Age: 87.0
Sex: F
Vaccine: COVID19
Symptoms: Urine ketone body present, Urine leukocyte esterase, Urobilinogen urine, White blood cell count increased, pH urine normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note    Encounter Info: Hospital, Emergency, 11/19/22 - 11/19/22    * Final Report *          History of Present Illness/Subjective     88-year-old woman transported to the ED from her ECF for evaluation of alteration in mental status, hypoxia, and tachycardia.  She was noted at the facility to be increasingly short of breath this morning and had O2 sats documented in the 70s on her baseline O2 (the amount of which is not well documented).  She became increasingly agitated and would not keep her oxygen on, so her sats fell even more, prompting the call to 911.  A 15 L nonrebreather mask was placed in the ambulance in route to the hospital, as the patient had become obtunded enough that she was no longer fighting the supplemental oxygen.  She has perked up quite a bit by the time of my evaluation and is able to provide some limited history, though she is quite confused, which apparently is to some extent her baseline) and does not have much recollection of the events that led to her presentation here.  According to chart review, family members previously stated that the patient has had 2 or 3 recent falls, fortunately without major trauma, and she has not been eating or drinking well at all.  She has had several recent hospitalizations, 1 at this facility earlier this year and 4 since September, for various issues, including rectal bleeding, uncontrolled atrial fibrillation, and encephalopathy, and just this week was admitted to another facility then discharged back to nursing home after being treated for pneumonia.  She has historically been fairly ambulatory at baseline, but of late she has really not been getting out of bed much at all.  She has not complained of chest pain and has had no documented fever.  She has had a mild nonproductive cough, but family members do not feel that this is much worse than her baseline.  On arrival to the ED today, she was afebrile but tachycardic and tachypneic.  Blood pressure has been adequately preserved throughout her course thus far.  She is now down to 3L NC and doing better, though still some what disoriented. Covid test was positive, and patient remains in afib w/ rvr and therefore she will be admitted to icu for cardizem drip.  Review of Systems     Notable for the aforementioned shortness of breath and confusion that led to patient's presentation today.  She also has had progressive generalized weakness, ambulatory dysfunction, anorexia, and decreased oral intake in recent months.  She has had several witnessed falls at the facility, fortunately without major trauma.  She has had no recognized fever, vomiting, diarrhea, complaints of chest or abdominal pain, cough, or hemoptysis.  The remainder the 12 point review of systems is unobtainable due to the patient's confused state.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.2 (36.2-36.2)  Temp (FAHR) 97.2 (97.2-97.2), BP 156/67 (125-156)/(58-90), HR 125 (76-128), RR 20 (18-20), O2Sat 97 (94-97) Neurologic (most recent and range for last 24 hours)  GCS 13(13-13)     Patient Weight  Current Daily Weight:    84 kg    11/19/22    Patient Height  Current Height:    170.2 cm    11/19/22        General:  alert, no acute distress Skin: warm, dry , pink, no pallor, no rash Head:  normocephalic Eye: PERRLA, EOMI, normal conjunctiva ENT: oral mucosa moist , no pharyngeal erythema or exudate Neck:  supple Cardiovascular:  Irregularly irregular and tachycardic HR , no murmur, no edema Respiratory: scattered velcrow-like crackles, no wheeze, respirations non-labored, BS equal Chest Wall: no deformity, no tenderness Back: normal ROM Gastrointestinal:  soft, non tender , non distended , normal BS,,  no organomegaly Extremities:  no tenderness , normal ROM, normal strength, +1 pitting edema to ankles b/l Neurological:  no focal neuro deficits , A&O x4, CN II - XII intact, normal sensory, normal motor, normal speech Psych: cooperative , appropriate mood and affect  Assessment/Plan     Admit to ICU   1. Atrial fibrillation with RVR   I48.91  She has had paroxysmal atrial fibrillation going back to at least 2011 when she had a Lexiscan for ischemic evaluation ordered for atrial fibrillation. She previously was anticoagulated on warfarin, but has since switched to apixaban. EKG appears to be afib vs a-flutter with RVR with right bundle branch block. She has a known history of paroxysmal atrial fibrillation.  EKGs going back to June of this year showed atrial fibrillation with right bundle branch block.  The EKG from today appears to be very similar to the EKG from October 5th of this year as well as on 11/14/22. We will start a diltiazem infusion with a goal of rate control.  She is on apixaban 5 mg p.o. twice daily, she does not meet 2 criteria to reduce dose. Her CHA2DS2-VASc score is 4, HAS-BLED 3.   -diltiazem infusion to keep HR < 100 bpm, Hold for SBP < 100 mmHg  -trend trops and serial ecgs, though mild elevation in trop likely is a result of hypoxia/ and resultant demand ischemia   2. COVID-19   U07.1  start remdesivir, monitor renal fxn  start decadron 6mg iv push qd  isolations, neg-pressure room  currently requiring 3L NC  patient is DNR/DNI   3. Acute on chronic respiratory failure with hypoxia   J96.21  Currently requiring 3 L per NC to maintain sats above 92%.  Presumed underlying etiology due to covid-19.  Will titrate oxygen as needed but hopefully can get back to her baseline (regimen to be determined) with stabilization of underlying cardiopulmonary issues and steroids.  4. Severe sepsis   R65.20  H criteria based on tachycardia, tachypnea, leukocytosis, hypoxia, and encephalopathy in the setting of underlying covid.  Sepsis protocol initiated but limiting basal fluid infusion due to concern for possible superimposed pulmonary edema.  Given recent hospital admission and leukocytosis, will also provide broad-spectrum antibiotics while culture results are pending.  Initial lactate within normal limits; procalcitonin pending though not clinically beneficial given concurrent covid.  Blood pressure adequately preserved throughout course thus far, and there is no current indication for pressor support.  5.  Adult failure to thrive   R62.7  This is been a subacute progression over the past few months.  She really is not getting up and around at all currently, nor is she eating well.  She sleeps quite a bit of the time.  Discussed with family members their goals for her care (she is not competent for medical decision-making in her current state).  They are interested in treating her pneumonia and in controlling her heart rate but they really do not want a great deal of additional testing or management.  They are interested in pursuit of hospice placement following discharge, and case management and hospice service can be engaged tomorrow to begin this process.  6.  Ambulatory dysfunction   R26.2  Patient has had multiple recent falls.  Can consider physical therapy evaluation, though I am uncertain whether her current cognitive status is sufficient to allow her to participate adequately with the therapies.  In the meantime, will maintain on fall precautions and continue aggressive treatment of underlying conditions.  7.  Toxic metabolic encephalopathy   G92.8  This seems to be improving and likely was related mainly to hypoxia.  Will minimize use of potentially exacerbating medications and will monitor for behavioral and/or cognitive changes.  8. History of lung cancer   Z85.118  Patient was diagnosed with non-small cell lung cancer in 2011; she underwent left upper lobe resection in November of that year, followed by adjuvant chemotherapy with carboplatin and etoposide through April 2012.  She was diagnosed with recurrent disease, metastatic, and September 2015 and was initiated on Alimta; she experienced progression of disease on this regimen, however, and received nivolumab as salvage therapy through the first part of 2016.  She has been in remission since that time.  She follows with Dr. in oncology, in the outpatient setting.  9.  Chronic obstructive pulmonary disease   J44.9  Not markedly bronchospastic on current exam.  Nebulized and/or inhaled bronchodilators available for as needed use per RT protocol  10. Essential hypertension   I10  Normotensive at presentation; will continue metoprolol per current regimen and monitor blood pressure.  Can supplement with oral clonidine if needed in the short-term.  11. Hyperlipidemia   E78.5  Has been on a stable statin regimen; will continue and defer further management to outpatient setting.  12. Hypothyroid   E03.9  Has been on a stable levothyroxine regimen; will continue and check screening TSH.  13. GERD (gastroesophageal reflux disease)   K21.9  Generally well controlled on outpatient PPI regimen; will continue Protonix and monitor for symptoms.  Code Status  DNR/DNI   Chronic Problem List    Acute on chronic respiratory failure with hypoxia  AKI (acute kidney injury)  AMS (altered mental status)  Anxiety  Asthma  Atrial fibrillation  B12 deficiency  Bilateral renal cysts  Change in bowel habit  Chronic back pain  Chronic hypoxemic respiratory failure  Chronic obstructive pulmonary disease  Compression fracture of spine  Compression fracture of thoracic vertebra  Constipation  COPD mixed type  Diverticulosis  Dysphagia  Elevated troponin  Encounter for care related to vascular access port  Encounter for monitoring coumadin therapy  Essential hypertension  Essential hypertension  Failure to thrive in adult  Falling episodes  Fatigue  GERD (gastroesophageal reflux disease)  H/O bilateral breast implants  Hallucination  Health care maintenance  Hiatal hernia  History of lung cancer  History of lung cancer  Hoarseness  Hyperlipidemia  Hypotension  Hypothyroid  Hypoxia  Impaired gait and mobility  Long term use of drug  Low vitamin D level  Lumbar pain  Lumbar stenosis  Lung cancer  Non-small cell carcinoma of lung  Osteoarthritis of left knee  Paroxysmal atrial fibrillation  Paroxysmal atrial fibrillation with rapid ventricular response  Port-A-Cath in place  Sepsis  Sepsis due to pneumonia  Skin rash  Sleep apnea  Stroke-like symptom  Thoracic compression fracture  Procedure/Surgical History  ?Colonoscopy (10/06/2022) ?egd (12/07/2016) ?lft uper lobectomy (2011) ?esophageal manometry w 24 hr ph (01/26/2010) ?appy ?Cataract Extraction ?Cesarean Section ?colonsocopy years ago w toulikian ?Cystoscopy ?foot ?Hysterectomy ?infusaport ?right Knee Replacement ?Tonsillectomy   Surgical History Internal  10/06/2022    Colonscpy Diagnostic/Screen      12/07/2016    EGD Bx      09/01/2015    Lymph Node Excision Biopsy      Medications   Home Medications (24) Active  albuterol (Eqv-ProAir HFA) 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q6H  amiodarone 200 mg oral tablet 200 mg = 1 Tablet, Orally, Daily  apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  calcium (as citrate)-vitamin D3 250 mg-5 mCg (200 intl units) oral tablet 1 Tablet, Orally, BID  cefPODOXime 200 mg oral tablet 200 mg = 1 Tablet, Orally, BID  cholecalciferol (vitamin D3) 125 mCg (5,000 intl units) oral tablet 125 mCg = 1 Tablet, Orally, Daily  CLonazePAM 2 mg oral tablet 2 mg = 1 Tablet, Orally, BID  Daliresp 500 mCg oral tablet 500 mCg = 1 Tablet, Orally, Daily  docusate-senna tablet 50 mg-8.6 mg 1 Tablet, PRN, Orally, BID  doxycycline monohydrate 100 mg oral capsule 100 mg = 1 Capsule, Orally, Q12  Effexor XR 75 mg oral capsule, extended release 75 mg = 1 Capsule, Orally, At Bedtime  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, TID  Florastor 250 mg oral capsule 250 mg = 1 Capsule, Orally, BID  fluticasone 50 mCg/inh nasal spray 50 mCg = 1 Spray, Nostrils, Both, BID  guaifenesin-600 mg oral tablet, extended release 600 mg = 1 Tablet, Orally, BID  ipratropium 0.02% inh soln 500 mCg = 2.5 mL, Neb Inhal, 4 Times Daily, Dx: J44.9  levothyroxine 100 mCg (0.1 mg) oral tablet 100 mCg = 1 Tablet, Orally, Daily, take 1 daily for hypothryoid  metoPROLOL tartrate 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  polyethylene glycol 3350 oral powder for reconstitution , PRN, Orally, Daily  predniSONE 5 mg oral tablet See Instructions, 4 tabs daily for 2 days,3 tabs daily for 2 days,2 tabs daily for 2 days,1 tab daily for 2 days,0.5 tabs daily for 2 days.  traMADOL 50 mg oral tablet 50 mg = 1 Tablet, PRN, Orally, Q12H  Active Scheduled Inpatient Medications  Amiodarone PREMIX + Dextrose 5% in Water PREMIX IV See Comments 0.999 mg/min      One-Time Medications Given 11/18/22 00:00:00 TO 11/19/22 07:02:27  Lactated Ringers (Lactated Ringers - ED Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 11/19/22 04:26:00)  PRN Medications (0600 - 0559) from 11/18 - 11/19  None Reported  Allergies   Advair Diskus (Unknown)  Levaquin (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Home equipment: Oxygen.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Breast cancer: Sister.  Congestive heart failure..: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 14.4 k/cumm High (11/19/22 02:27:00)  RBC: 4.2 million/cumm (11/19/22 02:27:00)  Hgb: 9.6 GM/dL Low (11/19/22 02:27:00)  Hct: 31.6 % Low (11/19/22 02:27:00)  MCV: 75 fL Low (11/19/22 02:27:00)  MCH: 22.8 pg Low (11/19/22 02:27:00)  MCHC: 30.3 GM/dL Low (11/19/22 02:27:00)  RDW: 21.3 % High (11/19/22 02:27:00)  Platelet: 358 k/cumm (11/19/22 02:27:00)  MPV: 8.7 fL (11/19/22 02:27:00)  Neutrophils %: 90 % (11/19/22 02:27:00)  Lymphocytes %: 4 % (11/19/22 02:27:00)  Monocytes %: 6 % (11/19/22 02:27:00)  Eosinophils %: 0 % (11/19/22 02:27:00)  Basophils %: 0 % (11/19/22 02:27:00)  Absolute Neutrophil: 12.9 k/cumm High (11/19/22 02:27:00)  Absolute Lymphocyte: 0.6 k/cumm Low (11/19/22 02:27:00)  Absolute Monocyte: 0.9 k/cumm (11/19/22 02:27:00)  Absolute Eosinophil: 0 k/cumm (11/19/22 02:27:00)  Absolute Basophil: 0 k/cumm (11/19/22 02:27:00)  Chemistry:  Sodium SerPl QN: 147 mmol/L High (11/19/22 02:27:00)  Potassium SerPl QN: 4.1 mmol/L (11/19/22 02:27:00)  Chloride SerPl QN: 109 mmol/L High (11/19/22 02:27:00)  Carbon Dioxide SerPl QN: 25 mmol/L (11/19/22 02:27:00)  Anion Gap: 13 mmol/L High (11/19/22 02:27:00)  BUN SerPl QN: 18 mg/dL (11/19/22 02:27:00)  Creatinine SerPl QN: 0.92 mg/dL (11/19/22 02:27:00)  Estimated GFR (CKD-EPI, no race): 60 mL/min/1.73m2 (11/19/22 02:27:00)  Estimated CRCL (CG): 47 mL/min Low (11/19/22 02:27:00)  Glucose SerPl QN: 108 mg/dL High (11/19/22 02:27:00)  Calcium Total SerPl QN: 8.6 mg/dL (11/19/22 02:27:00)  Magnesium SerPl QN: 1.8 mg/dL (11/19/22 02:27:00)  Troponin-I High Sensitivity: 16 ng/L High (11/19/22 03:41:00)  BNP Pl QN: 320 pg/mL High (11/19/22 03:41:00)  Lactate Venous Pl QN: 1.8 mmol/L (11/19/22 05:47:00)  Gluc-Strip, POC: 155 mg/dL High (11/18/22 16:15:00)  Urine Studies:  Color: Yellow (11/19/22 02:33:00)  Clarity: Clear (11/19/22 02:33:00)  Specific Gravity: 1.020 (11/19/22 02:33:00)  pH: 6.0 (11/19/22 02:33:00)  Protein: NEGATIVE (11/19/22 02:33:00)  Glucose: NEGATIVE (11/19/22 02:33:00)  Ketones: TRACE. Abnormal (11/19/22 02:33:00)  Bilirubin: NEGATIVE (11/19/22 02:33:00)  Hgb Ur: NEGATIVE (11/19/22 02:33:00)  Nitrite: NEGATIVE (11/19/22 02:33:00)  Urobilinogen: NormalUro (11/19/22 02:33:00)  Leukocyte Esterase Ur: NEGATIVE (11/19/22 02:33:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/19/22 02:27:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (11/19/22 02:27:00)  Micro - Last 7 days  L pneumo Urine Ag QL: Not Detected (11/14/22 21:23:00)  L pneumo Urine Ag QL Interp: L pneumo Urine Ag QL Interp (11/14/22 21:23:00)  Strep pneumo Ag Ur: GeneXpert NOT DETECTED (11/14/22 21:23:00)  Strep pneumo Ag Ur Interp: GeneXpert 46 (11/14/22 21:23:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/19/2022 02:45 - XR Chest PA or AP Portable  IMPRESSION:1. Limited study without significant interval change. Thank you for consulting with Radiology.  For HealthcareProviders, if you would like to discuss this case further, pleasecontact the Radiology department.                Signature Line Electronically Signed on 11/19/22 07:54 ________________________________________________________