Age: 85.0
Sex: F
Vaccine: FLU4
Symptoms: Malaise, Mean cell haemoglobin concentration normal, Mean cell haemoglobin decreased, Mean cell volume normal, Mean platelet volume normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 26, 2023 00:45   Verified By: MD on November 26, 2023 00:45   Encounter Info: Hospital, Emergency, 11/25/23 - 11/26/23    * Final Report *        Chief Complaint   Weakness, chills  History of Present Illness/Subjective     This is an 85-year-old female with past medical history of stage III chronic kidney disease, insulin-dependent diabetes with peripheral neuropathy, hypothyroidism, hypertension, here yesterday following a fall.  The patient states that she has been weak and malaise with shaking chills over the past few days, had an accidental fall yesterday in which she presented to the emergency department with a negative workup.  She returns today with worsening shaking chills and malaise, workup to date is demonstrating findings suggestive of cystitis and pyelitis/pyelonephritis, with some gas in the urinary bladder, could not exclude emphysematous pyelonephritis.  Urology was consulted and the recommendation per Dr was temporary bladder decompression with catheter with appropriate antibiotic coverage.  No interventional or surgical recommendations, no indication for transfer.    White blood cell count is normal with increased absolute neutrophil count.  INR normal.  Creatinine 1.47 with a BUN of 34, sodium 125, chloride 91, anion gap 15, serum bicarbonate 19, serum lactate elevated at 3.2, however, repeat was 1.1.  Troponin 23, 35 on repeat, no chest pain.  AST is 45 otherwise LFTs are normal.   Urine showing pyuria, negative for bacteria, glucosuria noted, trace ketosis.  COVID-19 negative, influenza negative.  Blood glucose nearly 400.  The patient has been persistently tachycardic with heart rate around 120s, respiratory rate in the high 20s to 30s although no hypoxia, no complaint of shortness of breath or cough, chest x-ray is clear.  VBG 7.45 with a pCO2 of 30, respiratory compensation with hyperventilation in response to metabolic acidosis, pH normal.     Review of Systems     Complains of shaking chills, fever, bilateral flank pain, malaise, denies syncope, denies chest pain.  Denies shortness of air or cough.  Denies urinary frequency or dysuria.  Remaining 10 point review of systems negative except as noted above.  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 38.7 °C (Axillary)  TMIN: 36.5 °C (Oral)  TMAX: 38.7 °C (Axillary)  BP: 138/70  HR: 120 (Monitored)  HR: 119 (Peripheral)  RR: 26  SpO2: 92%  Oxygen Therapy: Room air  WT: 74.90 kg (WFC)    Hemodynamics   Neurologic   Patient Weight  Current Daily Weight:    74.9 kg    11/25/23    Patient Height  Current Height:    167.9 cm    11/25/23         Constitutional:  No acute distress,  well-nourished, nontoxic Eyes:  PERRLA, normal conjunctiva ENMT: Oral mucosa very dry Neck:  Supple, no JVD Respiratory:  Lungs CTAB Cardiovascular: Regular rhythm, tachycardia Gastrointestinal:  Soft, non-tender, non-distended, nontender. Musculoskeletal:  No joint swelling, does have mild bilateral CVA tenderness to palpation Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Acute pyelonephritis   N10   Given clinical and radiographic findings of bilateral pyelonephritis, critical illness with sepsis and possibly severe sepsis given acute kidney injury, and possible emphysematous pyelonephritis, will cover broadly per recommendations including empiric ESBL coverage as well as Pseudomonas coverage.  Meropenem 1 g every 8 hours in addition to vancomycin.  Follow urine cultures and procalcitonin to guide antibiotic de-escalation.   2. Sepsis   A41.9   Present on admission, fever, tachycardia, tachypnea, elevated serum lactate.  On repeat examination, capillary refill and tissue perfusion intact although there has been a 40 point drop in systolic blood pressure since the time the patient initially presented concerning for worsening sepsis.  Will place in ICU for close hemodynamic monitoring and hemodynamic support if needed.  Follow urine and blood cultures.  Broad-spectrum antibiotic coverage.  Follow procalcitonin levels as well.   3. Acute kidney injury   N17.9   Likely prerenal, will check urine sodium and creatinine, fractional excretion of sodium, avoid nephrotoxic agents, renal dosing of medications.  Hold ACE inhibitor, no IV contrast.   4. Acute hyponatremia   E87.1  The patient has chronic hyponatremia, tends to run around 130.  Blood sugar is 400, corrected sodium closer to 130 at this time.  Will check thyroid function, correct hyperglycemia, gently hydrate and repeat in the morning   5. CKD stage 3 due to type 2 diabetes mellitus   E11.22   Noted   6. Essential hypertension   I10   Hold antihypertensives until hemodynamic stability is assured and then reimplement and titrate as needed   7. Depression with anxiety   F41.8   Mood appropriate, does not appear to be on home medication for this.   8. Hypothyroidism   E03.9   Check thyroid function and continue levothyroxine   9. Insulin dependent type 2 diabetes mellitus   E11.9   Hold metformin, continue basal insulin at 10 units with sliding scale prandial coverage, A1c, Accu-Cheks   10. Vitamin B 12 deficiency   E53.8   Continue supplementation   Full code   Heparin for DVT prophylaxis  Code Status   None Recorded   Chronic Problem List    Allergic rhinitis  Bilateral hip pain  Chronic kidney disease stage 3 (disorder)  CKD stage 3 due to type 2 diabetes mellitus  Depression with anxiety  Diabetic peripheral neuropathy  Double vision  Encounter for long-term (current) use of medications  Essential hypertension  Heart murmur  Hypercalcemia  Hyperlipidemia  Hyponatremia  Hypothyroidism  Insomnia  Insulin dependent type 2 diabetes mellitus  Iron deficiency  Polyneuropathy due to type 2 diabetes mellitus (disorder)  Vitamin B 12 deficiency  Procedure/Surgical History  ?Diabetic retinal eye exam (11/10/2022) ?Colonoscopy (01/01/2013) ?Bladder Surgery ?Cesarean delivery ?Hysterectomy     Medications   Home Medications (26) Active  amLODIPine 10 mg oral tablet See Instructions, TAKE 1 TABLET EVERY DAY  aspirin 81 mg oral tablet, chewable 81 mg, Orally, Daily  Basaglar (insulin glargine) KwikPen 100 units/mL subcutaneous solution 10 Units, Subcutaneous, Daily, Use up to a total of 20 units daily, SEE INSTRUCTIONS FROM YOUR PROVIDER  BD Single Use Swab 70% topical pad See Instructions, to cleanse area once to twice daily when testing blood sugars  BD Ultra-Fine Nano (4mm x 32G) Pen Needle Use 1 per day, Subcutaneous, Daily, Use to inject Victoza once daily  Blood Glucose Meter See Instructions, to test blood sugar once daily  Blood Glucose Test Strips See Instructions, to test blood sugars once daily  Clora Calcium , Orally, Daily  Coenzyme Q10 100 mg oral capsule 100 mg = 1 Capsule, Orally, Daily  DROPLET PEN NEEDLES 32GX4MM 32G X 4 MM See Instructions, USE  TO INJECT  VICTOZA SUBCUTANEOUSLY ONE TIME DAILY  ferrous sulfate 325 mg (65 mg elemental iron) oral delayed release tablet 325 mg = 1 Tablet, Orally, TID, may take with food to minimize abdominal discomfort, avoid dairy products.  FreeStyle Libre Glucose Reader Not Applicable, Other, Unscheduled  FreeStyle Libre Sensors Use As Directed, Other, Unscheduled  gabapentin 300 mg oral capsule 300 mg = 1 Capsule, Orally, Daily  hydroCODONE-acetaminophen 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q6H, not to exceed 8 tablets/day  Lancets See Instructions, to test blood sugars once daily  levothyroxine 112 mCg (0.112 mg) oral tablet 112 mCg = 1 Tablet, Orally, Daily  lisinopril 40 mg oral tablet See Instructions, TAKE 1 TABLET EVERY DAY  lovastatin 40 mg oral tablet See Instructions, TAKE 1 TABLET EVERY DAY  metFORMIN 500 mg oral tablet See Instructions, TAKE 2 TABLETS TWICE DAILY  Misc Supplement , barefoot coral calcium complete with Vitamin D  Potassium , Orally, Daily, Take one tablet (99 mg) by mouth daily.  traZODONE 50 mg oral tablet See Instructions, TAKE 1 TABLET AT BEDTIME  Trulicity Pen 0.75 mg/0.5 mL subcutaneous solution 0.75 mg, Subcutaneous, Every Week  Tylenol Extra Strength 500 mg, Orally, BID  venlafaxine 75 mg oral capsule, extended release See Instructions, TAKE 1 CAPSULE EVERY DAY  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 11/25/23 00:00:00 TO 11/26/23 00:45:43  acetaminophen, Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 11/25/23 23:14:00)  ceftRIAXone, Injection, 2 GM, IV Push, ONCE, (1 DOSE 11/25/23 21:00:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 11/25/23 19:49:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 11/25/23 21:48:00)  PRN Medications (0600 - 0559) from 11/25 - 11/26  None Reported  Allergies   Mushrooms  Wygesic (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Work/School description: IU ticket office. Keeps busy with handiwork (crochet)..   Home/Environment   Pt. lives with spouse, Home equipment: Walker/Cane, Partial upper denture.   Nutrition/Health   Type of diet: Pt. eats two to three meals daily. Caffeine intake amount: half caf coffee - 2 cups daily.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Diabetes mellitus type 1: Mother.  Heart disease..: Mother.  High blood pressure..: Mother.  Stroke: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.7 k/cumm (11/25/23 19:28:00)  RBC: 4.36 million/cumm (11/25/23 19:28:00)  Hgb: 11.4 GM/dL Low (11/25/23 19:28:00)  Hct: 35 % (11/25/23 19:28:00)  MCV: 80 fL Low (11/25/23 19:28:00)  MCH: 26.1 pg Low (11/25/23 19:28:00)  MCHC: 32.5 GM/dL (11/25/23 19:28:00)  RDW: 14.1 % (11/25/23 19:28:00)  Platelet: 232 k/cumm (11/25/23 19:28:00)  MPV: 8.1 fL (11/25/23 19:28:00)  Neutrophils %: 91 % (11/25/23 19:28:00)  Lymphocytes %: 5 % (11/25/23 19:28:00)  Monocytes %: 3 % (11/25/23 19:28:00)  Eosinophils %: 0 % (11/25/23 19:28:00)  Basophils %: 0 % (11/25/23 19:28:00)  Absolute Neutrophil: 8.8 k/cumm High (11/25/23 19:28:00)  Absolute Lymphocyte: 0.5 k/cumm Low (11/25/23 19:28:00)  Absolute Monocyte: 0.3 k/cumm (11/25/23 19:28:00)  Absolute Eosinophil: 0 k/cumm (11/25/23 19:28:00)  Absolute Basophil: 0 k/cumm (11/25/23 19:28:00)  Chemistry:  Sodium SerPl QN: 125 mmol/L Low (11/25/23 19:28:00)  Potassium SerPl QN: 4.1 mmol/L (11/25/23 19:28:00)  Chloride SerPl QN: 91 mmol/L Low (11/25/23 19:28:00)  Carbon Dioxide SerPl QN: 19 mmol/L Low (11/25/23 19:28:00)  Anion Gap: 15 mmol/L High (11/25/23 19:28:00)  BUN SerPl QN: 34 mg/dL High (11/25/23 19:28:00)  Creatinine SerPl QN: 1.47 mg/dL High (11/25/23 19:28:00)  Estimated GFR (CKD-EPI, no race): 35 mL/min/1.73m2 Low (11/25/23 19:28:00)  Estimated CRCL (CG): 29 mL/min Low (11/25/23 19:28:00)  Glucose SerPl QN: 395 mg/dL High (11/25/23 19:28:00)  Calcium Total SerPl QN: 9.3 mg/dL (11/25/23 19:28:00)  Alkaline Phos SerPl QN: 84 Units/L (11/25/23 19:28:00)  ALT SerPl QN: 26 Units/L (11/25/23 19:28:00)  AST SerPl QN: 45 Units/L High (11/25/23 19:28:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (11/25/23 19:28:00)  Total Protein SerPl QN: 7.5 GM/dL (11/25/23 19:28:00)  Albumin SerPl QN: 4.1 GM/dL (11/25/23 19:28:00)  Lipase SerPl QN: 41 Units/L (11/25/23 19:28:00)  Troponin-I High Sensitivity: 35 ng/L High (11/25/23 21:46:00)  Ketones SerPl QN: Negative (11/25/23 19:28:00)  Lactate Venous Pl QN: 1.1 mmol/L (11/25/23 22:55:00)  Blood Gas Comment: venous (11/25/23 19:27:00)  pH Bld Venous QN: 7.45 (11/25/23 19:27:00)  PCO2 Bld Venous QN: 30 mmHg Low (11/25/23 19:27:00)  PO2 Bld Venous QN: 42 mmHg (11/25/23 19:27:00)  Base Excess Bld Venous: -2 mmol/L (11/25/23 19:27:00)  Bicarb Bld Venous Calc: 21 mmol/L Low (11/25/23 19:27:00)  O2 Sat Bld Venous Calc: 80 % (11/25/23 19:27:00)  Patient Temperature: 37 DegC (11/25/23 19:27:00)  TSH 3rd Gen SerPl QN: 0.968 mcU/mL (11/25/23 20:48:00)  Coagulation:  PT: 11.8 seconds (11/25/23 19:28:00)  INR: 1.04 (11/25/23 19:28:00)  Urine Studies:  Color: Yellow (11/25/23 20:58:00)  Clarity: Slightly Cloudy (11/25/23 20:58:00)  Specific Gravity: 1.014 (11/25/23 20:58:00)  pH: 7 (11/25/23 20:58:00)  Protein: 100 Abnormal (11/25/23 20:58:00)  Glucose: 1000 Abnormal (11/25/23 20:58:00)  Ketones: TRACE. Abnormal (11/25/23 20:58:00)  Bilirubin: NEGATIVE (11/25/23 20:58:00)  Hgb Ur: Mod 2+ Abnormal (11/25/23 20:58:00)  Nitrite: NEGATIVE (11/25/23 20:58:00)  Urobilinogen: Normal (11/25/23 20:58:00)  Leukocyte Esterase Ur: Large500 Abnormal (11/25/23 20:58:00)  WBC: 21-50 Abnormal (11/25/23 20:58:00)  RBC: 21-50 Abnormal (11/25/23 20:58:00)  Bacteria: NONE (11/25/23 20:58:00)  Squamous Epithelial: Few (11/25/23 20:58:00)  Mucous: PRESENT. (11/25/23 20:58:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/25/23 20:48:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/25/23 20:48:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (11/25/23 20:48:00)  Rapid Influenza A PCR: Not Detected (11/25/23 20:48:00)  Rapid Influenza B PCR: Not Detected (11/25/23 20:48:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/25/2023 21:48 - XR Chest PA or AP Portable  IMPRESSION:1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists at Physicians Radiology. Please contact us with any questions.    11/25/2023 21:51 - CT Head W/o IV Contrast  IMPRESSION: 1.  No acute CT abnormality of the head. No acute intracranialhemorrhage or hydrocephalus.2.  Findings raising question for normal pressure hydrocephalus forwhich clinical correlation is recommended.-Thank you for consulting our team of subspecialty radiologists at  Physicians Radiology. Please contact us with any questions.    11/25/2023 21:52 - CT Abd/Pelvis W/O IV Contrast  IMPRESSION:1.  Bladder wall appears somewhat thickened for degree of distention.Correlate for cystitis. There is nonspecific perinephric stranding.Ascending urinary tract infection is not excludable on imaging. Noevidence of ureteral stone or obstruction.2.  Gas in the urinary bladder. This could be a normal finding ifthere has been recent catheterization or instrumentation. Otherwiseintraluminal gas can be sign of infection with gas producingorganisms or fistula.3.  Colonic diverticulosis without evidence of acute diverticulitis.4.  Atherosclerosis including coronary artery disease.Thank you for consulting our team of subspecialty radiologists at  Physicians Radiology. Please contact us with any questions.    11/25/2023 21:57 - CT Cervical Spine W/o IV Contrast  IMPRESSION: 1.  No acute findings of the cervical spine.2.  A 5 mm RIGHT upper lobe lung nodule. If patient has risk factorsfor lung cancer, consider 12 month follow-up chest CT withoutcontrast. If low risk no specific follow-up is needed. Thank you for consulting our team of subspecialty radiologists at Physicians Radiology. Please contact us  with any questions.                Signature Line Electronically Signed on 11/26/23 00:45 ________________________________________________________ MD