Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Red blood cell count decreased, Red cell distribution width increased, Scalp haematoma, Scan with contrast abnormal, Sepsis
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Performed By: MD on October 10, 2024 11:32  Verified By: MD on October 10, 2024 11:32  Encounter Info: Hospital, Inpatient, 10/09/24 -     * Final Report *        Subjective     This note was dictated using Dictation. If any errors with dictation, please contact me via diagnotes for clarification.   f/u intussusception, strangulated hernia, colonic obstruction   Surgery following   Nothing acute overnight.  Vitals are stable overnight.  Leukocytosis still present but improved to 17,300.  H&H slightly lower this morning, will monitor.  Hyponatremia, mild, stable.  Potassium elevated at 5.7, slightly hemolyzed.  Will get a repeat stat potassium at this time (8:42 AM.  Creatinine continues to trend downwards, 1.44, monitor.  Mild AST elevation, monitor LFTs.   Seen this morning. Denied CP, SOB, abd pain, n/v/c/d. Nursing reports she had multiple BM's this morning. Holding off on operative intervention per my discussion w/ surgery. KUB pending. Repeat K is 5.3.   Review of Systems     per HPI???????  Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 36.7 °C (Axillary)  BP: 142/78  HR: 63 (Monitored)  RR: 20  SpO2: 94%  Oxygen Therapy: Room air  Oxygen Flow Rate: 2 (L/min)    Hemodynamics  Left Ventricular Ejection Fraction: 61.2569  Neurologic  Glasgow Coma Score: 14  Patient Weight  Current Daily Weight:    79.0 kg    10/09/24  Previous Daily Weight:    79.0 kg    10/09/24  BMI:    32.9    10/09/24    Obese (BMI 30-39.9) Patient Height  Current Height:    154.9 cm    10/09/24      Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 10/09 - 10/10  Total Intake 556.15 mL    Total Output 0.00 mL     Balance 556.15 mL     Physical Exam     Awake, did not want to answer orientation questions but seemed to answer my questions appropriately otherwise.   NAD.   HR regular  Abd nontender, BS present  No acute edema  Nonlabroed respirations and lungs overall clear  Assessment/Plan       1. Colonic obstruction   K56.609    2. Hernia with strangulation   K46.0    3. Intussusception of colon   K56.1  Problems 1-3:   Surgery consulted  KUB 10/10/24: pending  Holding off on operative intervention today -- made her NPO at midnight though.   Reportedly had BM's this morning per RN -- monitor.     (10/08/2024 22:07 CT Abd/Pelvis W/IV Contrast) IMPRESSION: 1. Ventral wall hernia containing a short segment of the transverse colon with transition point present where colon enters the hernia sac. The upstream colon is abnormally dilated to 9.2 cm. Downstream colon is completely decompressed. Findings worrisome for high-grade colonic obstruction. There is some fluid in the hernia sac, also raising concern for strangulation. 2. Other chronic and incidental findings as above. [1]   4. Leukocytosis   D72.829    5. Sepsis   A41.9  Problems 4-5:  Sepsis criteria met on admission - may be related to underlying UTI vs problems listed above.   C/w Zosyn  Blood culture 10/8/2024: Pending  Urine culture 10/8/2024: Pending   6. AKI (acute kidney injury)   N17.9    7. CKD (chronic kidney disease)   N18.9  Problem 6-7:  Creatinine is trending downwards, monitor   8. DM type 2 (diabetes mellitus, type 2)   E11.9  Hemoglobin A1C HPLC Bld QN: 7.4 % High (02/27/24 15:04:00)  Hemoglobin A1C HPLC Bld QN: 7 % High (05/31/23 13:26:00)  HbA1c, POC: 6.8 % High (08/12/24 14:16:00)  HbA1c, POC: 6.5 % High (08/23/23 14:37:00)  CDA   9. Dehydration   E86.0   NS 125/h   10. Hyponatremia   E87.1   The patient presents with a fluid and electrolyte imbalance including hypoNa.  Continue to trend serial analysis as appropriate with replenishment of fluid and electrolyte imbalance as required for stabilization.   11. Hypothyroidism   E03.9  TSH Last 3 TSH 3rd Gen SerPl QN: 1.739 mcU/mL (10/08/24)  TSH 3rd Gen SerPl QN: 4.964 mcU/mL High (02/27/24)  TSH 3rd Gen SerPl QN: 4.995 mcU/mL High (05/31/23)  C/w current management   12. Essential hypertension   I10  Titrate antihypertensives accordingly    13. Hyperlipidemia   E78.5   C/w current management???????   14. NPH (normal pressure hydrocephalus)   G91.2  Noted  (10/08/2024 21:51 CT Head W/o IV Contrast) IMPRESSION: 1. Left parietal scalp contusion and hematoma. 2. No acute intracranial abnormality. 3. Right frontal approach ventricular shunt catheter with tip terminating near the foramen of Munro. Similar size of the ventricular system when compared to prior CT cervical spine. 4. Negative for acute fracture or traumatic subluxation. [2]   15. UTI (urinary tract infection)   N39.0  C/w Zosyn    16. Elevated troponin   R79.89  Troponin curve flat  Echo reviewed  Telemetry  No chest pain    17. Fall   V00.388A  PT/OT   CT head reviewed (see above)  CT abd/pelvis reviewed (see above)  (10/08/2024 21:51 CT Cervical Spine W/o IV Contrast) IMPRESSION: 1. Left parietal scalp contusion and hematoma. 2. No acute intracranial abnormality. 3. Right frontal approach ventricular shunt catheter with tip terminating near the foramen of Munro. Similar size of the ventricular system when compared to prior CT cervical spine. 4. Negative for acute fracture or traumatic subluxation [3]  (10/08/2024 22:06 CT Chest W/ IV Contrast) IMPRESSION: 1. No acute findings in the chest. [4]   18. Weakness   R53.1  PT/OT   19. Elevated brain natriuretic peptide (BNP) level   R79.89  Does not appear to be acutely volume overloaded. Echo reviewed. Will monitor.    Echo 10/9/24: 1. Left ventricular systolic function is normal with an ejection fraction by 4 Chamber Method of Disc of 61 %.  2. Left ventricular chamber dimension is normal.  3. Left ventricular segmental wall motion is normal.  4. Normal left ventricular wall thickness.  5. There is mild aortic valve stenosis with a peak velocity of 2.05 m/s, mean gradient of 9 mmHg, DVI 0.52, and aortic valve area  of 1.6 cm2.  6. There is mild aortic valve regurgitation.  7. There is trace tricuspid valve regurgitation.   20. Hyperkalemia   E87.5  Repeat K this morning 5.3 -- monitor.    DVT ppx: SCD  Code: DNR/DNI/Comprehensive   Dispo:   ???????Labs reviewed  Imaging reviewed  Echo reviewed  Cultures pending  Discussed with surgery  Starting IV fluids  CLD, NPO at midnight  KUB: pending  Continue with hospital management of multiple problems listed above which can pose a threat to life/bodily function  ???????   Orders:   piperacillin-tazobactam, 3.375 GM, IVPB, Injection, Q8H, Reason for Use: Sepsis (Update Indication in 36-48 hrs), 10/09/24 13:00:00, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV Continuous, 10/10/24 8:49:00, 125 mL/hr, Clinical Weight  Clear Liquid Diet  NPO  Potassium SerPl QN   Code Status  Resuscitation Status - Ordered    -- 10/09/24 10:10:00, Full Code  Resuscitation Status - Ordered    -- 10/09/24 14:45:00, DNR/DNI/Comprehensive Care   Medications   Active Scheduled Inpatient Medications  amLODIPine, Tablet, 5 mg, Orally, Daily, Start: 10/10/24 09:00:00  atorvastatin, Tablet, 40 mg, Orally, At Bedtime, Start: 10/09/24 21:00:00  busPIRone, Tablet, 30 mg, Orally, BID, Start: 10/09/24 21:00:00  DULOXetine, Cap, Delayed Rel, 30 mg, Orally, Daily, Start: 10/10/24 09:00:00  levothyroxine, Tablet, 75 mCg, Orally, Daily, Start: 10/10/24 06:00:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 10/10/24 09:00:00  Zosyn, Injection, 3.375 GM, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 10/09/24 13:00:00  traZODONE, Tablet, 50 mg, Orally, At Bedtime, Start: 10/09/24 21:00:00  Dextrose 10% in Water  500 mL IV Continuous  Per Core Diabetes App - See Comments     Sodium Chloride 0.9%  1,000 mL IV Continuous  125 mL/hr       One-Time Medications Given 10/09/24 00:00:00 TO 10/10/24 11:31:51  influenza virus vaccine, inactivated (influenza virus vaccine, inactivated trivalent IM suspension), Injection, 0.5 mL, IM, ONCE, Ordered NOT yet given  PRN Medications (0600 - 0559) from 10/09 - 10/10  ALprazoLAM, 0.5 mg, Orally, BID, 0  Dose(s)   acetaminophen, 650 mg, Rectally, Q4H, 0  Dose(s)   glucagon, 0.5 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Core Diabetes App , IV Push, Unscheduled, 0  Dose(s)   haloperidol, 2 mg, IV Push, Q6H, 1  Dose(s)   insulin lispro, Per Core Diabetes App , Subcutaneous, Unscheduled, 0  Dose(s)   promethazine, 12.5 mg, IVPB, Q6H, 0  Dose(s)   tiZANidine, 2 mg, Orally, Q8H, 0  Dose(s)   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 17.3 k/cumm High (10/10/24 03:07:00)  RBC: 3.05 million/cumm Low (10/10/24 03:07:00)  Hgb: 9.6 GM/dL Low (10/10/24 03:07:00)  Hct: 29.2 % Low (10/10/24 03:07:00)  MCV: 96 fL (10/10/24 03:07:00)  MCH: 31.6 pg (10/10/24 03:07:00)  MCHC: 33 GM/dL (10/10/24 03:07:00)  RDW: 16.4 % High (10/10/24 03:07:00)  Platelet: 329 k/cumm (10/10/24 03:07:00)  MPV: 10 fL (10/10/24 03:07:00)  Neutrophils %: 85 % (10/10/24 03:07:00)  Lymphocytes %: 9 % (10/10/24 03:07:00)  Monocytes %: 5 % (10/10/24 03:07:00)  Eosinophils %: 0 % (10/10/24 03:07:00)  Basophils %: 1 % (10/10/24 03:07:00)  Absolute Neutrophil: 14.7 k/cumm High (10/10/24 03:07:00)  Absolute Lymphocyte: 1.6 k/cumm (10/10/24 03:07:00)  Absolute Monocyte: 0.8 k/cumm (10/10/24 03:07:00)  Absolute Eosinophil: 0 k/cumm (10/10/24 03:07:00)  Absolute Basophil: 0.2 k/cumm (10/10/24 03:07:00)  Chemistry:  Sodium SerPl QN: 131 mmol/L Low (10/10/24 03:07:00)  Potassium SerPl QN: 5.3 mmol/L (10/10/24 10:01:00)  Chloride SerPl QN: 102 mmol/L (10/10/24 03:07:00)  Carbon Dioxide SerPl QN: 21 mmol/L Low (10/10/24 03:07:00)  Anion Gap: 8 mmol/L (10/10/24 03:07:00)  BUN SerPl QN: 18 mg/dL (10/10/24 03:07:00)  Creatinine SerPl QN: 1.44 mg/dL High (10/10/24 03:07:00)  Estimated GFR (CKD-EPI, no race): 36 mL/min/1.73m2 Low (10/10/24 03:07:00)  Estimated CRCL (CG): 27 mL/min Low (10/10/24 03:07:00)  Glucose SerPl QN: 69 mg/dL Low (10/10/24 03:07:00)  Calcium Total SerPl QN: 8.2 mg/dL Low (10/10/24 03:07:00)  Alkaline Phos SerPl QN: 107 Units/L (10/10/24 03:07:00)  ALT SerPl QN: 20 Units/L (10/10/24 03:07:00)  AST SerPl QN: 44 Units/L High (10/10/24 03:07:00)  Bilirubin Total SerPl QN: 0.7 mg/dL (10/10/24 03:07:00)  Total Protein SerPl QN: 6.2 GM/dL Low (10/10/24 03:07:00)  Albumin SerPl QN: 3.1 GM/dL Low (10/10/24 03:07:00)  Troponin-I High Sensitivity: 23 ng/L High (10/09/24 15:20:00)  BNP Pl QN: 772 pg/mL High (10/09/24 15:20:00)  Gluc-Strip, POC: 165 mg/dL High (10/10/24 11:21:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.            [1] CT Abd/Pelvis W/IV Contrast; MD 10/08/2024 22:07  [2] CT Head W/o IV Contrast; MD 10/08/2024 21:51  [3] CT Cervical Spine W/o IV Contrast; MD 10/08/2024 21:51  [4] CT Chest W/ IV Contrast; MD 10/08/2024 22:06   Signature Line Electronically Signed on 10/10/24 11:32  ________________________________________________________ MD