Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Acinetobacter test, Acute kidney injury, Alanine aminotransferase normal, Angiogram cerebral normal, Anion gap
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Performed By:  MD on December 05, 2023 12:40   Verified By: MD on December 05, 2023 12:40   Encounter Info: Hospital, Inpatient, 12/02/23 -     * Final Report *        Subjective     Admission Date: 12/02/2023 18:45  LOS: 3 Days  75 year old woman w/ bipolar d/o, myasthenia gravis, T2DM and seizures who presents from facility after a episode of unresponsiveness   seen and evaluated by her bedside E.coli bacteremia, repeat blood cx sent- negative VSS  CM to discuss NH options with family. Family does not want to send her back to where she is coming from for safety concerns   12/5/23:  no new complaints.  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 36.3 °C (Axillary)  TMIN: 36.3 °C (Axillary)  TMAX: 36.6 °C (Oral)  BP: 179/79  HR: 80 (Monitored)  RR: 15  SpO2: 92%  Oxygen Therapy: Room air  WT: 73.4 kg    Hemodynamics   Neurologic  Glasgow Coma Score: 14  Patient Weight  Current Daily Weight:    73.4 kg    12/05/23  Previous Daily Weight:    72.4 kg    12/04/23  Difference from Previous:    1.000 kg    Patient Height      Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 12/04 - 12/05  Total Intake 200.00 mL    Total Output 1425.00 mL     Balance -1225.00 mL     Physical Exam     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, no nuchal rigidity 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, no rebound tenderness Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, no obvious rashes Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact.  Assessment/Plan        1. UTI (urinary tract infection)   N39.0  c/w current treatment.  same bacteria in blood.   2. E coli bacteremia   R78.81   Will need few days of IV abx.  will need to repeat blood cultures.   3. CVA (cerebrovascular accident)   I63.9    -Subacute  -Had w/u including TTE a few weeks for an acute lacunar infarct. CTA at that time showed no significant obstruction  -Continue statin and DAPT  -PT OT ST  - AKI is improving       4. AKI (acute kidney injury)   N17.9   Improving.   5. Weakness   R53.1  Noted  PT OT evaluation.    6. Diabetes   E11.9  continue with regimen.    7. Hypertension   I10  controlled.    8. Myasthenia gravis   G70.00    9. COVID   U07.1  NO need for treatments.     Code Status  Resuscitation Status - Ordered    -- 12/02/23 18:23:00, Full Code   Medications   Active Scheduled Inpatient Medications  aspirin (Aspirin Enteric Coated), Tab, Delayed Rel, 81 mg, Orally, Daily, Start: 12/03/23 09:00:00  atorvastatin, Tablet, 40 mg, Orally, Daily, Start: 12/03/23 09:00:00  busPIRone, Tablet, 30 mg, Orally, BID, Start: 12/02/23 21:00:00  carBAMazepine, Tab, Chewable, 100 mg, Orally, Daily, Start: 12/03/23 09:00:00  ceftRIAXone, Injection, 1 GM, IVPB, Q24H, Indication: Bacteremia - Source Unknown, Start: 12/03/23 15:00:00  cholecalciferol, Tablet, 125 mCg, Orally, Daily, Start: 12/03/23 09:00:00  clopidogrel, Tablet, 75 mg, Orally, Daily, Start: 12/03/23 09:00:00  cyanocobalamin, Tablet, 500 mCg, Orally, Daily, Start: 12/03/23 09:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 12/03/23 18:00:00  insulin glargine (Lantus (insulin glargine) 100 units/mL subcutaneous solution), Injection, 10 Units, Subcutaneous, Daily, Start: 12/03/23 09:00:00  lamoTRIgine, Tablet, 200 mg, Orally, At Bedtime, Start: 12/02/23 21:00:00  olanzapine, Tab, Oral Disintegrating, 10 mg, Orally, At Bedtime, Start: 12/02/23 21:00:00  pantoprazole, Tab, Delayed Rel, 20 mg, Orally, Daily, Start: 12/03/23 09:00:00  primidone, Tablet, 50 mg, Orally, BID, Start: 12/02/23 21:00:00  PYRIDostigmine, Tablet, 90 mg, Orally, TID, Start: 12/02/23 21:00:00  traZODONE, Tablet, 100 mg, Orally, At Bedtime, Start: 12/02/23 21:00:00  vilazodone (Viibryd), Tablet, 20 mg, Orally, QAM, Start: 12/03/23 09:00:00  Lactated Ringers 1,000 mL IV Continuous 100 mL/hr 0  12/03/23  Dextrose 10% in Water  500 mL IV Continuous  Per Core Diabetes App - See Comments       One-Time Medications Given 12/04/23 00:00:00 TO 12/05/23 12:39:55  None Reported  PRN Medications (0600 - 0559) from 12/04 - 12/05  acetaminophen, 650 mg, Orally, Q6H, 2  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Core Diabetes App , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Per Core Diabetes App , Subcutaneous, Unscheduled, 1  Dose(s)   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.7 k/cumm (12/05/23 03:23:00)  RBC: 2.6 million/cumm Low (12/05/23 03:23:00)  Hgb: 7.2 GM/dL Low (12/05/23 03:23:00)  Hct: 20.9 % Low (12/05/23 03:23:00)  MCV: 81 fL (12/05/23 03:23:00)  MCH: 27.8 pg (12/05/23 03:23:00)  MCHC: 34.5 GM/dL (12/05/23 03:23:00)  RDW: 17.8 % High (12/05/23 03:23:00)  Platelet: 262 k/cumm (12/05/23 03:23:00)  MPV: 7 fL (12/05/23 03:23:00)  Neutrophils %: 71 % (12/05/23 03:23:00)  Lymphocytes %: 13 % (12/05/23 03:23:00)  Monocytes %: 11 % (12/05/23 03:23:00)  Eosinophils %: 4 % (12/05/23 03:23:00)  Basophils %: 1 % (12/05/23 03:23:00)  Absolute Neutrophil: 5.5 k/cumm (12/05/23 03:23:00)  Absolute Lymphocyte: 1 k/cumm (12/05/23 03:23:00)  Absolute Monocyte: 0.9 k/cumm (12/05/23 03:23:00)  Absolute Eosinophil: 0.3 k/cumm (12/05/23 03:23:00)  Absolute Basophil: 0.1 k/cumm (12/05/23 03:23:00)  Chemistry:  Sodium SerPl QN: 129 mmol/L Low (12/05/23 03:23:00)  Potassium SerPl QN: 3.7 mmol/L (12/05/23 03:23:00)  Chloride SerPl QN: 99 mmol/L (12/05/23 03:23:00)  Carbon Dioxide SerPl QN: 26 mmol/L (12/05/23 03:23:00)  Anion Gap: 4 mmol/L (12/05/23 03:23:00)  BUN SerPl QN: 10 mg/dL (12/05/23 03:23:00)  Creatinine SerPl QN: 1.01 mg/dL (12/05/23 03:23:00)  Estimated GFR (CKD-EPI, no race): 58 mL/min/1.73m2 Low (12/05/23 03:23:00)  Estimated CRCL (CG): 52 mL/min Low (12/05/23 03:23:00)  Glucose SerPl QN: 78 mg/dL (12/05/23 03:23:00)  Calcium Total SerPl QN: 7.7 mg/dL Low (12/05/23 03:23:00)  Phosphorus SerPl QN: 3.5 mg/dL (12/05/23 03:23:00)  Alkaline Phos SerPl QN: 142 Units/L High (12/05/23 03:23:00)  ALT SerPl QN: 8 Units/L (12/05/23 03:23:00)  AST SerPl QN: 13 Units/L (12/05/23 03:23:00)  Bilirubin Total SerPl QN: 0.2 mg/dL (12/05/23 03:23:00)  Total Protein SerPl QN: 5.3 GM/dL Low (12/05/23 03:23:00)  Albumin SerPl QN: 2.5 GM/dL Low (12/05/23 03:23:00)  Magnesium SerPl QN: 1.7 mg/dL (12/05/23 03:23:00)  Gluc-Strip, POC: 90 mg/dL (12/05/23 10:49:00)  Micro - Last 7 days  Staphylococcus spp: Not Detect (11/30/23 14:42:00)  Staphylococcus aureus: Not Detect (11/30/23 14:42:00)  Staphylococcus epidermidis: Not Detect (11/30/23 14:42:00)  Staphylococcus lugdunensis: Not Detect (11/30/23 14:42:00)  Streptococcus spp: Not Detect (11/30/23 14:42:00)  Streptococcus agalactiae (Group B): Not Detect (11/30/23 14:42:00)  Streptococcus pneumoniae: Not Detect (11/30/23 14:42:00)  Streptococcus pyogenes (Group A): Not Detect (11/30/23 14:42:00)  Enterococcus faecalis: Not Detect (11/30/23 14:42:00)  Enterococcus faecium: Not Detect (11/30/23 14:42:00)  Listeria monocytogenes: Not Detect (11/30/23 14:42:00)  Enteric gram-negative bacilli: Detect Abnormal (11/30/23 14:42:00)  Enterobacter cloacae cmplx: Not Detect (11/30/23 14:42:00)  Escherichia coli: Detect Abnormal (11/30/23 14:42:00)  Klebsiella aerogenes: Not Detect (11/30/23 14:42:00)  Klebsiella oxytoca: Not Detect (11/30/23 14:42:00)  Klebsiella pneumoniae grp: Not Detect (11/30/23 14:42:00)  Proteus spp: Not Detect (11/30/23 14:42:00)  Salmonella spp: Not Detect (11/30/23 14:42:00)  Serratia marcescens: Not Detect (11/30/23 14:42:00)  Haemophilus influenzae: Not Detect (11/30/23 14:42:00)  Neisseria meningitidis: Not Detect (11/30/23 14:42:00)  Pseudomonas aeruginosa: Not Detect (11/30/23 14:42:00)  Stenotrophomonas maltophilia: Not Detect (11/30/23 14:42:00)  Acinetobacter baumannii cmplx: Not Detect (11/30/23 14:42:00)  Bacteroides fragilis: Not Detect (11/30/23 14:42:00)  CTX-M: Not Detect (11/30/23 14:42:00)  IMP: Not Detect (11/30/23 14:42:00)  KPC: Not Detect (11/30/23 14:42:00)  mcr-1: Not Detect (11/30/23 14:42:00)  mecA/C: Test Not Performed (11/30/23 14:42:00)  mecA/C and MREJ (MRSA): Test Not Performed (11/30/23 14:42:00)  NDM: Not Detect (11/30/23 14:42:00)  OXA-48-like: Not Detect (11/30/23 14:42:00)  vanA/B: Test Not Performed (11/30/23 14:42:00)  VIM: Not Detect (11/30/23 14:42:00)  Candida albicans: Not Detect (11/30/23 14:42:00)  Candida auris: Not Detect (11/30/23 14:42:00)  Candida glabrata: Not Detect (11/30/23 14:42:00)  Candida krusei: Not Detect (11/30/23 14:42:00)  Candida parapsilosis: Not Detect (11/30/23 14:42:00)  Candida tropicalis: Not Detect (11/30/23 14:42:00)  Cryptococcus neoformans/gattii: Not Detect (11/30/23 14:42:00)  Blood Pathogen Interp: Blood Pathogen Interp (11/30/23 14:42:00)  Blood CX: POS Critical (11/30/23 14:42:00)  Urine CX: NEG (12/01/23 16:41:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.             Signature Line Electronically Signed on 12/05/23 12:40  ________________________________________________________ MD