Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Pupillary reflex impaired, Red blood cell count normal, Red blood cells urine positive, Red cell distribution width normal, Renal function test normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: A NP on February 05, 2023 16:54  Verified By: A NP on February 05, 2023 16:54  Hospital, Inpatient, 02/05/23 -     * Final Report *  Document Contains Addenda          History of Present Illness/Subjective     67 year old male w/ a hx of stroke, dementia, DM, and encephalopathy presents to the ED via EMS for AMS onset last night. Initial history given by RN bedside, who states pt comes from facility, where multiple residents have tested positive for COVID; pt's most recent test was negative. Staff there observed sluggish pupils, trouble speaking, confusion, drooling out of the left side of his mouth, incontinence, and inability to tolerate PO medication. Pt is AAO and ambulatory w/ a walker at baseline.   EMS reportedly observed coarse lung sounds, cough, some dry crust around the mouth suggestive of emesis, a temperature of 99.7 F, and a glucose of 160. EMS state they didn't notice any signs of stroke   Daughter bedside states he has had multiple episodes of today's presentation about every 6 months related to cerebral edema, and steroids were helpful in relieving symptoms. Endorses a stroke last August; she doesn't believe pt is anti-coagulated. Explains pt has left-sided deficits at baseline. She hasn't seen pt in a couple weeks.   Upon ER evaluation his temperature was up to 102.4, heart rate was up to 120, respiratory rate was up to 27 and he required 2 L per nasal cannula.  Lab work revealed normal white blood cell count of 10.6, renal function was normal with a GFR greater than 90, lipase was 10, CK was 173, troponin was 6 with repeat 8, BNP was 31, lactate was 2.0 UA showed moderate hemoglobin, COVID-19 testing was positive, flu a and B were negative.  Chest x-ray did not show any radiographic cardiopulmonary process.  Head CT was obtained and is pending.  Upon exam patient had coma score of 8.  Patient was gurgling on oral secretions and phlegm was not coughing.  ER staff instructed to suction patient.  Patient's eyes were initially rolled back in his head, opened his eyes he did make focus for 1 brief moment then closed his eyes again breath sounds are very coarse patient appeared ill.  Will bring patient in for further evaluation management of COVID-19 infection with sepsis to the ICU for close monitoring and evaluation.  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  None reported this timeframe     Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress,  well-nourished Eyes:  PEERL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Severe cognitive impairment,  Psychiatric:     Assessment/Plan       1. Sepsis with acute hypoxic respiratory failure  Sepsis criteria with his temperature greater than 102.4, heart rate elevated at 120, respiratory rate is elevated, source of infection is COVID-19,  Will start antibiotics and remdesivir ? Blood cultures are pending,   2. Pneumonia due to COVID-19 virus  Patient received Zosyn and Phenergan while in the ED ? We will continue with Unasyn and doxycycline ? Admit to inpatient ? Speech therapy to evaluate for possible aspiration, n.p.o. at this time, procalcitonin Legionella strep pending  Will monitor daily COVID labs, dexamethasone 6 mg IV daily, will start remdesivir  RT protocol, Pt is on 2l nc at this time.   3. COVID-19  As above   4. CVA (cerebrovascular accident)   History of, CT head pending   5. AMS (altered mental status) -CT head pending, depakote level pending, EEG ordered , ammonia level ordered  -Possibly due to sepsis but will rule out other possible causes.   6. Diabetes mellitus   We will start sliding scale insulin   7. GERD (gastroesophageal reflux disease)   Resume home PPI when patient able to safely swallow   8. HTN (hypertension)  Stable at this time, resume home meds when patient is more alert and can safely swallow   9. Heart disease  Resume home meds when patient is more alert and can safely swallow   10. Seizure disorder   Depakote level pending, resume home meds when patient can safely swallow   11. Microhematuria   12. Hyperlipidemia    Patient is a DNR/DNI, DVT prophylaxis with Lovenox   Orders:   Ammonia Pl QN  Electroencephalogram Awake + Asleep  Valproic Acid SerPl QN  Code Status   None Recorded   Chronic Problem List    AMS (altered mental status)  COVID-19  CVA (cerebrovascular accident)  Diabetes mellitus  Ds DNA antibody positive  Encephalopathy  GERD (gastroesophageal reflux disease)  Heart disease  Heart murmur  Hematuria  Hemorrhoids  HTN (hypertension)  Hyperlipidemia  Microhematuria  Pneumonia due to COVID-19 virus  Seizure disorder  Seizure disorder  Sepsis  Sepsis with acute hypoxic respiratory failure  Procedure/Surgical History  ?colonoscopy (12/14/2017) ?Neck Surgery (2010) ?Ulnar Nerve moved (2010) ?Neck Surgery (2002)   Surgical History Internal  12/14/2017    Colonscpy Diagnostic/Screen  Medications   Home Medications (17) Active  alendronate 70 mg oral tablet 70 mg = 1 Tablet, Orally, Every Wednesday  Aricept 5 mg oral tablet   aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  busPIRone 7.5 mg oral tablet   Clear Eyes   Depakote 125 mg oral delayed release tablet   leveTIRACetam 250 mg oral tablet 750 mg = 3 Tablet, Orally, BID  metFORMIN 850 mg oral tablet 850 mg = 1 Tablet, Orally, BID With Meals  multivitamin 1 Tablet, Orally, QAM  mycophenolate mofetil 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  predniSONE 10 mg oral tablet 30 mg = 3 Tablet, Orally, Daily, Prednisone taper:60mg x5 days50mg x5 days40mg x5 days30mg continue indefinitely  predniSONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily, Prednisone taper:60mg x5 days50mg x5 days40mg x5 days30mg continue indefinitely  Risperdal 0.5 mg oral tablet   tamsulosin 0.4 mg oral capsule   traZODONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, At Bedtime  Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/04/23 00:00:00 TO 02/05/23 16:54:35  None Reported  PRN Medications (0600 - 0559) from 02/04 - 02/05  None Reported  Allergies   NKA  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.      Exercise   Exercise frequency: 1-2 times/week. Exercise type: Walking.   Home/Environment   Lives with Spouse.   Sexual   Identifies as male What is your current gender identity? (Check all the apply).   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Dementia: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.6 k/cumm (02/05/23 14:26:00)  RBC: 5.62 million/cumm High (02/05/23 14:26:00)  Hgb: 15.7 GM/dL (02/05/23 14:26:00)  Hct: 47.3 % (02/05/23 14:26:00)  MCV: 84 fL (02/05/23 14:26:00)  MCH: 27.9 pg (02/05/23 14:26:00)  MCHC: 33.2 GM/dL (02/05/23 14:26:00)  RDW: 14.2 % (02/05/23 14:26:00)  Platelet: 231 k/cumm (02/05/23 14:26:00)  MPV: 8.4 fL (02/05/23 14:26:00)  Neutrophils %: 86 % (02/05/23 14:26:00)  Lymphocytes %: 3 % (02/05/23 14:26:00)  Monocytes %: 11 % (02/05/23 14:26:00)  Eosinophils %: 0 % (02/05/23 14:26:00)  Basophils %: 0 % (02/05/23 14:26:00)  Absolute Neutrophil: 9.1 k/cumm High (02/05/23 14:26:00)  Absolute Lymphocyte: 0.3 k/cumm Low (02/05/23 14:26:00)  Absolute Monocyte: 1.2 k/cumm (02/05/23 14:26:00)  Absolute Eosinophil: 0 k/cumm (02/05/23 14:26:00)  Absolute Basophil: 0 k/cumm (02/05/23 14:26:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (02/05/23 14:26:00)  Potassium SerPl QN: 4 mmol/L (02/05/23 14:26:00)  Chloride SerPl QN: 98 mmol/L (02/05/23 14:26:00)  Carbon Dioxide SerPl QN: 29 mmol/L (02/05/23 14:26:00)  Anion Gap: 12 mmol/L High (02/05/23 14:26:00)  BUN SerPl QN: 17 mg/dL (02/05/23 14:26:00)  Creatinine SerPl QN: 0.85 mg/dL (02/05/23 14:26:00)  Estimated CRCL (CG): 81 mL/min (02/05/23 14:26:00)  Glucose SerPl QN: 127 mg/dL High (02/05/23 14:26:00)  Calcium Total SerPl QN: 9.6 mg/dL (02/05/23 14:26:00)  Alkaline Phos SerPl QN: 102 Units/L (02/05/23 14:26:00)  ALT SerPl QN: 12 Units/L (02/05/23 14:26:00)  AST SerPl QN: 20 Units/L (02/05/23 14:26:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (02/05/23 14:26:00)  Total Protein SerPl QN: 6.6 GM/dL (02/05/23 14:26:00)  Albumin SerPl QN: 4.3 GM/dL (02/05/23 14:26:00)  Lipase SerPl QN: 10 Units/L (02/05/23 14:26:00)  CK SerPl QN: 173 Units/L (02/05/23 14:26:00)  Troponin-I High Sensitivity: 8 ng/L (02/05/23 15:15:00)  BNP Pl QN: 31 pg/mL (02/05/23 14:26:00)  Lactate Venous Pl QN: 2 mmol/L (02/05/23 14:26:00)  Urine Studies:  Color: Yellow (02/05/23 15:00:00)  Clarity: Clear (02/05/23 15:00:00)  Specific Gravity: >=1.030 (02/05/23 15:00:00)  pH: 5.5 (02/05/23 15:00:00)  Protein: NEGATIVE (02/05/23 15:00:00)  Glucose: NEGATIVE (02/05/23 15:00:00)  Ketones: 15 Abnormal (02/05/23 15:00:00)  Bilirubin: SC Small Abnormal (02/05/23 15:00:00)  Hgb Ur: MODERATE. Abnormal (02/05/23 15:00:00)  Nitrite: NEGATIVE (02/05/23 15:00:00)  Urobilinogen: Normal Uro (02/05/23 15:00:00)  Leukocyte Esterase Ur: NEGATIVE (02/05/23 15:00:00)  WBC: 0-5 (02/05/23 15:00:00)  RBC: 3-5 Abnormal (02/05/23 15:00:00)  Bacteria: NONE (02/05/23 15:00:00)  Squamous Epithelial: NONE (02/05/23 15:00:00)  Mucous: PRESENT. (02/05/23 15:00:00)  Hyaline Casts: 0-2 (02/05/23 15:00:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (02/05/23 14:26:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (02/05/23 14:26:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/05/23 14:26:00)  Rapid Influenza A PCR: Not Detected (02/05/23 14:26:00)  Rapid Influenza B PCR: Not Detected (02/05/23 14:26:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/05/2023 16:10 - XR Chest PA or AP Portable  IMPRESSION:1. No acute radiographic cardiopulmonary process.       Addendum by doctor on February 05, 2023 17:15:58    General: Alert but does not follow commands. Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. Cardiovascular: Normal rate, Regular rhythm. Gastrointestinal: Soft, Non-tender. Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect     I saw and evaluated the patient in addition to the APP. I provided a substantive portion of the care for this patient. I personally performed in its entirety exam for this encounter. I have reviewed and verified this documentation and it accurately reflects our care.       Hospital Medicine 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.