Age: 74.0
Sex: M
Vaccine: COVID19
Symptoms: Cardiac murmur, Coagulation test, Cognitive disorder, Computerised tomogram head normal, Computerised tomogram spine
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on February 12, 2023 06:19    Verified By: DO on February 12, 2023 06:19    Encounter Info: Hospital, Inpatient, 02/12/23 -     * Final Report *        Chief Complaint   confusion  History of Present Illness/Subjective     This is a 76-year-old man with a history of advanced dementia, non-Hodgkin's lymphoma, CKD stage III, hypertension, hyperlipidemia, pancytopenia, obstructive sleep apnea, Walden Strom macroglobulinemia, who presented to ED complaining of confusion with hallucinations that began yesterday according to his family family states that patient fell yesterday evening while in the bathroom he was found down for an unknown period of time.  The patient's daughter who is at bedside reports that he tested positive for COVID the week after Christmas and again tested +6 days prior to presentation.  She states that since his bout with COVID he has been confused and had difficulty ambulating due to feeling unsteady.  She also states that because of how much he was coughing he has not been wearing his CPAP the past week.  She also notes that he takes aspirin but no other blood thinners and the other reason he has not been wearing his CPAP is because he has been having frequent nosebleeds this past week.   CTA chest performed in the ED demonstrated multifocal pneumonia but no PE.  Patient is resting comfortably and was sleeping prior to interview while using his CPAP.   The plan was discussed with the daughter at bedside all questions were answered.  I confirmed his CODE STATUS is DNR/DNI comprehensive care.  Review of Systems     unable to assess due to dementia  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 143/68 (143-143)/(68-68), HR 96 (77-96), RR 16 (16-16), O2Sat 98 (98-98)     Patient Weight  Current Daily Weight:    72.5 kg    02/12/23  BMI:    25.1    02/12/23    Overweight (BMI 25-29.9) Patient Height        Constitutional:  No acute distress,  well-nourished Eyes:  PERRL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs with scattered crackles worse in bases b/l, no resp distress, using cpap Cardiovascular:  Regular rate and rhythm, + murmur Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Mild cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  Assessment/Plan       1. Dementia   F03.90  Confusion is likely exacerbated by hypoxia and primarily possible dementia.  Continue home meds   2. Multifocal pneumonia   J18.9  Likely result of superimposed bacterial pneumonia after COVID infection  Continue CAP coverage patient is not septic at time of presentation will cover with Rocephin Doxy considering QTc is prolonged  Respiratory assessment, SVNs as needed, supplemental O2 as needed  Patient has had COVID for approximately 6 weeks now, it is beyond the stage in which steroids would benefit to reduce inflammation in the lungs or remdesivir would help, therefore we will not start these therapies and will only utilize antibiotics and SVNs   3. Elevated troponin   R77.8  Cardiology reviewed the case while patient is in ED did not recommend initiating anticoagulation  Continue to trend troponin until it is reached peak, serial EKGs  Patient is a poor historian but denies any chest pain  Likely secondary to demand ischemia   4. CKD (chronic kidney disease), stage III   N18.30  Noted.  Avoid nephrotoxic medications monitor renal function   5. Hypertension   I10  Continue home meds goal SBP 100-140 while inpatient   6. Hyperlipidemia   E78.5  Continue home meds   7. Sleep apnea, obstructive   G47.33  CPAP at night   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/12/23 6:07:00   ceftRIAXone, 1 GM, IVPB, Injection, Q24H, Indication: Pneumonia - CAP, 02/13/23 7:00:00, for 4 Doses, 02/16/23 7:00:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  ceftRIAXone, 1 GM, IVPB, Injection, ONCE, Indication: Pneumonia - CAP, NOW, 02/12/23 6:07:00, 02/12/23 6:0 7:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  docusate, 100 mg, Orally, Capsule, BID, 02/12/23 9:00:00   doxycycline, 100 mg, Orally, Tablet, Q12H, Indication: Pneumonia - CAP, 02/12/23 19:00:00, for 9 Doses, 02/16/23 19:00:00   enoxaparin, 40 mg, Subcutaneous, Injection, Q24H, Routine, 02/12/23 7:00:00   Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 02/12/23 6:07:00, 100 mL/hr, Clinical Weight  Admit to Inpatient   Basic Metabolic Panel  Bladder Scan  BNP Pl QN  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  CBC w/Differential  CK SerPl QN  CK SerPl QN  Comp Metabolic Panel  Continuous Oxygen Saturation  CRP SerPl QN  CRP SerPl QN  D-Dimer Pl QN  D-Dimer Pl QN  Dysphagia Screen by RN  Echocardiogram with Cardiac Doppler PW/CW/Color  Fall Precautions  Ferritin SerPl QN  Ferritin SerPl QN  Fibrinogen  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Oxygen Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  LDH SerPl QN  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Magnesium SerPl QN  Medical Service  No NSAIDS (includes COX-2 Inhibitors)  NPO Advance as Tolerated  Phosphorus SerPl QN  Procalcitonin  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Strep pneumoniae Ag Urine  Telemetry Class III 24hr Recommendation  Troponin-I High Sensitivity  Troponin-I High Sensitivity  Urinalysis  Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 02/12/23 6:07:00, DNR/DNI/Comprehensive Care   Chronic Problem List    Anemia  B-cell lymphoma  Back pain  Bradycardia  Chronic maxillary sinusitis  CKD (chronic kidney disease), stage III  CNS lymphoma  Cough  Depression  Fatigue  History of nasal septoplasty  Hyperlipidemia  Hypertension  Idiopathic neuropathy  Memory loss  Mixed bipolar affective disorder, mild (disorder)  Neuropathy  Non congenital macroglossia  Onychogryphosis  Onychomycosis  Pancytopenia  Prostate neoplasm  Sleep apnea, obstructive  Tobacco use  Waldenstrom macroglobulinemia  Procedure/Surgical History  oEGD (03/04/2021) oColonoscopy (10/28/2020) oColonoscopy (02/21/2017) oUltrasound scan of carotid (10/23/2007) ofx L arm repair ofx nose repair oNasal surgery oProstatectomy oSkin CA removed from head oT & A   Surgical History Internal  03/04/2021    EGD Bx    MD  10/28/2020    Colonscpy Snare Tmr Polyp Lsn    MD  01/30/2007    Prostatectomy DaVinci    MD  Medications   Home Medications (25) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  albuterol 2.5 mg/0.5mL (0.5%) inhalation solution 2.5 mg = 0.5 mL, Neb Inhal, Q8H  amLODIPine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Aspirin Low Strength 81 mg oral delayed release tablet 81 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet See Instructions, TAKE 1 TABLET BY MOUTH EVERY NIGHT AT BEDTIME  citalopram 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  CLonazePAM 1 mg oral tablet 1 mg = 1 Tablet, Orally, BID  cloNIDine 0.1 mg oral tablet 0.1 mg = 1 Tablet, Orally, TID, For SBP >150  Coricidin HBP Cough and Cold 4 mg-30 mg oral tablet 1 Tablet, Orally, BID, Packaged   DME Walker Not Applicable, Other, Unscheduled  Effexor XR 37.5 mg oral capsule, extended release 37.5 mg = 1 Capsule, Orally, Daily  fenofibrate 145 mg oral tablet 145 mg = 1 Tablet, Orally, Daily  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, Daily  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Magic Potion with tetracycline Use as directed, Orally, 4 Times Daily, Use 1 teaspoon (5 mL) as mouth rinse and gargle 5 times a day.  Mucinex DM 30 mg-600 mg oral tablet, extended release 1 Tablet, Orally, BID, Packaged   multivitamin Multiple Vitamins oral tablet 1 Tablet, Orally, Daily  Namzaric 10 mg-28 mg oral capsule, extended release 1 Capsule, Orally, QPM  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily, K21.9  predniSONE 10 mg oral tablet See Instructions, 5 tab orally today, then 4 tab x 3 days, then 3 tab x 3 days, then 2 tab x 3 days, then 1 tab x 3 days  primidone 50 mg oral tablet 50 mg = 1 Tablet, Orally, TID  Rituxan 10 mg/mL intravenous solution , IVPB, Every Month  Tessalon Perles 100 mg oral capsule 100 mg = 1 Capsule, Orally, TID  topiramate 25 mg oral tablet 25 mg = 1 Tablet, Orally, QHS  Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  ceftRIAXone, Injection, 1 GM, IVPB, ONCE, Indication: Pneumonia - CAP, Start: 02/12/23 06:07:00  ceftRIAXone, Injection, 1 GM, IVPB, Q24H, Indication: Pneumonia - CAP, Start: 02/13/23 07:00:00  docusate (docusate sodium), Capsule, 100 mg, Orally, BID, Start: 02/12/23 09:00:00  doxycycline, Capsule, 100 mg, Orally, Q12H, Indication: Pneumonia - CAP, Start: 02/12/23 16:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 02/12/23 07:00:00  Sodium Chloride 0.9%  1,000 mL IV  100 mL/hr       One-Time Medications Given 02/11/23 00:00:00 TO 02/12/23 06:19:19  None Reported  PRN Medications (0600 - 0559) from 02/11 - 02/12  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Current, Beer   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Breast cancer: Sister.  Cancer: Father.Negative: Mother.  Cancer of colon: Negative: Mother and Father.  Cancer of esophagus: Negative: Mother and Father.  Coronary artery disease: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 13.7 k/cumm High (02/12/23 00:20:00)  RBC: 3.7 million/cumm Low (02/12/23 00:20:00)  Hgb: 10 GM/dL Low (02/12/23 00:20:00)  Hct: 31 % Low (02/12/23 00:20:00)  MCV: 84 fL (02/12/23 00:20:00)  MCH: 27 pg (02/12/23 00:20:00)  MCHC: 32.3 GM/dL (02/12/23 00:20:00)  RDW: 16.2 % High (02/12/23 00:20:00)  Platelet: 257 k/cumm (02/12/23 00:20:00)  MPV: 9.3 fL (02/12/23 00:20:00)  Neutrophils %: 87 % (02/12/23 00:20:00)  Lymphocytes %: 8 % (02/12/23 00:20:00)  Monocytes %: 5 % (02/12/23 00:20:00)  Eosinophils %: 0 % (02/12/23 00:20:00)  Basophils %: 0 % (02/12/23 00:20:00)  Absolute Neutrophil: 11.9 k/cumm High (02/12/23 00:20:00)  Absolute Lymphocyte: 1.1 k/cumm (02/12/23 00:20:00)  Absolute Monocyte: 0.6 k/cumm (02/12/23 00:20:00)  Absolute Eosinophil: 0 k/cumm (02/12/23 00:20:00)  Absolute Basophil: 0 k/cumm (02/12/23 00:20:00)  Chemistry:  Sodium SerPl QN: 142 mmol/L (02/12/23 00:20:00)  Potassium SerPl QN: 3.8 mmol/L (02/12/23 00:20:00)  Chloride SerPl QN: 109 mmol/L High (02/12/23 00:20:00)  Carbon Dioxide SerPl QN: 23 mmol/L (02/12/23 00:20:00)  Anion Gap: 10 mmol/L (02/12/23 00:20:00)  BUN SerPl QN: 19 mg/dL (02/12/23 00:20:00)  Creatinine SerPl QN: 1.74 mg/dL High (02/12/23 00:20:00)  Estimated GFR (CKD-EPI, no race): 40 mL/min/1.73m2 Low (02/12/23 00:20:00)  Estimated CRCL (CG): 35 mL/min Low (02/12/23 00:20:00)  Glucose SerPl QN: 144 mg/dL High (02/12/23 00:20:00)  Calcium Total SerPl QN: 9.4 mg/dL (02/12/23 00:20:00)  Alkaline Phos SerPl QN: 94 Units/L (02/12/23 00:23:00)  ALT SerPl QN: 51 Units/L (02/12/23 00:23:00)  AST SerPl QN: 43 Units/L High (02/12/23 00:23:00)  Bilirubin Direct SerPl QN: 0.1 mg/dL (02/12/23 00:23:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (02/12/23 00:23:00)  Total Protein SerPl QN: 5.9 GM/dL Low (02/12/23 00:23:00)  Albumin SerPl QN: 3.6 GM/dL (02/12/23 00:23:00)  Magnesium SerPl QN: 1.6 mg/dL (02/12/23 00:20:00)  Lipase SerPl QN: 31 Units/L (02/12/23 00:23:00)  CK SerPl QN: 503 Units/L High (02/12/23 00:28:00)  Troponin-I High Sensitivity: 100 ng/L High (02/12/23 03:31:00)  BNP Pl QN: 24 pg/mL (02/12/23 00:23:00)  Lactate Venous Pl QN: 1.3 mmol/L (02/12/23 00:23:00)  Coagulation:  PT: 13.9 seconds High (02/12/23 00:20:00)  INR: 1.21 (02/12/23 00:20:00)  aPTT: 32.4 seconds (02/12/23 00:20:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/06/23 14:46:00)  Rapid Influenza A PCR: Not Detected (02/06/23 14:46:00)  Rapid Influenza B PCR: Not Detected (02/06/23 14:46:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/12/2023 01:36 - CT Head W/o IV Contrast  IMPRESSION:  No findings of acute traumatic intracranial injuryThank you for consulting our team of subspecialty radiologists at Radiology.      02/12/2023 01:37 - CT Cervical Spine W/o IV Contrast  IMPRESSION: 1.  No acute fracture or traumatic subluxation.2.  Aerated secretions within the sphenoid sinus and partially imagedparanasal sinuses, also described on the prior head CT. This cansuggest acute sinusitis.Thank you for consulting our team of subspecialty radiologists at Radiology.      02/12/2023 01:40 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for pulmonary embolism.2.  Multifocal pneumonia.Thank you for consulting our team of subspecialty radiologists at Radiology.                  Signature Line Electronically Signed on 02/12/23 06:19  ________________________________________________________ DO