Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen abnormal, Computerised tomogram abdomen normal, Computerised tomogram head normal, Computerised tomogram normal, Cough
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on February 12, 2023 06:42 EST   Verified By: DO on February 12, 2023 06:42 EST   Encounter Info: Hospital, Inpatient, 02/12/23 -     * Final Report *        Chief Complaint   cough and abdominal pain  History of Present Illness/Subjective     79 year old male  with hx of CHF, CAD, DM, and cardiac defibrillator placement presents to the ED via private vehicle complaining of headache and abd pain onset yesterday. Pt states he fell x4 times since yesterday due to feeling dizzy and lightheaded. Denies head strike. Pt is not anticoagulated. He states its unusual for him to fall. Pt states his left hip hurt earlier today after falling, however it has since subsided. Endorses new cough and vomiting. Pt denies hematochezia. He also endorses some dizziness/vertigo which improves when lying still with his eyes close.   In the ED he tested positive for COVID, ct's were all negative.  Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.8 (36.8-36.8)  Temp (FAHR) 98.2 (98.2-98.2), BP 109/66 (106-109)/(65-66), HR 71 (70-71), RR 18 (16-18), O2Sat 97 (97-97) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    81.2 kg    02/12/23  Previous Daily Weight:    79.5 kg    02/12/23  Difference from Previous:    1.700 kg  BMI:    23    02/12/23    Normal Weight (BMI 18.5-24.9) Patient Height        General: Patient is awake, alert, oriented to person, place, and time. Well appearing. In no acute distress. Resting comfortably. HEENT: NC/AT. PERRL. EOMI. No nystagmus. Conjunctiva without injection or exudate. Oropharynx is clear. Mucous membranes are moist. Nose without discharge. Neck: Neck is soft and supple. Respiratory: Chest is CTAB. Breathing is non-labored. Cardiovascular: Heart is normal rate with regular rhythm without murmur. Chest wall nontender to palpation. Peripheral pulses intact in all four extremities. Abdomen: Abdomen is soft and nontender, nondistended. No peritoneal signs. Normal, active bowel sounds. Musculoskeletal: Extremities without deformity or tenderness. Normal joint range of motion. Integument: No rashes or lesions. Neurologic: Cranial nerves: II-XII are grossly intact. Strength (5/5) and equal in BUE and BLE. Sensation to light touch intact and equal in bilateral upper and lower extremities. Normal gait. Normal finger-nose. Normal heel-shin. No dysdiadochokinesia.  Assessment/Plan       1. Multiple falls   R29.6   2. Nausea and vomiting   R11.2   3. Abdominal pain   R10.9  Likely 2/2 Covid, ct head and abd neg, physical exam suggests vertigo  start meclizine 12.5mg TID, if not improving will consider further workup such as MRI  cannot give antinausea meds given prolonged qtc   4. COVID-19   U07.1  start dexamethasone but given impaired renal fxn will not start remdesivir given it's low potential to provide therapeutic benefit, doxycycline  resp assessment  supplemental O2  inflammatory markers   5. HFrEF (heart failure with reduced ejection fraction)   I50.20  aicd in place, need to interrogate PM if not done in the ED to determine if there have been any terminated arrhythmias as possible cause of falls  maintain telemetry   6. CAD (coronary artery disease)   I25.10  cont home meds   7. Diabetes   E11.9  iss, poc glucose checks   8. GERD (gastroesophageal reflux disease)   K21.9  cont home meds   9. Hyperlipidemia   E78.5  cont home meds   10. Hypertension   I10  cont home meds as bp will allow, avoid hypotension   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/12/23 4:12:00 EST  albuterol, 2 Puff, Inhalation, Aerosol, MDI/DPI Inhaler Treatment, Q4H, PRN, Dyspnea, 02/12/23 7:00:00 EST  dexamethasone, 6 mg, IV Push, Injection, Q24H, 02/12/23 5:00:00 EST, for 10 Days, 02/21/23 5:00:00 EST  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 02/12/23 4:12:00 EST, PRN - See Comments, Clinical Weight  docusate, 100 mg, Orally, Capsule, BID, 02/12/23 9:00:00 EST  doxycycline, 100 mg, Orally, Capsule, Q12, Indication: Pneumonia - CAP, 02/12/23 10:00:00 EST  enoxaparin, 40 mg, Subcutaneous, Injection, Q24H, Routine, 02/12/23 5:00:00 EST  famotidine, 20 mg, IV Push, Injection, Q12H, 02/12/23 5:00:00 EST  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 02/12/23 4:12:00 EST  glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 02/12/23 4:12:00 EST  insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 02/12/23 4:12:00 EST  meclizine, 12.5 mg, Orally, Tablet, TID, 02/12/23 9:00:00 EST  180 gm Carb per day Diet  Admit to Inpatient   Bladder Scan  BNP Pl QN  Call (Specify)  Call Blood Glucose  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  CK SerPl QN  CK SerPl QN  Comp Metabolic Panel  CRP SerPl QN  CRP SerPl QN  D-Dimer Pl QN  D-Dimer Pl QN  Electrocardiogram  Fall Precautions  Ferritin SerPl QN  Ferritin SerPl QN  Fibrinogen  Fluid Intake Requirement  Gluc-Strip POC  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Oxygen Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Interleukin 6 QN  L pneumophila Ag Ur QL  LDH SerPl QN  LDH SerPl QN  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  No NSAIDS (includes COX-2 Inhibitors)  Notify Provider  Notify Provider  Notify Provider  Patient Isolation  Peripheral IV Insertion  Procalcitonin  PT Evaluation and Treatment  Reason for Not Ordering Long-acting Insulin  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  Troponin-I High Sensitivity  Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 02/12/23 4:12:00 EST, Full Code   Chronic Problem List    Anxiety  Asthma  BPH (benign prostatic hyperplasia)  CAD (coronary artery disease)  Cardiac defibrillator in place  Cardiomyopathy  CHF, acute on chronic  Chronic renal failure, stage 3 (moderate)  Cough  Depression  Diabetes  Diabetic neuropathy  Fracture of phalanx of right index finger  GERD (gastroesophageal reflux disease)  Hallux abductovalgus  Hyperlipidemia  Hypertension  Hypothyroidism  Injury of nail bed of finger of left hand  Insomnia  Laceration of right index finger with damage to nail  Left bundle branch block  Long term use of drug  Medicare annual wellness visit, subsequent  Needs flu shot  Neuropathy due to type 2 diabetes mellitus  Obstructive sleep apnea  Onychogryphosis  Onychomycosis  Pre-ulcerative calluses  Right hand pain  Procedure/Surgical History  oDefibrillator (02/01/2019) oPSA - Prostate specific antigen (03/13/2018) oLt Wrist 1st Dorsal Compartment Release 5/23/2016 (05/23/2016) oColonoscopy (05/21/2010) oPacemaker with AICD (1994) oAngioplasty with Stent, Coronary/Thoracic (1990) oCABG x 2 - Coronary artery bypass grafts x 2 (01/01/1990) oRhinoplasty (1957) oCardiac Cath ohearing screening - has hearing aids - passed oKnee Replacement oNose oRevision Amputation LT Distal Thumb, dos 6-7-19, doi 6-6-19  oTeeth Extraction ovision screening - 2017   Surgical History Internal  07/29/2015    Circumcision.     MD  04/29/2015    Hand Finger Tendon Muscle Repair  (Left)    MD  Medications   Home Medications (19) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  amiodarone 200 mg oral tablet 200 mg = 1 Tablet, Orally, Daily  aspirin 81 mg oral tablet, delayed release 81 mg, Orally, At Bedtime  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Flonase 50 mCg/inh nasal spray 1 Spray, Nostrils, Both, BID  Flovent Diskus 100 mCg inhalation powder 1 Puff, Inhalation, BID  Janumet XR 100 mg-1000 mg oral tablet, extended release 1 Tablet, Orally, With Dinner  Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, BID  levothyroxine 25 mCg (0.025 mg) oral tablet 25 mCg = 1 Tablet, Orally, Daily  losartan 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  mexiletine 200 mg oral capsule 200 mg = 1 Capsule, Orally, Q12H  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  Plavix 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily  Potassium Chloride (Eqv-K-Tab) 20 mEq oral tablet, extended release 20 mEq = 1 Tablet, Orally, BID  tamsulosin 0.4 mg oral capsule See Instructions, TAKE 2 CAPSULES BY MOUTH EVERY DAY  traZODONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, At Bedtime  Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q6H  Xopenex HFA 45 mCg/inh inhalation aerosol 2 Puff, Inhalation, Q4H  Zoloft 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  dexamethasone, Injection, 6 mg, IV Push, Q24H, Start: 02/12/23 05:00:00  docusate (docusate sodium), Capsule, 100 mg, Orally, BID, Start: 02/12/23 09:00:00  doxycycline, Capsule, 100 mg, Orally, Q12, Indication: Pneumonia - CAP, Start: 02/12/23 10:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 02/12/23 05:00:00  famotidine (famotidine inj), Injection, 20 mg, IV Push, Q12H, Start: 02/12/23 05:00:00  meclizine, Tablet, 12.5 mg, Orally, TID, Start: 02/12/23 09:00:00  Dextrose 10% in Water  500 mL IV  PRN - See Comments       One-Time Medications Given 02/11/23 00:00:00 TO 02/12/23 06:41:58  ampicillin-sulbactam, Injection, 3 GM, IVPB, ONCE, (1 DOSE 02/12/23 04:53:00)  azithromycin, Tablet, 500 mg, Orally, ONCE, (1 DOSE 02/12/23 04:53:00)  PRN Medications (0600 - 0559) from 02/11 - 02/12  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2 Puff, Inhalation, 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)   Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   MARRIED, Lives with Spouse.   Other   Right Handed   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker - quit 45 years ago.  Family History   Chest pain..: Mother.  Heart disease..: Mother.  SOB (shortness of breath)..: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.3 k/cumm (02/11/23 20:48:00)  RBC: 3.58 million/cumm Low (02/11/23 20:48:00)  Hgb: 11.1 GM/dL Low (02/11/23 20:48:00)  Hct: 32.7 % Low (02/11/23 20:48:00)  MCV: 92 fL (02/11/23 20:48:00)  MCH: 31 pg (02/11/23 20:48:00)  MCHC: 33.8 GM/dL (02/11/23 20:48:00)  RDW: 13.7 % (02/11/23 20:48:00)  Platelet: 115 k/cumm Low (02/11/23 20:48:00)  MPV: 8.2 fL (02/11/23 20:48:00)  Neutrophils %: 73 % (02/11/23 20:48:00)  Lymphocytes %: 14 % (02/11/23 20:48:00)  Monocytes %: 12 % (02/11/23 20:48:00)  Eosinophils %: 0 % (02/11/23 20:48:00)  Basophils %: 1 % (02/11/23 20:48:00)  Absolute Neutrophil: 4.6 k/cumm (02/11/23 20:48:00)  Absolute Lymphocyte: 0.9 k/cumm Low (02/11/23 20:48:00)  Absolute Monocyte: 0.7 k/cumm (02/11/23 20:48:00)  Absolute Eosinophil: 0 k/cumm (02/11/23 20:48:00)  Absolute Basophil: 0 k/cumm (02/11/23 20:48:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (02/11/23 20:48:00)  Potassium SerPl QN: 4.1 mmol/L (02/11/23 20:48:00)  Chloride SerPl QN: 104 mmol/L (02/11/23 20:48:00)  Carbon Dioxide SerPl QN: 26 mmol/L (02/11/23 20:48:00)  Anion Gap: 9 mmol/L (02/11/23 20:48:00)  BUN SerPl QN: 19 mg/dL (02/11/23 20:48:00)  Creatinine SerPl QN: 1.66 mg/dL High (02/11/23 20:48:00)  Estimated GFR (CKD-EPI, no race): 42 mL/min/1.73m2 Low (02/11/23 20:48:00)  Estimated CRCL (CG): 41 mL/min Low (02/11/23 20:48:00)  Glucose SerPl QN: 110 mg/dL High (02/11/23 20:48:00)  Calcium Total SerPl QN: 8.7 mg/dL (02/11/23 20:48:00)  Alkaline Phos SerPl QN: 88 Units/L (02/11/23 20:48:00)  ALT SerPl QN: 16 Units/L (02/11/23 20:48:00)  AST SerPl QN: 28 Units/L (02/11/23 20:48:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (02/11/23 20:48:00)  Total Protein SerPl QN: 5.9 GM/dL Low (02/11/23 20:48:00)  Albumin SerPl QN: 3.9 GM/dL (02/11/23 20:48:00)  Magnesium SerPl QN: 1.7 mg/dL (02/12/23 05:57:00)  Lipase SerPl QN: 24 Units/L (02/11/23 20:48:00)  CK SerPl QN: 81 Units/L (02/12/23 04:50:00)  Troponin-I High Sensitivity: 23 ng/L High (02/12/23 04:50:00)  BNP Pl QN: 851 pg/mL High (02/12/23 04:50:00)  C-Reactive Prot SerPl QN: 2.9 mg/dL High (02/12/23 04:50:00)  Coagulation:  D-Dimer Pl QN: 431 ng/mL DDU High (02/12/23 04:50:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (02/11/23 20:48:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (02/11/23 20:48:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/11/2023 21:37 - XR Chest PA or AP Portable  IMPRESSION:Minimal streaky right basilar opacities favoring subsegmentalatelectasisThank you for consulting our team of subspecialty radiologists at Radiology.      02/11/2023 21:37 - CT Abd/Pelvis W/O IV Contrast  IMPRESSION:1.  No acute findings in the abdomen or pelvis.2.  Large right renal cyst as detailed above.Thank you for consulting our team of subspecialty radiologists at Radiology.      02/11/2023 21:38 - CT Head W/o IV Contrast  IMPRESSION:  1.  No acute intracranial findingsThank you for consulting our team of subspecialty radiologists at Radiology.      02/12/2023 00:09 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Limited assessment of the pulmonary arteries due to motionartifact as detailed above. No obvious pulmonary embolism isidentified, but the right lower lobe pulmonary arteries are normalwell assessed.2.  Mild atelectasis/scarring in the right upper and lower lobes.Thank you for consulting our team of subspecialty radiologists at Radiology.                  Signature Line Electronically Signed on 02/12/23 06:42 EST ________________________________________________________ DO