Age: 28.0
Sex: M
Vaccine: COVID19
Symptoms: Systemic inflammatory response syndrome, Tachycardia, Tachypnoea, White blood cell count normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on December 11, 2024 14:04 EST   Verified By: MD on December 11, 2024 14:04 EST   Encounter Info: Hospital, Emergency, 12/11/24 -     * Final Report *          History of Present Illness/Subjective     30-year-old male, with history of hypokalemia, hypophosphatemia, cerebral palsy with quadriplegia, baseline nonverbal, acute on chronic respiratory failure with hypoxia, aspiration pneumonia, community-acquired pneumonia, anemia, on supplemental oxygen, presented to the emergency department due to fever that started few hours prior to presentation   Patient was seen and evaluated with mother by the bedside in the ER.  Patient is nonverbal and could not provide any history.  Mother notes that for the past 1 day, patient seems to be unwell.  Early hours of the morning prior to presentation, he was noted to have a fever.    Patient is nonverbal and could not complain of anything in particular.  At baseline, he is on trach collar with 3 L of oxygen and ventilator at night.  Mother endorsed that multiple family members are sick with COVID.  Patient has been vaccinated for COVID x 2   In the ER  Vitals  Heart rate 115, respiratory rate 27, SpO2 91% on 3 and half liters of oxygen, temperature 38   Labs  WBC 6.6, hemoglobin 9.7, platelets 200, sodium 135, potassium 4.2, chloride 103, BUN/creatinine 21/0.24,  Blood gas pH 7.43 otherwise unremarkable, FiO2 40% trach collar  COVID positive   Imaging  Hypoinflated lungs. Bibasilar airspace opacities may represent  atelectasis or developing infiltrate.???????  Review of Systems     Did not respond, non verbal  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 37.2 °C (Axillary)  TMIN: 37.2 °C (Axillary)  TMAX: 38.5 °C (Oral)  BP: 91/64  HR: 115 (Monitored)  RR: 27  SpO2: 91%  Oxygen Therapy: Trach Collar  Oxygen Flow Rate: 8 (L/min)  FiO2: 0.35  WT: 60 kg (Estimated)    Hemodynamics   Neurologic   Patient Weight    Patient Height  Current Height:    167.6 cm             General:  No acute distress.  Lethargic, nonverbal, G-tube in place Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: Respirations are non-labored. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Neurologic: Not assessed due to nonverbal status Psychiatric: Not assessed??????? Musculoskeletal: No swelling,     Assessment/Plan      1. Pneumonia due to COVID-19 virus   U07.1  30-year-old man, history of cerebral palsy, bedbound, G-tube PEG tube present, nonverbal status presenting with respiratory distress and fever now known to be from COVID pneumonia  Patient appears lethargic on exam, is nonverbal and so no history was obtained however mother was by the bedside and provided history  Respiratory therapist was met by the bedside, patient is currently on 35% FiO2 of oxygen through a trach collar.  At baseline patient is on 3 and half liters of oxygen which is equivalent to current oxygen requirement.   -Will admit to ICU for close monitoring and begin COVID-specific treatments such as remdesivir and dexamethasone  -antibiotics???????  -RT to continue to follow  IV fluid hydration-   2. COVID-19   U07.1    3. Sepsis   A41.9  Meet SIRS criteria with tachycardia, tachypnea and fever  Sepsis protocol ongoing.    Follow-up blood culture.  Commence antibiotics  Send respiratory culture   4. Anemia   D64.9  Seems chronic.  No obvious signs of bleeding.  Trend daily   5. Cerebral palsy, quadriplegic   G80.8  history of cerebral palsy, bedbound, G-tube PEG tube present, nonverbal status    6. Chronic respiratory failure with hypoxia   J96.11  Noted.    Currently at baseline oxygen requirements   7. GERD (gastroesophageal reflux disease)   K21.9  PPI   8. Tracheostomy status   Z93.0  Noted.    Respiratory following.   Hypoxemia   R09.02    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    Anemia  Asthma  Cerebral palsy, quadriplegic  Chest deformity  Chronic respiratory failure with hypoxia  Conductive hearing loss  Constipation  Dental caries  Dependence on supplemental oxygen  Diarrhea  Gastrojejunostomy tube status  GERD (gastroesophageal reflux disease)  History of MDR Pseudomonas aeruginosa infection  Hypokalemia  Hypophosphatemia  Pressure ulcer, other site  Recurrent pneumonia  Sleep disorder  Tracheostomy status  Undescended testis  Procedure/Surgical History  ?ERCP to remove gallstone (2021) ?trachesotmy (2017) ?eye surgery (1996) ?Abdominal ?Adenoidectomy ?Gastrostomy tube ?NIESSEN FUNDOPLAST ?Surgery ?Surgery ?Tonsillectomy   Surgical History Internal  11/01/2024    EGD Diagnostic    MD  05/01/2024    Laparotomy Exploratory    MD  04/29/2024    Gastrostomy Tube Placement    MD  04/18/2024    EGD Diagnostic   MD  04/11/2024    EGD Bx    MD PhD  03/20/2023    EGD Diagnostic    MD  08/06/2021    G Tube J Tube Placement    MD  06/18/2021    Cholecystectomy Laparoscopic    MD  04/30/2021    ERCP Stone Rmv    MD  03/16/2021    G Tube J Tube Placement    MD  11/09/2020    G Tube J Tube Placement    MD  06/12/2020    G Tube J Tube Placement    MD  08/20/2019    G Tube J Tube Placement    MD  12/30/2018    EGD Diagnostic    MD  08/12/2018    EGD Diagnostic    MD  12/26/2017    Bronchoscopy Diagnostic    MD  12/19/2017    Tracheostomy    MD  12/19/2017    Bronchoscopy Diagnostic    MD  12/09/2017    Gastrostomy Tube Placement    MD  12/06/2017    Bowel Resection    MD  05/09/2017    Gastrojejunostomy    DO  01/06/2011    Central Line Insertion.    MD  12/12/2010    Central Line Temporary Insertion.   MD  04/18/2010    Central Line Temporary Insertion.    MD  12/14/2006    Central Line Temporary Insertion.    MD  12/07/2006    Laparoscopic Exploration    MD  11/02/2006    Central Line Temporary Insertion.    MD  09/13/2006    Gastrostomy Percutaneous Insert Tube    MD  Medications   Home Medications (20) Active  Acephen 650 mg rectal suppository 650 mg = 1 Suppository, PRN, Rectally, Q4H  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, Inhalation, Q6H, Takes at 0800 - 1200 - 1600 - 2000J30.2  buDESOnide 0.5 mg/2 mL inhalation suspension 0.5 mg = 2 mL, Neb Inhale, BID, TAKE AT 0800 AND 2000  DME (Vendor) Mattress See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor)  See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  glycerin adult 2.1 g rectal suppository , PRN, Rectally, Daily  Heparin Lock Flush 100 Units/mL intravenous solution See Instructions, For Home Health Nurse to flush Port A Cath before and after Blood Draws  iron (as bisglycinate) 28 mg oral capsule   Konvomep 2 mg-84 mg/mL oral suspension See Instructions, SHAKE LIQUID AND TAKE 20 ML BY MOUTH DAILY  metoPROLOL tartrate 25 mg oral tablet 25 mg = 1 Tablet, J Tube, BID, crush and flush down J tube  Misc Supplies See Instructions, 22 G 3/4' Huber Needle for Home Health Nurse to perform Blood Draws through Port A Cath  Misc Supplies See Instructions, Insertion Trays ( Sterile Dressing Change Kits) for Home Health Nurse to change on Port A Cath  Misc Supplies See Instructions, 22 G 3/4' Huber Needle for Home Health Nurse to perform Blood Draws through Port A Cath  Misc Supplies See Instructions, Clave (Adapters) For Home Health Nurse to maintain Port A Cath  montelukast 4 mg oral granule 8 mg = 2 Packet, G Tube, Every PM, MIX 2 PACKETS AND GIVE THROUGH GTUBE EVERY MORNING  Normal Saline Flush See Instructions, For Home Health Nurse to Flush Port before and after  Blood Draws  potassium chloride 20 mEq/15 mL oral liquid 20 mEq = 15 mL, Orally, TID  Zyrtec 5 mg, G Tube, QPM, through gastric tube - liquid 5ml  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 12/10/24 00:00:00 TO 12/11/24 14:03:48  acetaminophen, Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 12/11/24 12:56:00)  albuterol (albuterol 2.5 mg/0.5 mL (0.5%) inhalation solution), Inhalation SOLN, 2.5 mg, Neb Inhale, ONCE, (1 DOSE 12/11/24 13:31:00)  dexamethasone, Injection, 6 mg, IV Push, ONCE, (1 DOSE 12/11/24 13:03:00)  PRN Medications (0600 - 0559) from 12/10 - 12/11  None Reported  Allergies   Tape (rash)  vancomycin (Red Man Syndrome)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   disabled from birth   Exercise   Home/Environment   LIVES WITH MOM, DAD, AND 2 SISTERS. NO DAYCARE   Nutrition/Health   Type of diet: t continuous tube feeds - 46.5 ml/hr.   Other   all medication given through gastric tube flushed with pedi-lite after   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Atrial fibrillation: Mother.  Breast cancer: Aunt.  Diabetes mellitus type 2: Uncle.  High blood pressure..: Mother.  Hypothyroid: Father.  Lung cancer..: Grandmother.   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.6 k/cumm (12/11/24 12:07:00)  RBC: 4.47 million/cumm (12/11/24 12:07:00)  Hgb: 9.7 GM/dL Low (12/11/24 12:07:00)  Hct: 30.9 % Low (12/11/24 12:07:00)  MCV: 69 fL Low (12/11/24 12:07:00)  MCH: 21.7 pg Low (12/11/24 12:07:00)  MCHC: 31.4 GM/dL Low (12/11/24 12:07:00)  RDW: 22.1 % High (12/11/24 12:07:00)  Platelet: 200 k/cumm (12/11/24 12:07:00)  MPV: 8.2 fL (12/11/24 12:07:00)  MCV Comment: MCV Follow Up (12/11/24 12:07:00)  Neutrophils %: 75 % (12/11/24 12:07:00)  Lymphocytes %: 5 % (12/11/24 12:07:00)  Monocytes %: 19 % (12/11/24 12:07:00)  Eosinophils %: 0 % (12/11/24 12:07:00)  Basophils %: 0 % (12/11/24 12:07:00)  Absolute Neutrophil: 5 k/cumm (12/11/24 12:07:00)  Absolute Lymphocyte: 0.3 k/cumm Low (12/11/24 12:07:00)  Absolute Monocyte: 1.3 k/cumm (12/11/24 12:07:00)  Absolute Eosinophil: 0 k/cumm (12/11/24 12:07:00)  Absolute Basophil: 0 k/cumm (12/11/24 12:07:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (12/11/24 12:07:00)  Potassium SerPl QN: 4.2 mmol/L (12/11/24 12:07:00)  Chloride SerPl QN: 103 mmol/L (12/11/24 12:07:00)  Carbon Dioxide SerPl QN: 26 mmol/L (12/11/24 12:07:00)  Anion Gap: 6 mmol/L (12/11/24 12:07:00)  BUN SerPl QN: 21 mg/dL High (12/11/24 12:07:00)  Creatinine SerPl QN: 0.24 mg/dL Low (12/11/24 12:07:00)  Estimated GFR (CKD-EPI, no race): >90 (12/11/24 12:07:00)  Estimated CRCL (CG): >120 (12/11/24 12:07:00)  Glucose SerPl QN: 106 mg/dL High (12/11/24 12:07:00)  Calcium Total SerPl QN: 8.6 mg/dL (12/11/24 12:07:00)  Lactate Venous Pl QN: 1.2 mmol/L (12/11/24 12:07:00)  pH Bld Arterial QN: 7.43 (12/11/24 13:24:00)  PCO2 Bld Arterial QN: 42 mmHg (12/11/24 13:24:00)  PO2 Bld Arterial QN: 86 mmHg (12/11/24 13:24:00)  Base Excess Bld Arterial: 3 mmol/L High (12/11/24 13:24:00)  Bicarb Bld Arterial Calc: 28 mmol/L (12/11/24 13:24:00)  O2 Sat Bld Arterial Calc: 97 % (12/11/24 13:24:00)  FIO2: 40% trachcollar (12/11/24 13:24:00)  Patient Temperature: 37 DegC (12/11/24 13:24:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (12/11/24 11:06:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (12/11/24 11:06:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 12/11/2024 12:37 - XR Chest PA or AP Portable  IMPRESSION:1.  Hypoinflated lungs. Bibasilar airspace opacities may representatelectasis or developing infiltrate.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at XXX-XX-XXX with any questions.                Signature Line Electronically Signed on 12/11/24 14:04 EST ________________________________________________________ MD