5 mmol/L (10/13/23 17:49:00)  Chloride SerPl QN: 107 mmol/L (10/13/23 17:49:00)  Carbon Dioxide SerPl QN: 20 mmol/L Low (10/13/23 17:49:00)  Anion Gap: 11 mmol/L (10/13/23 17:49:00)  BUN SerPl QN: 24 mg/dL High (10/13/23 17:49:00)  Creatinine SerPl QN: 1.34 mg/dL High (10/13/23 17:49:00)  Estimated GFR (CKD-EPI, no race): 38 mL/min/1.73m2 Low (10/13/23 17:49:00)  Estimated CRCL (CG): 28 mL/min Low (10/13/23 17:49:00)  Glucose SerPl QN: 108 mg/dL High (10/13/23 17:49:00)  Calcium Total SerPl QN: 9.1 mg/dL (10/13/23 17:49:00)  Alkaline Phos SerPl QN: 64 Units/L (10/13/23 17:49:00)  ALT SerPl QN: 8 Units/L (10/13/23 17:49:00)  AST SerPl QN: 17 Units/L (10/13/23 17:49:00)  Bilirubin Total SerPl QN: 1.4 mg/dL High (10/13/23 17:49:00)  Total Protein SerPl QN: 7.3 GM/dL (10/13/23 17:49:00)  Albumin SerPl QN: 4.6 GM/dL (10/13/23 17:49:00)  Micro - Last 7 days  Rapid Strep A Method: EIA (10/12/23 11:22:00)  RapStrepA: Negative (10/12/23 11:22:00)  Strep Grp A PCR QL: Not Detected (10/12/23 11:22:00)  Rapid Influenza Method: PCR - Liat (10/12/23 11:22:00)  Rapid Influenza A PCR: Not Detected (10/12/23 11:22:00)  Rapid Influenza B PCR: Not Detected (10/12/23 11:22:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 10/13/2023 16:48 - CT Head W/o IV Contrast  IMPRESSION:1.  Findings suggestive of a posterior parafalcine subdural hematoma,as well as a probable small subdural hematoma overlying the rightfrontoparietal convexity.2. Patchy subarachnoid hemorrhage in the bilateral frontoparietalcortical sulci, and probably in the right temporal occipital corticalsulci.3. No significant intracranial mass effect or calvarial fracture.4. Sclerotic focus in the right parietal calvarium of uncertainsignificance; discussion and differential diagnosis as above.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.Results were communicated and receipt was documented in the Results Reporting System.                Signature Line Electronically Signed on 10/13/23 19:05 EDT ________________________________________________________ MD  Electronically Signed on 10/13/23 19:09 EDT ________________________________________________________ MD