Age: 83.0
Sex: M
Vaccine: FLU4
Symptoms: Haemoglobin urine present, Influenza A virus test negative, Influenza B virus test, Laboratory test abnormal, Legionella test
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: on December 16, 2022 17:46   Verified By: on December 16, 2022 18:03   Encounter Info: Emergency, 12/16/22 - 12/16/22    * Final Report *  Document Contains Addenda        Chief Complaint   Altered mental status  History of Present Illness/Subjective     This is a 83 year old patient with a past medical history significant for Hx of benign prostatic hypertrophy, Abdominal aortic aneurysm, AF (atrial fibrillation), Gilbert's disease, Renal stones, Stroke, Anemia, Myocardial infarction,  Major depression, that presented to ED from home with c/o altered mental status and is being admitted to inpatient for UTI.  This patient was seen and evaluated while still in ED.  He was found to be lying in bed, alert and in no distress.  His wife is present at bedside and providing most of his history.  She states that he was at his baseline yesterday and this morning he started vomiting was acting somewhat confused and disoriented.  He is weak and needing assistance with ambulation.  She said this is quite similar to an episode he had in October where he needed admission to the hospital for UTI.  He does have known frequent UTIs.  They tend to be all multidrug-resistant and need IV antibiotics.  He has had no falls or head trauma.  He has had no new medications.    Vs stable. WBC wnl.  Hgb 11.5. BUN 31, Cr 1.60, Glucose 153, bilirubin 1.6, protein 8.3. CXR shows Coarse interstitial opacities are noted in the mid and lower lung zones bilaterally. This is indeterminant and could be a chronic finding. Interstitial edema or an atypical infectious/inflammatory process could also appear similarly. Covid and flu negative.  Large leuks and nitrite pos in urine.  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,  no cough,  no wheeze Cardiovascular:  No chest pain,  no palpitations,  no edema Gastrointestinal:  No abdominal pain,  + nausea,  + 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:  No arthralgia,  no myalgia Skin:  No rash,  no pruritus Neurological:  No headache,  no focal weakness,  no numbness +confusion Psychiatric:  No anxiety,  no depression  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.5 (36.5-36.5)  Temp (FAHR) 97.7 (97.7-97.7), BP 129/60 (129-132)/(60-82), HR 92 (92-94), RR 22 (22-22), O2Sat 97 (97-97)     Patient Weight  Current Daily Weight:    107.7 kg    12/16/22    Patient Height  Current Height:    182.39 cm    12/16/22        Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  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: Mild cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan     This is a 83 year old patient with a past medical history significant for Hx of benign prostatic hypertrophy, Abdominal aortic aneurysm, AF (atrial fibrillation), Gilbert's disease, Renal stones, Stroke, Anemia, Myocardial infarction,  Major depression, that presented to ED from home with c/o altered mental status and is being admitted to inpatient for UTI.   1. UTI (urinary tract infection)   N39.0  acute on chronic  does not meet sepsis criteria  Pos urine culture with hx of ESBL that is multidrug resistant including carbapenems.  Gentamicin given in ED.  will continue with this.   follows with dr.  hx of bph and urinary retention  holding on fluids given pulm edema noted on cxr and hx of CHF.    2. Encephalopathy   G93.40  likely 2/2 above   3. Pneumonia   J18.9  procal, Respiratory culture/stain, Legionella antigen, and strep pneumoniae antigen, and blood cx pending Could possibly be from aspiration as he was vomiting.  Will cover with cefepime and Flagyl and obtain ST consult will will add doxy to cover atypicals, will deescalate antibiotics as appropriate    RT eval  keep O2 sats at or above 92% -- > currently 97% on RA  supplemental O2 prn   4. Pulmonary edema   J81.1  continue home lasix  previous echo in 2019 was nonactionable  new echo pending   5. Weakness   R53.1  2/2 above  PT/OT eval   6. AF (atrial fibrillation)   I48.91  rate controlled  cotinue home metoprolol and apixaban -- > changed dose to renal dosing   7. Anemia   D64.9  stable and at baseline, will monitor   8. CVA (cerebrovascular accident)   I63.9  noted   9. Chronic diastolic congestive heart failure   I50.32  continue spironolactone   10. Depression   F32.A  continue home Cymbalta   11. GERD (gastroesophageal reflux disease)   K21.9  resume home ppi   12. Hyperlipidemia   E78.5  resume home statin   13. Hypertension   I10  stable resume home meds   14. Hypothyroidism   E03.9  resume home levothyroxine   15. On anticoagulant therapy   Z79.01  resume home apixaban   16. Recurrent falls   R29.6  pt/ot eval  fall risk precautions   17. Stage 3 chronic kidney disease   N18.30  noted and at baseline  renally dose medications and avoid nephrotoxins   18. Type 2 diabetes mellitus with renal complication   E11.29  AC and HS blood sugar checks with sliding scale. Carb controlled diet  hold home oral meds         19. Monoclonal gammopathy   D47.2  noted   20. Nausea and vomiting   R11.2  likely d/t UTI  zofran prn      Inpatient, medical floor  Daily labs - CBC, CMP Daily   Low Carb Diet  IV fluids SL  Full Code  VTE Prophylaxis - Fully anticoagulated with apixaban     Code Status   None Recorded   Chronic Problem List    Anemia  Atrial fibrillation, chronic  Chronic diastolic congestive heart failure  CVA (cerebrovascular accident)  Depression  GERD (gastroesophageal reflux disease)  History of arterial ischemic stroke  Hyperlipidemia  Hypertension  Hypothyroidism  Monoclonal gammopathy  On anticoagulant therapy  Recurrent falls  Stage 3 chronic kidney disease  Type 2 diabetes mellitus with renal complication  Procedure/Surgical History  ?Esophagogastroduodenoscopy (01/04/2019) ?Appendectomy ?Hernia repair ?Procedure on bladder ?TURP   Surgical History Internal  01/04/2019    EGD Bx  10/14/2013    Prostatectomy HoLEP   Medications   Home Medications (17) Active  Aldactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Anoro Ellipta 62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  Blood Glucose Meter See Instructions, Tests twice dailyE11.9  Blood Glucose Test Strips See Instructions, Pt tests twice dailyE11.9  Contour Next Test Strips See Instructions, Use to test blood sugar TIDDX: E11.9  Cymbalta 60 mg oral delayed release capsule 60 mg = 1 Capsule, Orally, Daily, do not crush or chew  Wheelchair Not Applicable, Other, Unscheduled, I63.9R29.6R26.81  glipiZIDE-metFORMIN 2.5 mg-250 mg oral tablet 1 Tablet, Orally, BID  Lancet Device See Instructions, Tests twice dailyE11.9  Lancets See Instructions, Tests twice dailyE11.9  Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, 3x/WK  Lipitor 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  Synthroid 125 mCg (0.125 mg) oral tablet 125 mCg = 1 Tablet, Orally, Daily  Toprol-XL 25 mg oral tablet, extended release 25 mg = 1 Tablet, Orally, BID  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 12/15/22 00:00:00 TO 12/16/22 17:46:24  gentamicin, Injection, 560 mg, IVPB, ONCE, (1 DOSE 12/16/22 17:39:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 12/16/22 14:57:00)  PRN Medications (0600 - 0559) from 12/15 - 12/16  None Reported  Allergies   Contrast Dye (Anaphylaxis, Fainting)  penicillins (hives)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Diabetes mellitus type 1: Father.  Diabetes mellitus type 2: Sister.  Heart disease..: Father.  Hypertension: Sister.  Prostate cancer: Child.  Stroke: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.4 k/cumm (12/16/22 14:19:00)  RBC: 3.97 million/cumm Low (12/16/22 14:19:00)  Hgb: 11.5 GM/dL Low (12/16/22 14:19:00)  Hct: 34.4 % Low (12/16/22 14:19:00)  MCV: 87 fL (12/16/22 14:19:00)  MCH: 28.9 pg (12/16/22 14:19:00)  MCHC: 33.4 GM/dL (12/16/22 14:19:00)  RDW: 14.3 % (12/16/22 14:19:00)  Platelet: 223 k/cumm (12/16/22 14:19:00)  MPV: 7.1 fL (12/16/22 14:19:00)  Neutrophils %: 78 % (12/16/22 14:19:00)  Lymphocytes %: 16 % (12/16/22 14:19:00)  Monocytes %: 4 % (12/16/22 14:19:00)  Eosinophils %: 2 % (12/16/22 14:19:00)  Basophils %: 0 % (12/16/22 14:19:00)  Absolute Neutrophil: 5.7 k/cumm (12/16/22 14:19:00)  Absolute Lymphocyte: 1.2 k/cumm (12/16/22 14:19:00)  Absolute Monocyte: 0.3 k/cumm (12/16/22 14:19:00)  Absolute Eosinophil: 0.1 k/cumm (12/16/22 14:19:00)  Absolute Basophil: 0 k/cumm (12/16/22 14:19:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (12/16/22 14:19:00)  Potassium SerPl QN: 4.5 mmol/L (12/16/22 14:19:00)  Chloride SerPl QN: 100 mmol/L (12/16/22 14:19:00)  Carbon Dioxide SerPl QN: 27 mmol/L (12/16/22 14:19:00)  Anion Gap: 11 mmol/L (12/16/22 14:19:00)  BUN SerPl QN: 31 mg/dL High (12/16/22 14:19:00)  Creatinine SerPl QN: 1.6 mg/dL High (12/16/22 14:19:00)  Estimated GFR (CKD-EPI, no race): 42 mL/min/1.73m2 Low (12/16/22 14:19:00)  Estimated CRCL (CG): 45 mL/min Low (12/16/22 14:19:00)  Glucose SerPl QN: 153 mg/dL High (12/16/22 14:19:00)  Calcium Total SerPl QN: 10 mg/dL (12/16/22 14:19:00)  Alkaline Phos SerPl QN: 82 Units/L (12/16/22 14:19:00)  ALT SerPl QN: 7 Units/L (12/16/22 14:19:00)  AST SerPl QN: 10 Units/L Low (12/16/22 14:19:00)  Bilirubin Total SerPl QN: 1.6 mg/dL High (12/16/22 14:19:00)  Total Protein SerPl QN: 8.3 GM/dL High (12/16/22 14:19:00)  Albumin SerPl QN: 4.1 GM/dL (12/16/22 14:19:00)  Lactate Venous Pl QN: 1.9 mmol/L (12/16/22 14:19:00)  Urine Studies:  Color: Yellow (12/16/22 15:40:00)  Clarity: Clear (12/16/22 15:40:00)  Specific Gravity: 1.015 (12/16/22 15:40:00)  pH: 6.5 (12/16/22 15:40:00)  Protein: NEGATIVE (12/16/22 15:40:00)  Glucose: NEGATIVE (12/16/22 15:40:00)  Ketones: NEGATIVE (12/16/22 15:40:00)  Bilirubin: NEGATIVE (12/16/22 15:40:00)  Hgb Ur: SMALL. Abnormal (12/16/22 15:40:00)  Nitrite: POSITIVE Abnormal (12/16/22 15:40:00)  Urobilinogen: 1.0. (12/16/22 15:40:00)  Leukocyte Esterase Ur: LARGE. Abnormal (12/16/22 15:40:00)  WBC: 21-50 Abnormal (12/16/22 15:40:00)  RBC: 11-20 Abnormal (12/16/22 15:40:00)  Bacteria: Moderate Abnormal (12/16/22 15:40:00)  Squamous Epithelial: Few (12/16/22 15:40:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (12/16/22 14:19:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (12/16/22 14:19:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/16/22 14:19:00)  Rapid Influenza A PCR: Not Detected (12/16/22 14:19:00)  Rapid Influenza B PCR: Not Detected (12/16/22 14:19:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/16/2022 16:03 - XR Chest PA or AP Portable  IMPRESSION:1.  Coarse interstitial opacities are noted in the mid and lower lungzones bilaterally. This is indeterminant and could be a chronicfinding. Interstitial edema or an atypical infectious/inflammatoryprocess could also appear similarly.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact. For after-hours or emergency department cases.                Signature Line Electronically Signed on 12/16/22 18:03  ________________________________________________________   Addendum on December 16, 2022 18:13:58  (Verified)    General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. No added sounds Cardiovascular: Normal rate, Regular rhythm. s1 s2 positive Gastrointestinal: Soft, Non-tender. BS present all 4 quadrants Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact    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 examfor this encounter. I have reviewed and verified this documentation and it accurately reflects our care.        Hospital Medicine   Signature Line Electronically Signed on 12/16/22 18:14 ________________________________________________________