Age: 54.0
Sex: F
Vaccine: COVID19
Symptoms: Procedural pain, Protein total normal, Protein urine present, Pyrexia, Red blood cell count decreased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on July 10, 2024 23:19  Verified By: MD on July 10, 2024 23:19 Encounter Info: Hospital, Inpatient, 07/11/24 -     * Final Report *        Chief Complaint   Back pain  History of Present Illness/Subjective     This is a 57-year-old woman with past medical history of Nash resulting in cirrhosis with now splenomegaly on imaging, CKD stage II, anemia, protein calorie malnutrition, diabetes mellitus with neuropathy, anxiety and depression, GERD, RLS, chronic pancreatitis on pancrelipase, and tobacco use currently practicing cessation.  Also has a recent surgery of the left upper extremity with subsequent development of bilateral lower extremity pain and swelling, worse on the right.  Now presenting to Hospital on 7/10/2024.   Primary complaints on presentation are surrounding back pain, persistent progressive over the days prior to presentation, also endorses chronic cough.  Patient states that since 6/21/2024, her bilateral lower extremities have been swelling with pain along the inner thigh and popliteal region.   On initial evaluation, hemogram values show leukocytosis of 12.2 thousand, absolute neutrophils of 11.3 thousand.  D-dimer elevated at 688.  Hemoglobin 9.7 g/dL and consistent with a chronic and stable anemia.  Electrolyte analysis shows reduction in sodium at 131.  Renal function analysis shows acute worsening of baseline CKD stage II.  Hepatobiliary labs relatively within normal limits.  Albumin 2.8.  Lipase negative.  Initial lactate 2.4, downtrending to 3.5 (confounded in setting of liver disease and crystalloid fluid administration lactated Ringer's in the emergency department).   Vital signs show the patient to be febrile, persistently tachypneic and tachycardic, now saturating well on 2 L nasal cannula, and intermittently hypotensive still receiving 30 cc/kg bolus on admission.   Chest x-ray was performed showing no acute findings in the chest.   CT abdomen pelvis shows gas within the urinary bladder concerning for emphysematous cystitis in the setting of overtly infectious urinalysis.  Fatty liver disease with nodular liver and cirrhosis with sequelae of splenomegaly also noted.   CT of the chest was performed showing no pulmonary embolism, once again cirrhosis with splenomegaly noted.   This time the patient will be placed on inpatient ICU status.   In all greater than 50 minutes critical care time spent in coordination of care.  The patient is critically ill due to metabolic, hemodynamic and/or respiratory instability. He/she requires high complexity evaluation care and decision making. He/she requires critical evaluation/decision making and/or ICU level of care and monitoring due to high risk of clinical decompensation with high risk of morbidity and mortality. Critical care time includes bedside assessment, review of medical record, radiographic and laboratory results, ventilator and/or respiratory management, review of ekg and/or cardiac monitoring, critical decision making, coordination of care with consultants and/or care team, and documentation of critical intervention/plans, and consultation with patient and/or family. Time excludes any procedural time.  Review of Systems     Constitutional:  No fevers,  no chills,  no sweats Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No ear pain,  no nasal congestion,  no sore throat Respiratory:  No shortness of breath,  + cough chronically,  no wheeze Cardiovascular:  No chest pain,  no palpitations,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea,  no constipation Genitourinary:  No frequency,  no urgency,  no dysuria,  no hematuria Hematologic/Lymphatic:  No bruising,  no enlarged lymph nodes Allergic/Immunologic:  No hives Endocrine:  No cold intolerance,  no heat intolerance,  no polyuria,  no polydipsia Musculoskeletal:  + Arthralgia,  + myalgia Skin:  No rash,  no pruritus Neurological:  No headache,  no focal weakness,  no numbness Psychiatric:  No anxiety,  no depression  Physical Exam/Objective Vitals & Measurements most recent past 24 hours    Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported      Constitutional:  No acute distress Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  No acute respiratory distress, nonlabored respiratory pattern, no overt wheezing or stridor Cardiovascular:  Tachycardic no JVD, B/L LE swelling R>L with popliteal tenderness Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Sepsis secondary to UTI   A41.9   Present on admission, borderlining shock physiology with 30 cc/kg bolus still infusing while excepted on admission.  Will continue up to 3-4 L of crystalloid fluid supplementation prior to initiation of vasopressor support.  Patient being placed in ICU for moderate to high probability of hemodynamic and respiratory instability.  Blood cultures, urine culture, repeat lactate, and procalcitonin pending.  Will continue empiric coverage with cefepime.  Patient is a known cirrhotic and received lactated Ringer's in the emergency department, this may confound the lactate, will transition crystalloid fluid to normal saline.   2. Lactic acidosis   E87.20   2/2 to intravascular volume depletion in the setting of severe sepsis and reflective of severity with potential development of end organ damage with underlying reduction in baseline perfusion status, trend q 6h until normalized   3. Acute kidney injury superimposed on CKD   N17.9   2/2 intravascular volume depletion in the setting of severe sepsis and reflective of severity with end organ damage    4. Respiratory failure with hypoxia   J96.91   evaluation and treatment as noted above, RT eval and treat, supplement BIPAP/O2 as tolerated and required   5. Elevated white blood cell count   D72.829   Likely reactive vs infectious. Follow up Cultures and Continue IV Abx. Continue Daily trends.   6. Anemia   D64.9   The patient presents with anemia chronic and normocytic due to other chronic disease at present is stable.  Continue to trend serial analysis as appropriate with nutritional or blood product supplementation as required.   7. Elevated d-dimer   R79.89   likely acute phase reactant, CTA PE negative,  asymmetric swelling of the lower extremities R>L with pain along deep venous system to suggest DVT developing post operatively since 6/20/24, will empirically anticoagulate and obtain Doppler or LE to r/o DVT   8. Protein calorie malnutrition   E46   The patient presents with malnutrition including moderate protein calorie malnutrition.  Nutritional consultation in place, yes.  Continue to trend clinical course and serial laboratory analysis as appropriate.  Encourage adequate caloric intake and lifestyle modification to optimize correction.   9. Cirrhosis of liver   K74.60   Avoid diuretic therapy at this time given hypotension, reinitiate baseline regimen as appropriate.   10. Diabetes mellitus with neuropathy   E11.40   Continue subcutaneous insulin via CDA protocol and carb controlled diet for tight glycemic control.  Initiate baseline basal/bolus regimen as indicated by clinical course with appropriate titration, resume home oral agents/analogs as appropriate when nearing discharge.    11. Anxiety and depression   F41.9   Continue appropriate anxiolytics/antidepressants   12. GERD (gastroesophageal reflux disease)   K21.9   Noted   13. RLS (restless legs syndrome)   G25.81   Noted   14. Chronic pancreatitis   K86.1   Continue pancrelipase   15. Tobacco use   Z72.0   Continue to promote cessation   Orders:   enoxaparin, 100 mg, Subcutaneous, Injection, BID, 07/10/24 23:00:00  VL Venous Duplex Extremity   Code Status  full code   Chronic Problem List    Cervical radiculopathy  Cirrhosis of liver  Depression  Diabetic neuropathy  Dupuytren's contracture of hand  Elevated alkaline phosphatase level  Encounter for follow-up  Fatty liver  Fracture of humeral shaft, left, closed  GERD (gastroesophageal reflux disease)  Hx of pancreatitis  Hypomagnesemia  Injury of left humerus  Insomnia  Left shoulder pain  Left trigger finger  Left wrist sprain  Lumbar radiculopathy  Microalbuminuria due to type 2 diabetes mellitus  Recurrent acute pancreatitis  Restless leg syndrome  Right rotator cuff tendinitis  Right trigger finger  RUQ pain  Sacral radiculopathy  Severe obesity  Situational mixed anxiety and depressive disorder  Subacromial impingement of right shoulder  Tobacco use  Type 2 diabetes mellitus with hyperglycemia, with long-term current use of insulin  Procedure/Surgical History  ?Diabetic retinal eye exam (08/04/2022) ?Diabetic retinal eye exam (05/27/2021) ?Esophagogastroduodenoscopy (03/12/2020) ?Cesarean section ?Cholecystectomy ?ORIF Left Humerus Shaft Fracture. 6/21/24.   Surgical History Internal  06/21/2024    Shoulder Dislocation Open Reduction  (Left)  MD  01/30/2024    EGD ENDO Ultrasound    MD  07/27/2020    Carpal Tunnel Decompression  (Right)   MD  03/12/2020    EGD Diagnostic    MD  07/17/2018    Carpal Tunnel Decompression  (Right)   MD  06/19/2018    Finger Thumb Tendon Muscle Release  (Left)   MD  Medications   Home Medications (15) Active  Creon 36,000 units oral delayed release capsule 1 Capsule, Orally, TID, with each meal  FreeStyle Libre 3 Sensors Use As Directed, Other, Unscheduled  glipiZIDE 5 mg oral tablet, extended release 5 mg = 1 Tablet, Orally, Daily  Lantus (insulin glargine) SoloStar Pen 100 units/mL subcutaneous solution 52 Units, Subcutaneous, At Bedtime  levothyroxine 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, QAM  melatonin 5 mg oral tablet 5 mg = 1 Tablet, Orally, At Bedtime  Misc Supplement 250 mg, Orally, At Bedtime  montelukast 10 mg oral tablet 1 Tablet, Orally, QPM  NovoLOG (insulin aspart) FlexPen 100 units/mL subcutaneous solution 5 Units, Subcutaneous, With Meals, with sliding scale  nystatin 100,000 units/g topical powder 1 App, Topical, TID  omeprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, Daily  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, QAM  Pen Needles - Insulin (4mm x 32G) Use 4 times daily, Other, Unscheduled, Dispense QS 90 days  rOPINIRole 4 mg oral tablet 4 mg = 1 Tablet, Orally, QHS  torsemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  enoxaparin (Lovenox), Injection, 100 mg, Subcutaneous, BID, Start: 07/10/24 23:00:00    One-Time Medications Given 07/09/24 00:00:00 TO 07/10/24 23:19:42  None Reported  PRN Medications (0600 - 0559) from 07/09 - 07/10  None Reported  Allergies   lisinopril (Cough)  Chloraprep (rash)  ketamine (Anxiety depression)  Social History    Alcohol   Past   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Unemployed   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: 5-9 cigarettes (between 1/4 to 1/2 pack)/day in last 30 days. Smoking cessation information given: Yes.  Family History   Coronary artery disease..: Mother.  Heart attack..: Mother.  Heart disease..: Mother and Father.  High blood pressure..: Mother.  Liver cancer..: Brother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12.2 k/cumm High (07/10/24 19:06:00)  RBC: 3.28 million/cumm Low (07/10/24 19:06:00)  Hgb: 9.7 GM/dL Low (07/10/24 19:06:00)  Hct: 29.3 % Low (07/10/24 19:06:00)  MCV: 89 fL (07/10/24 19:06:00)  MCH: 29.6 pg (07/10/24 19:06:00)  MCHC: 33.2 GM/dL (07/10/24 19:06:00)  RDW: 15.2 % High (07/10/24 19:06:00)  Platelet: 155 k/cumm (07/10/24 19:06:00)  MPV: 7.8 fL (07/10/24 19:06:00)  Neutrophils %: 92 % (07/10/24 19:06:00)  Lymphocytes %: 3 % (07/10/24 19:06:00)  Monocytes %: 4 % (07/10/24 19:06:00)  Eosinophils %: 0 % (07/10/24 19:06:00)  Basophils %: 0 % (07/10/24 19:06:00)  Absolute Neutrophil: 11.3 k/cumm High (07/10/24 19:06:00)  Absolute Lymphocyte: 0.4 k/cumm Low (07/10/24 19:06:00)  Absolute Monocyte: 0.5 k/cumm (07/10/24 19:06:00)  Absolute Eosinophil: 0 k/cumm (07/10/24 19:06:00)  Absolute Basophil: 0 k/cumm (07/10/24 19:06:00)  Chemistry:  Sodium SerPl QN: 131 mmol/L Low (07/10/24 19:06:00)  Potassium SerPl QN: 3.9 mmol/L (07/10/24 19:06:00)  Chloride SerPl QN: 96 mmol/L Low (07/10/24 19:06:00)  Carbon Dioxide SerPl QN: 28 mmol/L (07/10/24 19:06:00)  Anion Gap: 7 mmol/L (07/10/24 19:06:00)  BUN SerPl QN: 15 mg/dL (07/10/24 19:06:00)  Creatinine SerPl QN: 1.39 mg/dL High (07/10/24 19:06:00)  Estimated GFR (CKD-EPI, no race): 44 mL/min/1.73m2 Low (07/10/24 19:06:00)  Estimated CRCL (CG): 48 mL/min Low (07/10/24 19:06:00)  Glucose SerPl QN: 171 mg/dL High (07/10/24 19:06:00)  Calcium Total SerPl QN: 8.1 mg/dL Low (07/10/24 19:06:00)  Alkaline Phos SerPl QN: 201 Units/L High (07/10/24 19:06:00)  ALT SerPl QN: 7 Units/L (07/10/24 19:06:00)  AST SerPl QN: 15 Units/L (07/10/24 19:06:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (07/10/24 19:06:00)  Total Protein SerPl QN: 6.7 GM/dL (07/10/24 19:06:00)  Albumin SerPl QN: 2.8 GM/dL Low (07/10/24 19:06:00)  Lipase SerPl QN: 32 Units/L (07/10/24 19:06:00)  Lactate Venous Pl QN: 3.5 mmol/L High (07/10/24 21:42:00)  pH Bld Venous QN: 7.46 High (07/10/24 19:06:00)  PCO2 Bld Venous QN: 41 mmHg (07/10/24 19:06:00)  PO2 Bld Venous QN: 37 mmHg (07/10/24 19:06:00)  Base Excess Bld Venous: 5 mmol/L High (07/10/24 19:06:00)  Bicarb Bld Venous Calc: 29 mmol/L (07/10/24 19:06:00)  O2 Sat Bld Venous Calc: 74 % (07/10/24 19:06:00)  FIO2: venous (07/10/24 19:06:00)  Patient Temperature: 37 DegC (07/10/24 19:06:00)  Coagulation:  D-Dimer Pl QN: 688 ng/mL DDU High (07/10/24 19:06:00)  Urine Studies:  Color: Dark-Orange (07/10/24 21:42:00)  Clarity: Cloudy (07/10/24 21:42:00)  Specific Gravity: 1.036 High (07/10/24 21:42:00)  pH: 6 (07/10/24 21:42:00)  Protein: 300 Abnormal (07/10/24 21:42:00)  Glucose: Normal (07/10/24 21:42:00)  Ketones: TRACE. Abnormal (07/10/24 21:42:00)  Bilirubin: NEGATIVE (07/10/24 21:42:00)  Hgb Ur: Mod 2+ Abnormal (07/10/24 21:42:00)  Nitrite: NEGATIVE (07/10/24 21:42:00)  Urobilinogen: Normal (07/10/24 21:42:00)  Leukocyte Esterase Ur: Large500 Abnormal (07/10/24 21:42:00)  WBC: >100 Abnormal (07/10/24 21:42:00)  RBC: 21-50 Abnormal (07/10/24 21:42:00)  WBC Clumps: PRESENT. Abnormal (07/10/24 21:42:00)  Bacteria: Many Abnormal (07/10/24 21:42:00)  Squamous Epithelial: Few (07/10/24 21:42:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (07/10/24 19:06:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (07/10/24 19:06:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 07/10/2024 19:22 - XR Chest PA or AP Portable  IMPRESSION:No acute findings.    07/10/2024 20:50 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  No pulmonary embolism.2.  No acute findings in the chest.3.  Cirrhosis with splenomegaly.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at with any questions.    07/10/2024 20:50 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Small amount of gas in the urinary bladder of uncertainsignificance. Correlate for any recent instrumentation.2.  Fatty liver with nodular liver contour and splenomegaly.3.  No acute findings in the abdomen or pelvis.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at with any questions.                Signature Line Electronically Signed on 07/10/24 23:19 MD