Age: 62.0
Sex: M
Vaccine: FLU3
Symptoms: Protein urine present, Pyrexia, Red blood cell count decreased, Red blood cells urine positive, Red cell distribution width normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on November 09, 2024 16:43   Verified By: NP on November 09, 2024 16:43  Encounter Info: Hospital, Inpatient, 11/09/24 -     * Final Report *  Document Contains Addenda        Chief Complaint   right leg cellulitis  History of Present Illness/Subjective     This is a 62 year old patient with a past medical history significant for HF, Afib, aflutter, BPH, COPD, that presented to hospital on 11/09/2024 from home  via pov with c/o cellulitis and is being admitted to inpatient pcu for cellulitis of RLE and hypotension.    This patient was seen and evaluated while still in the ED.  He was found to be lying in bed, alert and oriented and in no distress.  Patient notes he has had recurrent cellulitis in his RLE.  He first had it back in July and was admitted to the hospital.  At that time he had bacteremia and had a long course of IV atbx.  Since then it returned about a month ago and he was treated outpatient with oral Keflex.  He has had no improvement in symptoms since.  His symptoms have seemed to worsen.  Today his pain increased and her reports a subjective fever.  Also reports poor po intake and chronic cough.    No leukocytosis.  Mild anemia.  No thrombocytopenia.  Dimer negative.  He is anticoagulated on Eliquis.  Mild hyponatremia.  CMP within normal limits.  Urine positive for small amount of blood. lactic wnl. BP hypotensive with a map of 51 and systolic pressures of 82.  He was given IVF and his pressures were fluid responsive and are now stable with systolic pressures in the 110s. He is afebrile.  HR rate controlled.  CXR negative. E???????KG shows normal this rhythm with ventricular rate of 73.  PR interval 174.  QTc prolonged at 484.  Normal axis no ectopy no ST elevation or depression. Similiar to previous ekg from 8/3/24  Review of Systems     Constitutional:  No fevers,  no chills Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No sore throat Respiratory:  No shortness of breath,  no cough Cardiovascular:  No chest pain,  + edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea Genitourinary:  No dysuria,  no hematuria Endocrine:  No polyuria,  no polydipsia Musculoskeletal:  R leg pain  Skin:  RLE erythema Neurologic:  No headache,  no focal weakness  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 37.2 °C (Oral)  BP: 112/67  HR: 74 (Peripheral)  RR: 22  SpO2: 96%  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 3 (L/min)  WT: 115.20 kg (WFC)    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    115.2 kg    11/09/24    Patient Height  Current Height:    177.8 cm    11/09/24         Constitutional:  No acute distress Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Skin:  RLE 3+ pitting edema, erythema, venous stasis skin changes, dry skin ??????? Neurologic:  Alert & oriented x 3, no cognitive impairment,  no focal deficits    Assessment/Plan      1. Cellulitis L03.90  Other than hypotension, no other sepsis criteria was met.  Will not start sepsis protocol   recurrent.  Treated inpatient for cellulitis in the same leg and was bacteremic in July. Then treated as an outpatient with Keflex a month ago for the same thing   will start with broad coverage with IV cefazolin and vanc  blood cx pending   given reoccurrence and recent hx of bacteremia, will obtain imaging to r/o osteo.  If needed will obtain an MRI but for now will order an xr of the tib/fib and right foot   2. Hypotension I95.9  Do not think this is due to sepsis. No other sepsis criteria met.  E/o unknown   pressures are low as 82 systolic.  Improved with IVF. will hold off on IVF for now given pressures are currently stable and he has a hx of fluid overload with CHF.   will monitor in PCU and if needed will add IVF.    will hold lisinopril and lasix for now.  Will hold sotalol as well but will monitor HR and will need to consider restarting if HR becomes uncontrolled as he has a hx of afib/afluter  3. (HFpEF) heart failure with preserved ejection fraction I50.30  Currently not in exacerbation   holding on Lasix for now so will need to monitor close  last echo obtained in july and EF was 60%  4. Atrial fibrillation I48.91  HR controlled   will monitor close given BB is being held as noted above   5. BPH (benign prostatic hyperplasia) N40.0  will need to hold home flomax given hypotension.  if pressures are stable overnight will restart   6. COPD with emphysema J43.9  not in exacerbation  will continue home neb treatments   7. Chronic venous insufficiency I87.2  venous doppler pending to right leg   8. Hyperlipidemia E78.5  noted   9. OSA on CPAP G47.33  RT eval   10. Prediabetes R73.03  Diet controlled. monitor with daily CMP for now   Inpatient, medical floor  Daily labs - CBC, CMP Daily   Low Sodium Diet  IV fluids Sl   Telemetry  Full Code Status  VTE Prophylaxis - Fully anticoagulated with Apixaban      Code Status   None Recorded   Chronic Problem List    (HFpEF) heart failure with preserved ejection fraction  Abnormal liver enzymes  Atelectasis of left lung  Atrial flutter  Bacteremia  BMI 37.0-37.9, adult  BPH (benign prostatic hyperplasia)  Cellulitis of leg  Cellulitis of right leg  CHF exacerbation  Chronic pain  Chronic respiratory failure with hypoxia  Chronic venous insufficiency  Class 2 severe obesity with body mass index (BMI) of 35 to 39.9 with serious comorbidity  Clubbing of nail  COPD exacerbation  COPD with emphysema  DDD (degenerative disc disease), lumbosacral  Dyshidrotic eczema  ED (erectile dysfunction)  Edema  Edema leg  Emphysema lung  Epicondylitis, lateral, left  Episcleritis of left eye  Ex-cigarette smoker  Exanthem  Exertional dyspnea  Fatty liver  Fluid overload  Hip pain, bilateral  Hospital discharge follow-up  Hyperlipidemia  Hypertrophy of both inferior nasal turbinates  Internal impingement of left shoulder  Keratitis  Left hip pain  Left shoulder pain  Leg edema  Localized swelling, mass and lump, lower limb  Long term use of drug  Long-term use of immunosuppressant medication  Lumbago without sciatica  Lumbar radiculopathy  Lung nodule  Mass of skin of head  Nasal septal deviation  Nevus of head  Nodule of lower lobe of right lung  Obesity  OSA on CPAP  Osteoarthritis, generalized  Osteoporosis  Prediabetes  Rash  Rheumatoid arthritis  Sepsis due to group A Streptococcus  Sicca syndrome  Solitary lung nodule  Streptococcal bacteremia  Supplemental oxygen dependent  Swelling of left knee joint  Tinea pedis of right foot  Urinary frequency  Vertebral compression fracture  Vitamin D insufficiency  Procedure/Surgical History  ?Colonoscopy (07/24/2024) ?EGD - esophagogastroduodenoscopy (09/06/2023) ?Colonoscopy (03/21/2019) ?Eye examination (06/09/2016) ?Colonoscopy (07/11/2008) ?Chest X-ray (05/02/1962) ?Appendectomy ?back surgery ?Cataract surgery ?foot surgery ?Rotator cuff repair   Surgical History Internal  07/24/2024    Colonoscopy Diagnostic/Screen    MD  09/06/2023    EGD Bx    MD  03/21/2019    Colonoscopy Snare Tmr Polyp Lsn    MD  05/23/2016    Cataract Extraction with IOL  (Left)   MD  04/19/2016    Cataract Extraction with IOL  (Right)   MD  Medications   Home Medications (25) Active  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, 4 Times Daily  apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  azelastine nasal 0.15% spray 2 Spray, intraNASAL, BID  cetirizine 10 mg oral tablet 10 mg = 1 Tablet, PRN, Orally, Daily  Clobetasol (Eqv-Temovate E) 0.05% topical cream 1 App, Topical, BID, apply a thin film right hand  diclofenac 1% topical gel 4 GM, Topical, 4 Times Daily, Use dosing card to measure dose of gel  DME Automated Home Blood Pressure Monitoring Device Not Applicable, Other, Unscheduled  DME Compression Stockings Not Applicable, Other, Unscheduled, knee high20 mm hg  fexofenadine 180 mg oral tablet 1 Tablet, Orally, Daily  fluticasone 50 mCg/inh nasal spray 1 Spray, intraNASAL, BID  fluticasone-umeclidinium-vilanterol 200 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  Fosamax 70 mg oral tablet 70 mg = 1 Tablet, Orally, Weekly, with 6-8 oz plain water, at least 30 minutes before first food, beverage, or medication of the day  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Humira Pen 40 mg/0.4 mL subcutaneous kit See Instructions, INJECT 40MG SUBCUTANEOUSLY EVERY OTHER WEEK  hydroxychloroquine 200 mg oral tablet 1 Tablet, Orally, BID, Eye exam 10/29/24  lisinopril 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Norco 7.5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, TID  Ocean nasal spray 0.65% 1 Spray, Nostrils, Both, TID  Pepcid 20 mg oral tablet 20 mg = 1 Tablet, Orally, BID  Potassium Chloride (Eqv-Klor-Con M10) 10 mEq oral tablet, extended release 10 mEq = 1 Tablet, Orally, BID  ProAir HFA 90 mCg/inh inhalation aerosol 90 mCg = 1 Puff, PRN, Inhalation, Q6H  sotalol 120 mg oral tablet 120 mg = 1 Tablet, Orally, BID  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily  terbinafine 1% topical cream 1 App, Topical, Daily, right foot toes/ ankle  triamcinolone 0.1% topical cream 1 App, Topical, BID, apply a thin filmto affected area  Active Scheduled Inpatient Medications  piperacillin-tazobactam, Injection, 3.375 GM, IVPB, ONCE, Indication: SSTI - Severe/DFI/Necrotizing Fasciitis, Start: 11/09/24 17:00:00  NORepinephrine PREMIX + Sodium Chloride 0.9% PREMIX IV Continuous Titrate - See Comments       One-Time Medications Given 11/08/24 00:00:00 TO 11/09/24 16:43:13  acetaminophen, Tablet, 650 mg, Orally, ONCE, (1 DOSE 11/09/24 13:03:00)  piperacillin-tazobactam, Injection, 4.5 GM, IV Push, ONCE, (1 DOSE 11/09/24 13:03:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 3,456 mL, IVPB, ONCE, (1 DOSE 11/09/24 14:54:00)  vancomycin, Infusion, 2 GM, IVPB, ONCE, (1 DOSE 11/09/24 13:02:00)  PRN Medications (0600 - 0559) from 11/08 - 11/09  Sodium Chloride 0.9%, 1,000 mL, IVPB, Unscheduled, 0  Dose(s)   fentaNYL, 50 mCg, IV Push, Q20min, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Current, Beer, 1-2 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Work/School description: Welder..   Home/Environment   Married.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Alcohol abuse: Father.  Cirrhosis of liver..: Father.  Seizure..: Brother.   Deceased Family Member(s)  Relationship: Father, Age: Unknown, Cause: alcoholic, cirrhosis of liver  Relationship: Brother, Age: Unknown, Cause: died after a seizure  Relationship: Mother, Age: Unknown  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.3 k/cumm (11/09/24 12:42:00)  RBC: 3.7 million/cumm Low (11/09/24 12:42:00)  Hgb: 11.6 GM/dL Low (11/09/24 12:42:00)  Hct: 34.1 % Low (11/09/24 12:42:00)  MCV: 92 fL (11/09/24 12:42:00)  MCH: 31.4 pg (11/09/24 12:42:00)  MCHC: 34.1 GM/dL (11/09/24 12:42:00)  RDW: 13.1 % (11/09/24 12:42:00)  Platelet: 173 k/cumm (11/09/24 12:42:00)  MPV: 7.9 fL (11/09/24 12:42:00)  Neutrophils %: 74 % (11/09/24 12:42:00)  Lymphocytes %: 12 % (11/09/24 12:42:00)  Monocytes %: 14 % (11/09/24 12:42:00)  Eosinophils %: 0 % (11/09/24 12:42:00)  Basophils %: 0 % (11/09/24 12:42:00)  Absolute Neutrophil: 7.6 k/cumm High (11/09/24 12:42:00)  Absolute Lymphocyte: 1.2 k/cumm (11/09/24 12:42:00)  Absolute Monocyte: 1.5 k/cumm High (11/09/24 12:42:00)  Absolute Eosinophil: 0 k/cumm (11/09/24 12:42:00)  Absolute Basophil: 0 k/cumm (11/09/24 12:42:00)  Chemistry:  Sodium SerPl QN: 130 mmol/L Low (11/09/24 12:42:00)  Potassium SerPl QN: 4.8 mmol/L (11/09/24 12:42:00)  Chloride SerPl QN: 96 mmol/L Low (11/09/24 12:42:00)  Carbon Dioxide SerPl QN: 27 mmol/L (11/09/24 12:42:00)  Anion Gap: 7 mmol/L (11/09/24 12:42:00)  BUN SerPl QN: 20 mg/dL (11/09/24 12:42:00)  Creatinine SerPl QN: 1.07 mg/dL (11/09/24 12:42:00)  Estimated GFR (CKD-EPI, no race): 78 mL/min/1.73m2 (11/09/24 12:42:00)  Estimated CRCL (CG): 91 mL/min (11/09/24 12:42:00)  Glucose SerPl QN: 105 mg/dL High (11/09/24 12:42:00)  Calcium Total SerPl QN: 8.7 mg/dL (11/09/24 12:42:00)  Alkaline Phos SerPl QN: 133 Units/L High (11/09/24 12:42:00)  ALT SerPl QN: 48 Units/L (11/09/24 12:42:00)  AST SerPl QN: 78 Units/L High (11/09/24 12:42:00)  Bilirubin Total SerPl QN: 0.9 mg/dL (11/09/24 12:42:00)  Total Protein SerPl QN: 7.5 GM/dL (11/09/24 12:42:00)  Albumin SerPl QN: 3.7 GM/dL (11/09/24 12:42:00)  Lactate Venous Pl QN: 1.8 mmol/L (11/09/24 12:42:00)  Coagulation:  D-Dimer Pl QN: 203 ng/mL DDU (11/09/24 13:27:00)  Urine Studies:  Color: Yellow (11/09/24 13:43:00)  Clarity: Clear (11/09/24 13:43:00)  Specific Gravity: 1.015 (11/09/24 13:43:00)  pH: 6 (11/09/24 13:43:00)  Protein: 50 Abnormal (11/09/24 13:43:00)  Glucose: Normal (11/09/24 13:43:00)  Ketones: NEGATIVE (11/09/24 13:43:00)  Bilirubin: NEGATIVE (11/09/24 13:43:00)  Hgb Ur: Large 3+ Abnormal (11/09/24 13:43:00)  Nitrite: NEGATIVE (11/09/24 13:43:00)  Urobilinogen: Normal (11/09/24 13:43:00)  Leukocyte Esterase Ur: NEGATIVE (11/09/24 13:43:00)  WBC: 0-5 (11/09/24 13:43:00)  RBC: 21-50 Abnormal (11/09/24 13:43:00)  Bacteria: NONE (11/09/24 13:43:00)  Squamous Epithelial: Few (11/09/24 13:43:00)  Hyaline Casts: 6-10 (11/09/24 13:43:00)  Misc UA Micro: Misc UA Micro (11/09/24 13:43:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/09/2024 14:24 - XR Chest PA or AP Portable  IMPRESSION:1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 11/09/24 16:43  ________________________________________________________ NP     Addendum by MD on November 09, 2024 17:26:20 (Verified)    I saw and evaluated the patient in addition to NP. I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care.  Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Breathing comfortably on room air Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  RLE w/ 3+ pitting edema and erythema Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  MD, FACP      Signature Line Electronically Signed on 11/09/24 17:26 ________________________________________________________ MD