Age: 65.0
Sex: M
Vaccine: VARZOS
Symptoms: Coagulation test, Computerised tomogram head abnormal, Condition aggravated, Confusional state, Creatinine renal clearance decreased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on October 12, 2022 13:11 EDT   Verified By: MD on October 12, 2022 13:11 EDT   Encounter Info: Hospital, Inpatient, 10/12/22 - 10/20/22    * Final Report *          History of Present Illness/Subjective      Chief Complaint: Altered mental state HPI: Patient is a 65-year-old male with previous medical history of hyperlipidemia, obesity, prediabetes, BPH, GERD, fibromyalgia on chronic pain medication and severe obstructive sleep apnea and COPD presented to emergency department via EMS for altered mental state.  Patient lives with his family and as per EMS the patient was not responding normally to family when they arrived.  Vital signs were unremarkable but he was this morning and being combative with EMS.  As per EMS report living conditions were very poor at the house.  So bad that 1 medic was vomiting outside the hospital due to the smell.  Patient has been in recliner and has been in recliner for many days seated and seated in his own urine and stool.  It took about for paramedics 2 hours to ask extricate him from the home.  Many insects are in the home wife and daughter told the crew that they had been trying to convince the patient to see his doctor for a while now but he has refused.  EMS also found a fentanyl patch on patient.  As per the family patient is confused since last night and has reported feeling ill all day yesterday.  Upon evaluation in the emergency room patient presented with a temp of 99 which max that 100.6 and blood pressure that was elevated at 185/95 with increased respirations.  Chest x-ray was done in the emergency room that showed right midlung opacity similar to 2/7/2021 may represent persistent scarring or atelectasis versus recurrent infiltrate.  CT head without IV contrast was also obtained that failed to reveal anything new.  Laboratory data was positive for a normal white count kidney function which appears to be slightly decreased with a creatinine of 1.5 with a baseline of about 1-1.1.  Sugar elevated at 158 normal liver enzymes normal cardiac enzymes ammonia levels normal lactate 1.9 and blood gas showing oxygenation to be low.  U tox positive for oxycodone.  Urinalysis negative flu negative COVID-negative.  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)  , BP 171/84 (171-199)/(74-119), HR 84 (76-87), RR 22 (22-29), O2Sat 89 (89-89)     Patient Weight    Patient Height  None Reported     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    Assessment/Plan       1. Sepsis   A41.9   Patient meets criteria for sepsis due to having a temp of 100.4 with increased respirations and some oxygen requirement indicating pneumonia on chest x-ray.  -Patient will be started on broad-spectrum antibiotics.  -Check procalcitonin, Legionella, strep antigen.  -De-escalate antibiotics as needed.  -Admit patient to ICU due to sepsis and hypertensive urgency.   2. Community acquired pneumonia   J18.9   Noted on the chest x-ray and from the vital signs.  -Management as in #1   3. Hypertensive urgency   I16.0  start patient on labetalol drip with SBP goal of 175 for first 24 hours. Monitor for end organ damage.  get echocardiogram   4. COPD exacerbation   J44.1   Mild exacerbation of COPD patient does have moderate COPD as per the notes from the chart.  -We will start patient on prednisone initially to see if he does okay with that otherwise we will start him on Solu-Medrol.  -RT protocol.   5. BPH (benign prostatic hyperplasia)   N40.0   Resume home medications   6. Chronic, continuous use of opioids   F11.90   We will investigate the use of chronic opioids.  Patient did have a fentanyl patch on his body.  As per the pharmacy report patient is being prescribed fentanyl patch 50 mcg/h and Percocet 10/325 5/day by Dr..  -Hold medications for now until patient is more alert and awake.   7. Obesity, Class III, BMI 40-49.9 (morbid obesity)   E66.01   Noted.   8. Hyperlipidemia   E78.5   Resume home medications   9. Noncompliance with CPAP treatment   Z91.14   RT protocol   10. GERD (gastroesophageal reflux disease)   K21.9   Start PPIs.   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 10/12/22 10:43:00 EDT  albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q2H, PRN, Shortness of Breath/Wheezing, 10/12/22 11:18:00 EDT, RT Care Assessment and Protocol per Policy  azithromycin, 500 mg, IVPB, Injection, Q24H, 10/13/22 11:00:00 EDT, for 4 Doses, 10/16/22 11:00:00 EDT, 250 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 250  cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), 10/12/22 12:00:00 EDT, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  heparin, 5,000 Units, Subcutaneous, Injection, Q12H, Routine, 10/12/22 11:00:00 EDT  labetalol 500 mg + Sodium Chloride 0.9% 150 mL, Total Volume (mL) = 250, IV, 10/12/22 10:39:00 EDT, Titrate - See Comments  metroNIDAZOLE, 500 mg, IVPB, Infusion, Q8H, 10/12/22 19:00:00 EDT, 100 mL/hr, Infuse Over 60 minutes, Total Volume (mL) = 100  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 10/12/22 10:43:00 EDT  pantoprazole, 40 mg, Orally, Tab, Delayed Rel, Daily, 10/13/22 9:00:00 EDT  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, 10/13/22 9:00:00 EDT  predniSONE, 40 mg, Orally, Tablet, Daily, 10/13/22 9:00:00 EDT, for 5 Days, 10/17/22 9:00:00 EDT  promethazine, 12.5 mg, IVPB, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 10/12/22 10:43:00 EDT, 300 mL/hr, Infuse Over 10 minutes, Total Volume (mL) = 50  Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 10/12/22 10:43:00 EDT, 150 mL/hr, Clinical Weight  vancomycin, 1.5 GM = 15 mL, IVPB, Injection, Q12H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 10/12/22 20:00:00 EDT  2000 mg Sodium, 20 gm Saturated Fat Diet  Admit to Inpatient   Basic Metabolic Panel  Blood CX  Blood CX  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  CBC w/Differential  COPD Education per Respiratory Care  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Echocardiogram with Cardiac Doppler PW/CW/Color  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  L pneumophila Ag Ur QL  Level of Care  Medical Service  MRSA PCR  OT Evaluation and Treatment  Peripheral IV Insertion  Procalcitonin  Procalcitonin  PT Evaluation and Treatment  PT Evaluation and Treatment  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  Strep pneumoniae Ag Urine  Vancomycin Pharmacy Dosing Consult  Vital Signs  Vital Signs  Weight   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.  Code Status   Resuscitation Status - Ordered    -- 10/12/22 10:43:00 EDT, Full Code   Chronic Problem List    Alopecia  BPH (benign prostatic hyperplasia)  Chronic pain  Chronic, continuous use of opioids  Encounter for long-term (current) use of medications  Fibromyalgia  GERD (gastroesophageal reflux disease)  History of 2019 novel coronavirus disease (COVID-19)  History of Barrett's esophagus  History of renal cell carcinoma  History of right nephrectomy  Hyperlipidemia  Idiopathic neuropathy  Leg weakness  Noncompliance with CPAP treatment  Obesity, Class III, BMI 40-49.9 (morbid obesity)  Onychogryphosis  Onychomycosis  Osteoarthritis  Plantar fasciitis of right foot  Prediabetes  Routine health maintenance  Severe obstructive sleep apnea  Stage 2 moderate COPD by GOLD classification  Vitamin D deficiency  Procedure/Surgical History  ?lipoma removal (03/22/2016) ?Cervical Fusion (2014) ?Cholecystectomy Open (2012) ?Lung (2011) ?Kidney (2010) ?right nephrectomy (2010) ?thumb (2009) ?Knee Replacement (2007) ?Rotator Cuff Repair (2007) ?Ventral Hernia Repair (2005) ?Knee Replacement (2003) ?Carpal Tunnel Repair ?Cataract Extraction ?Colonoscopy ?cyst removed from rt side of neck ?Lipoma ?Tarsal tunnel release   Surgical History Internal  10/15/2019    EGD Diagnostic    MD  07/30/2015    EGD Bx   MD       Medications   Home Medications (30) Active  Allegra-D 12 Hour 60 mg-120 mg oral tablet, extended release 1 Tablet, Orally, Q12H  aspirin 325 mg oral tablet 325 mg = 1 Tablet, Orally, QPM  Centrum 1 Tablet, Orally, QAM  DME Adult Diapers 5 Box, Other, Unscheduled, Use as needed for incontinence.  Depends  dutasteride 0.5 mg oral capsule See Instructions, TAKE 1 CAPSULE BY MOUTH EVERY DAY  Endocet 10/325 oral tablet 1 Tablet, Orally, 5 Times Daily, please notify pt when RX is readymust last 30 days  esomeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, BID  ezetimibe 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  fentaNYL 50 mCg/hr transdermal film, extended release 1 Patch, Topical, Q72H  ferrous sulfate 325 mg oral tablet 325 mg = 1 Tablet, Orally, QPM  fluticasone 50 mCg/inh nasal spray See Instructions, USE 2 SPRAYS IN EACH NOSTRIL ONCE DAILY  Incruse Ellipta 62.5 mCg inhalation powder 62.5 mCg = 1 Each, Inhalation, Q24H, doses should be taken at least 24 hours apart  Lexapro 20 mg oral tablet 15 mg = 0.75 Tablet, Orally, QAM  Lidoderm 5% patch 2 Patch, PRN, Topical, Q12H  Lidoderm 5% topical film 1 Patch, Topical, Daily, remove patches after 12 hours  Linzess 145 mcg oral capsule 145 mCg = 1 Capsule, PRN, Orally, QAM  Misc Supplies See Instructions, Pt needs a humidifier with his home O2 due to having nose bleeds  Narcan 4 mg/0.1 mL nasal spray 1 Spray, intraNASAL, ONCE, may repeat every 2 to 3 minutes until patient responds  Pataday 0.2% ophthalmic solution 1 Drop, Eyes, Both, Daily, as needed  Pepcid 40 mg oral tablet 40 mg = 1 Tablet, Orally, BID  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, BID  tiotropium 2.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, Daily  Trelegy Ellipta 200 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  Ventolin HFA 90 mCg/inh inhalation aerosol See Instructions, INHALE 2 PUFFS EVERY FOUR HOURS AS NEEDED FOR WHEEZING  Vitamin B-12 1000 mcg oral tablet 1,000 mCg = 1 Tablet, Orally, QAM  Vitamin C 500 mg oral tablet 1,000 mg = 2 Tablet, Orally, QAM  Vitamin D2 1.25 mg (50,000 intl units) oral capsule 50,000 Units = 1 Capsule, Orally, Weekly  Vitamin D3 2000 intl units oral tablet 2 tablets, Orally, QAM  Voltaren Topical 1% topical gel 4 GM, Topical, 4 Times Daily, Use dosing card to measure dose  Zofran 8 mg oral tablet 8 mg = 1 Tablet, Orally, Q8H, 1 tablet Q8H prn  Active Scheduled Inpatient Medications  azithromycin, Injection, 500 mg, IVPB, Q24H, Start: 10/13/22 11:00:00  cefePIME, Injection, 1 GM, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 10/12/22 12:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q12H, Start: 10/12/22 11:00:00  metroNIDAZOLE, Infusion, 500 mg, IVPB, Q8H, Start: 10/12/22 19:00:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 10/13/22 09:00:00  polyethylene glycol 3350, Powder, 17 GM, Orally, Daily, Start: 10/13/22 09:00:00  predniSONE, Tablet, 40 mg, Orally, Daily, Start: 10/13/22 09:00:00  Vancocin, Injection, 1.5 GM, IVPB, Q12H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), Start: 10/12/22 20:00:00  Sodium Chloride 0.9%  1,000 mL IV  150 mL/hr     Labetalol + Sodium Chloride 0.9% IV 0.5 mg/min 0.5 mg/min    Labetalol + Sodium Chloride 0.9% IV Titrate - See Comments 0.5 mg/min      One-Time Medications Given 10/11/22 00:00:00 TO 10/12/22 13:11:43  None Reported  PRN Medications (0600 - 0559) from 10/11 - 10/12  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2.5 mg, Neb Inhal, Q2H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   promethazine, 12.5 mg, IVPB, Q6H, 0  Dose(s)   Allergies   Cymbalta (shakey)  Plavix  Unlisted Material/Environmental Allergy (blisters)  Enbrel (body aches)  Tape  Zocor (Skin Rash, hives)  ibuprofen (jittery, Itching)  sulfa drugs (intestinal cramps)  KlonoPIN (Unknown)  Lipitor (Unknown)  Pentoxil  Rapaflo (Unknown)  Savella (Unknown)  Zoloft (Unknown)  dexamethasone (Unknown)  nortriptyline (Unknown)  sulindac (unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Arthritis...: Mother and Father.  Cancer: Negative: Mother.  Cancer: Father.  Chest pain...: Father.Negative: Mother.  Degenerative joint disease: Brother.  Diabetes mellitus...: Negative: Mother.  Diabetes...: Father.  Heart disease: Father.  Heart disease...: Negative: Mother.  Hypercholesteremia...: Negative: Mother.  Hyperlipidemia: Father.  Kidney disease: Father.  Low blood pressure...: Mother.  Lupus: Sister.  Osteoporosis...: Mother and Father.  Parkinson's disease..: Mother.  Prostate cancer..: Father.  Rheumatoid arthritis: Sister.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 8.7 k/cumm (10/12/22 04:45:00)  RBC: 4.85 million/cumm (10/12/22 04:45:00)  Hgb: 15 GM/dL (10/12/22 04:45:00)  Hct: 46.4 % (10/12/22 04:45:00)  MCV: 96 fL (10/12/22 04:45:00)  MCH: 30.9 pg (10/12/22 04:45:00)  MCHC: 32.3 GM/dL (10/12/22 04:45:00)  RDW: 14.5 % (10/12/22 04:45:00)  Platelet: 245 k/cumm (10/12/22 04:45:00)  MPV: 10 fL (10/12/22 04:45:00)  Neutrophils %: 75 % (10/12/22 04:45:00)  Lymphocytes %: 18 % (10/12/22 04:45:00)  Monocytes %: 6 % (10/12/22 04:45:00)  Eosinophils %: 1 % (10/12/22 04:45:00)  Basophils %: 0 % (10/12/22 04:45:00)  Absolute Neutrophil: 6.6 k/cumm (10/12/22 04:45:00)  Absolute Lymphocyte: 1.6 k/cumm (10/12/22 04:45:00)  Absolute Monocyte: 0.5 k/cumm (10/12/22 04:45:00)  Absolute Eosinophil: 0.1 k/cumm (10/12/22 04:45:00)  Absolute Basophil: 0 k/cumm (10/12/22 04:45:00)  Chemistry:  Sodium SerPl QN: 140 mmol/L (10/12/22 04:45:00)  Potassium SerPl QN: 4 mmol/L (10/12/22 04:45:00)  Chloride SerPl QN: 101 mmol/L (10/12/22 04:45:00)  Carbon Dioxide SerPl QN: 25 mmol/L (10/12/22 04:45:00)  Anion Gap: 14 mmol/L High (10/12/22 04:45:00)  BUN SerPl QN: 14 mg/dL (10/12/22 04:45:00)  Creatinine SerPl QN: 1.51 mg/dL High (10/12/22 04:45:00)  Estimated GFR (CKD-EPI): 48 mL/min/1.73m2 Low (10/12/22 04:45:00)  Estimated GFR (CKD-EPI, no race): 51 mL/min/1.73m2 Low (10/12/22 04:45:00)  Estimated CRCL (CG): 82 mL/min (10/12/22 04:45:00)  Glucose SerPl QN: 158 mg/dL High (10/12/22 04:45:00)  Calcium Total SerPl QN: 10.1 mg/dL (10/12/22 04:45:00)  Alkaline Phos SerPl QN: 54 Units/L (10/12/22 04:45:00)  ALT SerPl QN: 15 Units/L (10/12/22 04:45:00)  AST SerPl QN: 19 Units/L (10/12/22 04:45:00)  Bilirubin Direct SerPl QN: 0.2 mg/dL (10/12/22 04:45:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (10/12/22 04:45:00)  Total Protein SerPl QN: 8 GM/dL (10/12/22 04:45:00)  Albumin SerPl QN: 4.5 GM/dL (10/12/22 04:45:00)  Magnesium SerPl QN: 1.8 mg/dL (10/12/22 04:45:00)  Lipase SerPl QN: 14 Units/L (10/12/22 04:45:00)  Troponin-I High Sensitivity: 5 ng/L (10/12/22 04:45:00)  Ammonia Pl QN: 44 mCmol/L (10/12/22 04:45:00)  Lactate Venous Pl QN: 1.9 mmol/L (10/12/22 04:45:00)  Gluc-Strip, POC: 155 mg/dL High (10/12/22 04:07:00)  Blood Gas Comment: venous (10/12/22 04:45:00)  pH Bld Venous QN: 7.4 (10/12/22 04:45:00)  PCO2 Bld Venous QN: 48 mmHg (10/12/22 04:45:00)  PO2 Bld Venous QN: 46 mmHg High (10/12/22 04:45:00)  Base Excess Bld Venous: 4 mmol/L High (10/12/22 04:45:00)  Bicarb Bld Venous Calc: 30 mmol/L High (10/12/22 04:45:00)  O2 Sat Bld Venous Calc: 82 % (10/12/22 04:45:00)  FIO2: venous (10/12/22 04:45:00)  Patient Temperature: 37 DegC (10/12/22 04:45:00)  Coagulation:  PT: 12.4 seconds (10/12/22 04:45:00)  INR: 1.08 (10/12/22 04:45:00)  aPTT: 35.7 seconds (10/12/22 04:45:00)  Urine Studies:  Color: Yellow (10/12/22 04:45:00)  Clarity: Clear (10/12/22 04:45:00)  Specific Gravity: 1.020 (10/12/22 04:45:00)  pH: 6.0 (10/12/22 04:45:00)  Protein: NEGATIVE (10/12/22 04:45:00)  Glucose: NEGATIVE (10/12/22 04:45:00)  Ketones: NEGATIVE (10/12/22 04:45:00)  Bilirubin: NEGATIVE (10/12/22 04:45:00)  Hgb Ur: NEGATIVE (10/12/22 04:45:00)  Nitrite: NEGATIVE (10/12/22 04:45:00)  Urobilinogen: NormalUro (10/12/22 04:45:00)  Leukocyte Esterase Ur: NEGATIVE (10/12/22 04:45:00)  Toxicology:  Amphetamine Urine Scn QL: Negative (10/12/22 04:45:00)  Methamphetamine Urine Scn QL: Negative (10/12/22 04:45:00)  Barbiturates Urine Scn QL: Negative (10/12/22 04:45:00)  Benzodiazepines Urine Scn QL: Negative (10/12/22 04:45:00)  Cannabinoid Urine Scn QL: Negative (10/12/22 04:45:00)  Cocaine Urine Scn QL: Negative (10/12/22 04:45:00)  Opiates Urine Scn QL: Negative (10/12/22 04:45:00)  PCP Urine Scn QL: Negative (10/12/22 04:45:00)  Methadone Urine Scn QL: Negative (10/12/22 04:45:00)  Propoxyphene Urine Scn QL: Negative (10/12/22 04:45:00)  Oxycodone Urine Scn QL: Positive Abnormal (10/12/22 04:45:00)  Buprenorphine Urine Scn QL: Negative (10/12/22 04:45:00)  Tricyclic Antid Urine Scn QL: Negative (10/12/22 04:45:00)  Drugs of Abuse Comment: See Comment (10/12/22 04:45:00)  Ethanol Pl QN: <10 (10/12/22 04:45:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (10/12/22 04:45:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (10/12/22 04:45:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (10/12/22 07:05:00)  Rapid Influenza A PCR: Not Detected (10/12/22 07:05:00)  Rapid Influenza B PCR: Not Detected (10/12/22 07:05:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 10/12/2022 05:16 - CT Head W/o IV Contrast  IMPRESSION: 1.  Chronic findings as above without acute intracranial abnormality.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss this case further cancontact the Emergency Radiology.    10/12/2022 09:45 - XR Chest PA or AP Portable  IMPRESSION:Bibasilar subsegmental atelectasis or scarring.Right midlung opacity similar to 2/7/2021 may represent persistentscarring or atelectasis versus recurrent infiltrate.                Signature Line Electronically Signed on 10/12/22 13:11 EDT ________________________________________________________ MD