Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Klebsiella test positive, Limb injury, Marjolin's ulcer, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal
Clinical narrative: Date: 8/30/2022  PCP: MD (General)   Chief Complaint:  Chest pain   History Of Present Illness: Patient is a 70 y.o. male presents with chest pain.  He has pain when he lays flat or when he moves.  He is not able to expand on the pain.  He has some sob.  No cough or hemoptysis.  He was here 2 weeks ago and was supposed to go to rehab but did not and has been living in his truck       Past Medical History:  Patient  has a past medical history of Anxiety attack, Arthritis, Back pain, Blood clot, Community acquired pneumonia, COPD (chronic obstructive pulmonary disease), CVA (cerebral vascular accident), Depression, Diabetes (2008), DVT, GERD (gastroesophageal reflux disease), High Cholesterol, Hypertension, Kidney disease, Mental disorder, MRSA infection (08/18/2022), Neck pain, Pulmonary embolism, Sleep apnea, and Stroke.       Past Surgical History:  Patient's  has a past surgical history that includes Hx Knee Arthroscopy; Hx Acromioplasty/Rotator Cuff Repair, Open; Hx Hernia Repair; Hx Vena Cava Filter Insertion (2001); Hx Carpal Tunnel Release; Hx Broken/Fx Bones (2002); Hx Cardiac Catheterization; Hx Neck Surgery; Hx Spinal Fusion (N/A, 2/17/2012); Hx Arterial Line Insertion (Left, 2/17/2012); and Hx Incision And Drainage (Bilateral, 8/16/2022).   Family History:   Patient's family history includes Alzheimer's Disease in his mother; Cancer in his mother; Diabetes in his brother, mother, and sister; Endocrine Disorder in his mother; Heart Disease in his brother, father, and sister; Hypertension in his brother, father, mother, and sister.       Social History:  He  reports current alcohol use of about 12.5 standard drinks of alcohol per week.  He  reports no history of drug use.  He  reports that he has never smoked. He has never used smokeless tobacco.    Allergies:  Patient has no known allergies.   PTA Medications:  Prior to Admission Medications Prescriptions Last Dose Informant Patient Reported? Taking? -NONFORMULARY/HELP MEDICATION-     No No Sig: 2 L/min Daily. Portable oxygen. Dx: 496 Blood Pressure Monitor Kit     No No Sig: 1 Each Daily. Dx: I10 DULoxetine (CYMBALTA) 60 mg DR capsule     No No Sig: Take 1 Capsule by mouth Twice a day. HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet     No No Sig: Take 1 Tablet by mouth Every 6 hours as needed. Insulin Needles, Disposable, (BD ULTRA-FINE NANO PEN NEEDLE) 32 gauge x 5/32" Ndle     No No Sig: 1 Each Five times a day. Insulin Syringe-Needle U-100 (BD INSULIN SYRINGE ULTRA-FINE) 1 mL 31 gauge x 5/16 Syrg     No No Sig: 1 Each Twice a day. Lancets (COMFORT LANCETS) Misc     No No Sig: 1 Device Four times a day. E11.65 Miscellaneous Medical Supply Misc     No No Sig: 1 Each Daily. Shower bench to use daily to assist with bathing. Miscellaneous Medical Supply Misc     No No Sig: 1 Each Daily. Power mobility device to use daily to assist with mobility and activities of daily living. Miscellaneous Medical Supply Misc     No No Sig: 2 L/min Daily. Portable oxygen concentrator. Dx: 496 SaO2 67% on room air 09/22/12. Miscellaneous Medical Supply Misc     No No Sig: 1 Each Daily. Handicap ramp for entrance of home. Miscellaneous Medical Supply Misc     No No Sig: 1 Each Daily. Wheelchair lift for back of vehicle. Miscellaneous Medical Supply Misc     No No Sig: 1 Each Every week. Patient to check INR at home every week for 12 months. Miscellaneous Medical Supply Misc     No No Sig: 1 Each Once Daily. Blood pressure cuff to monitor blood pressure daily. Miscellaneous Medical Supply Misc     No No Sig: 1 Each Once Daily. Single point cane to use daily to assist with ambulation. Miscellaneous Medical Supply Misc     No No Sig: 1 Each Once Daily. Diabetic shoes with custom inserts. Miscellaneous Medical Supply Misc     No No Sig: 1 Each Once Daily. Rollator walker with seat to use daily to assist with ambulation. Nebulizer & Compressor For Neb Devi     No No Sig: 1 Each As directed. RT OXYGEN PER DELIVERY DEVICE     No No Sig: 2 L/min by Nasal Cannula route RT Continuous. SITagliptin (JANUVIA) 100 mg tablet     No No Sig: Take 1 Tab by mouth Daily. Warfarin (COUMADIN) 4 mg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. Take with coumadin 5 mg for a total dosage 9 mg daily. albuterol (PROAIR HFA) 90 mcg/Actuation inhaler     No No Sig: Take 2 Puffs by inhalation Every 6 hours as needed. albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulization     No No Sig: Take 3 mL by nebulization Every 4 hours as needed for Wheezing. atorvastatin (LIPITOR) 80 mg tablet     No No Sig: Take 1 Tablet by mouth At bedtime. benzonatate (TESSALON PERLES) 100 mg capsule     No No Sig: Take 1 Capsule by mouth Three times a day as needed for Cough. blood sugar diagnostic (ASCENSIA CONTOUR) test strips     No No Sig: by Other route Four times a day. blood-glucose meter (CONTOUR METER) Kit     No No Sig: 1 Kit Four times a day. E11.65 cyclobenzaprine (FLEXERIL) 10 mg tablet     No No Sig: Take 1 Tablet by mouth Twice a day as needed for Muscle spasms. docusate sodium (COLACE) 100 mg capsule     No No Sig: Take 1 Capsule by mouth Once Daily. doxycycline (VIBRAMYCIN) 100 mg capsule     No No Sig: Take 1 Capsule by mouth Every 12 hours for 7 days. famotidine (PEPCID) 20 mg tablet     No No Sig: Take 1 Tablet by mouth Twice a day. furosemide (LASIX) 40 mg tablet     No No Sig: Take 1 Tablet by mouth Daily. gabapentin (NEURONTIN) 300 mg capsule     No No Sig: Take 1 Capsule by mouth Three times a day. Take 1cap at night x3days then 1 cap bid x3days then 1 cap TID guaiFENesin (MUCINEX) 600 mg     No No Sig: Take 1 Tablet by mouth Twice a day. hydrALAZINE (APRESOLINE) 50 mg tablet     No No Sig: Take 1 Tablet by mouth Twice a day. hydrOXYzine hcl (ATARAX) 50 mg tablet     No No Sig: Take 1 Tablet by mouth Every 6 hours as needed for Anxiety. Indications: anxious insulin aspart U-100 (NOVOLOG FLEXPEN U-100 INSULIN) 100 unit/mL sub-q pen     No No Sig: Administer 30 Units subcutaneously Three times a day with meals. insulin detemir U-100 (LEVEMIR FLEXTOUCH U-100 INSULN) 100 unit/mL (3 mL) sub-q flexpen     No No Sig: Administer 50 Units subcutaneously Twice a day. ipratropium (ATROVENT) 0.03 % nasal spray     No No Sig: Spray 2 Sprays in nose Twice a day. losartan (COZAAR) 100 mg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. nebulizer accessories Kit     No No Sig: 1 Each Every 4 hours as needed. Nebulizer tubing, cup, T-piece, and mouthpiece. pantoprazole (PROTONIX) 40 mg DR tablet     No No Sig: Take 1 Tablet by mouth Once Daily. polyethylene glycol 3350 (MIRALAX) 17 gram packet     No No Sig: Take 17 g by mouth Once Daily. potassium chloride (KLOR-CON) 10 mEq tablet     No No Sig: Take 2 Tabs by mouth Once Daily. senna (SENOKOT) 8.6 mg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. walker Misc     No No Sig: 1 Each Daily. Rollator walker with seat to use daily to assist with ambulation. warfarin (COUMADIN) 5 mg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. Take with coumadin 4 mg for a total dosage 9 mg daily.  Facility-Administered Medications: None       Review of Systems:   Review of Systems  Constitutional: Negative for chills and fever.  HENT: Negative for sinus pressure.   Eyes: Negative for visual disturbance.  Respiratory: Negative for wheezing and stridor.   Cardiovascular: Positive for chest pain.  Gastrointestinal: Negative for abdominal pain and blood in stool.  Endocrine: Negative for polyuria.  Genitourinary: Negative for dysuria.  Musculoskeletal: Positive for arthralgias, back pain and myalgias.  Skin: Positive for wound.  Allergic/Immunologic: Negative for immunocompromised state.  Neurological: Negative for syncope and speech difficulty.  Hematological: Does not bruise/bleed easily.  Psychiatric/Behavioral: Negative.         Physical Exam: Blood pressure (!) 144/92, pulse 106, temperature 98.5 °F (36.9 °C), temperature source Oral, resp. rate 13, height 6' 3" (190.5 cm), weight (!) 162.3 kg (357 lb 11.2 oz), SpO2 95 %. Physical Exam Constitutional:      Appearance: He is obese.  HENT:     Head: Normocephalic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Regular rhythm.  Pulmonary:     Breath sounds: No wheezing or rhonchi.  Abdominal:     General: Bowel sounds are normal.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Deformity present. No tenderness.     Cervical back: Neck supple.  Skin:    Capillary Refill: Capillary refill takes 2 to 3 seconds.     Comments: He has large ulcers on both heels  Neurological:     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal.          Labs:   CBC:  Lab Results Component Value Date/Time   WBC 4.4 08/30/2022 1134   RBC 4.55 08/30/2022 1134   HGB 12.6 08/30/2022 1134   HCT 37.5 08/30/2022 1134   MCV 82.5 08/30/2022 1134   MCH 27.6 08/30/2022 1134   MCHC 33.5 08/30/2022 1134   RDW 16.4 08/30/2022 1134   MPV 9.2 08/30/2022 1134   PLATELETCNT 293 08/30/2022 1134   BMP:  Lab Results Component Value Date/Time   SODIUM 130 08/30/2022 1134   POTASSIUM 3.1 08/30/2022 1134   CHLORIDE 93 08/30/2022 1134   CO2 27 08/30/2022 1134   GLUCOSE 328 08/30/2022 1134   BUN 10 08/30/2022 1134   CREATININE 1.0 08/30/2022 1134   CALCIUM 7.5 08/30/2022 1134   OSMOLALITY 273 08/30/2022 1134   BC 10 08/30/2022 1134     Imaging:   cxr ok     ASSESSMENT/PLAN:   Problems and Relevant Co-morbid conditions:: Principal Problem:   Precordial pain Active Problems:   Essential hypertension   Heel ulcer   COVID   Type 2 diabetes mellitus with skin complication, with long-term current use of insulin       * Precordial pain Trend troponin Stress test   COVID Not hypoxic in ED No treatment   Heel ulcer Has heel ulcers bilat Had debridement recently He was supposed to go to rehab but didn't He states he has been living in his truck Wound care to see heels SW to see           DVT ppx - coumadin   MD Physician Specialty:  Infectious Diseases Consults    Signed Date of Service:  09/05/22 1441      Expand AllCollapse All       Hide copied text  Hover for details    ID Consultation Report Requesting Physician:  Wounds    Reason for Consultation:  Dr   Chief Complaint Patient presents with ? Chest Pain     History of Present Illness: Patient is a 70 y.o. male who was admitted on 8/30/2022 11:07 AM came in with a chief complaint of  BLE wounds. He has hx of BLE venous insufficiency. Patient says he developed wounds to both feet after walking.    He is diabetic with most recent HbA1c 14.3.  He had debridement by dr e cx had mrsa given doxy he said he did not take it     He came in for marjolin's of breath and chest pain He had a wbc 4.4 He tested COVID positive  he had a grand son with COVID-19 He was not given remdesivir He was given dexamethasone x1 Patient on room air Patient had vaccine x1 dose on the   Wound was found to be infected x-ray was negative Patient was taken to the all our debridement the vascular surgery or no reviewed       The bilateral wound area was then prepped with Betadine and draped in the usual sterile fashion. The bilateral wound was débrided using a 15 blade as well as a rongeur to removal all devitalized tissues in a sharp full thickness excisional manner to the level of adipose to the margins of viable tissue. Excellent bleeding was encountered.    Some purulent fluid was encountered and a culture swab was sent from each heel.    -Patient has been on cefepime and metronidazole vancomycin but culture today had via Isa was changed to daptomycin   I have been consulted by the team today to provide antibiotic recommendation as well as duration of treatment. Per Patient has a mild cough but no shortness of breath on room air h currently on room air He feeling much better     Past Medical History:  Patient  has a past medical history of Anxiety attack, Arthritis, Back pain, Blood clot, Community acquired pneumonia, COPD (chronic obstructive pulmonary disease), CVA (cerebral vascular accident), Depression, Diabetes (2008), DVT, GERD (gastroesophageal reflux disease), High Cholesterol, Hypertension, Kidney disease, Mental disorder, MRSA infection (08/18/2022), Neck pain, Pulmonary embolism, Sleep apnea, and Stroke.   He has no past medical history of AICD (automatic cardioverter/defibrillator) present, Asthma, Bleeding disorders, Blood transfusion, without reported diagnosis, Cancer, CHF (congestive heart failure), COPD, Crohn disease, Heart attack, Liver disease, Seizure, Thyroid disease, Tuberculosis, or Ulcer disease.   Past Surgical History:  Patient's  has a past surgical history that includes Hx Knee Arthroscopy; Hx Acromioplasty/Rotator Cuff Repair, Open; Hx Hernia Repair; Hx Vena Cava Filter Insertion (2001); Hx Carpal Tunnel Release; Hx Broken/Fx Bones (2002); Hx Cardiac Catheterization; Hx Neck Surgery; Hx Spinal Fusion (N/A, 2/17/2012); Hx Arterial Line Insertion (Left, 2/17/2012); Hx Incision And Drainage (Bilateral, 8/16/2022); Hx Debridement (Right, 8/31/2022); and Hx Debridement (Left, 8/31/2022).   Family History:   Patient's family history includes Alzheimer's Disease in his mother; Cancer in his mother; Diabetes in his brother, mother, and sister; Endocrine Disorder in his mother; Heart Disease in his brother, father, and sister; Hypertension in his brother, father, mother, and sister.    Social History:  He  reports current alcohol use of about 12.5 standard drinks of alcohol per week.  He  reports no history of drug use.  He  reports that he has never smoked. He has never used smokeless tobacco.     Allergies:  Patient has no known allergies.   Prior to Admission Medications:    ? blood sugar diagnostic (ASCENSIA CONTOUR) test strips by Other route Four times a day. ? insulin aspart U-100 (NOVOLOG FLEXPEN U-100 INSULIN) 100 unit/mL sub-q pen Administer 30 Units subcutaneously Three times a day with meals. ? insulin detemir U-100 (LEVEMIR FLEXTOUCH U-100 INSULN) 100 unit/mL (3 mL) sub-q flexpen Administer 50 Units subcutaneously Twice a day. ? Insulin Syringe-Needle U-100 (BD INSULIN SYRINGE ULTRA-FINE) 1 mL 31 gauge x 5/16 Syrg 1 Each Twice a day. ? hydrOXYzine hcl (ATARAX) 50 mg tablet Take 1 Tablet by mouth Every 6 hours as needed for Anxiety. Indications: anxious ? Miscellaneous Medical Supply Misc 1 Each Once Daily. Diabetic shoes with custom inserts. ? Miscellaneous Medical Supply Misc 1 Each Once Daily. Rollator walker with seat to use daily to assist with ambulation. ? [EXPIRED] doxycycline (VIBRAMYCIN) 100 mg capsule Take 1 Capsule by mouth Every 12 hours for 7 days. ? HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet Take 1 Tablet by mouth Every 6 hours as needed. ? gabapentin (NEURONTIN) 300 mg capsule Take 1 Capsule by mouth Three times a day. Take 1cap at night x3days then 1 cap bid x3days then 1 cap TID ? senna (SENOKOT) 8.6 mg tablet Take 1 Tablet by mouth Once Daily. ? docusate sodium (COLACE) 100 mg capsule Take 1 Capsule by mouth Once Daily. ? polyethylene glycol 3350 (MIRALAX) 17 gram packet Take 17 g by mouth Once Daily. ? cyclobenzaprine (FLEXERIL) 10 mg tablet Take 1 Tablet by mouth Twice a day as needed for Muscle spasms. ? DULoxetine (CYMBALTA) 60 mg DR capsule Take 1 Capsule by mouth Twice a day. ? Miscellaneous Medical Supply Misc 1 Each Once Daily. Single point cane to use daily to assist with ambulation. ? Miscellaneous Medical Supply Misc 1 Each Once Daily. Blood pressure cuff to monitor blood pressure daily. ? losartan (COZAAR) 100 mg tablet Take 1 Tablet by mouth Once Daily. ? Warfarin (COUMADIN) 4 mg tablet Take 1 Tablet by mouth Once Daily. Take with coumadin 5 mg for a total dosage 9 mg daily. ? warfarin (COUMADIN) 5 mg tablet Take 1 Tablet by mouth Once Daily. Take with coumadin 4 mg for a total dosage 9 mg daily. ? pantoprazole (PROTONIX) 40 mg DR tablet Take 1 Tablet by mouth Once Daily. ? famotidine (PEPCID) 20 mg tablet Take 1 Tablet by mouth Twice a day. ? potassium chloride (KLOR-CON) 10 mEq tablet Take 2 Tabs by mouth Once Daily. ? benzonatate (TESSALON PERLES) 100 mg capsule Take 1 Capsule by mouth Three times a day as needed for Cough. ? guaiFENesin (MUCINEX) 600 mg Take 1 Tablet by mouth Twice a day. ? furosemide (LASIX) 40 mg tablet Take 1 Tablet by mouth Daily. ? atorvastatin (LIPITOR) 80 mg tablet Take 1 Tablet by mouth At bedtime. ? Insulin Needles, Disposable, (BD ULTRA-FINE NANO PEN NEEDLE) 32 gauge x 5/32" Ndle 1 Each Five times a day. ? hydrALAZINE (APRESOLINE) 50 mg tablet Take 1 Tablet by mouth Twice a day. ? Miscellaneous Medical Supply Misc 1 Each Every week. Patient to check INR at home every week for 12 months. ? albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulization Take 3 mL by nebulization Every 4 hours as needed for Wheezing. ? ipratropium (ATROVENT) 0.03 % nasal spray Spray 2 Sprays in nose Twice a day. ? albuterol (PROAIR HFA) 90 mcg/Actuation inhaler Take 2 Puffs by inhalation Every 6 hours as needed. ? SITagliptin (JANUVIA) 100 mg tablet Take 1 Tab by mouth Daily. ? Miscellaneous Medical Supply Misc 1 Each Daily. Handicap ramp for entrance of home. ? Miscellaneous Medical Supply Misc 1 Each Daily. Wheelchair lift for back of vehicle. ? Nebulizer & Compressor For Neb Devi 1 Each As directed. ? nebulizer accessories Kit 1 Each Every 4 hours as needed. Nebulizer tubing, cup, T-piece, and mouthpiece. ? Miscellaneous Medical Supply Misc 2 L/min Daily. Portable oxygen concentrator. Dx: 496 SaO2 67% on room air 09/22/12. ? Miscellaneous Medical Supply Misc 1 Each Daily. Power mobility device to use daily to assist with mobility and activities of daily living. ? RT OXYGEN PER DELIVERY DEVICE 2 L/min by Nasal Cannula route RT Continuous. ? Miscellaneous Medical Supply Misc 1 Each Daily. Shower bench to use daily to assist with bathing. ? walker Misc 1 Each Daily. Rollator walker with seat to use daily to assist with ambulation. ? Blood Pressure Monitor Kit 1 Each Daily. Dx: I10 ? blood-glucose meter (CONTOUR METER) Kit 1 Kit Four times a day. E11.65 ? Lancets (COMFORT LANCETS) Misc 1 Device Four times a day. E11.65 ? -NONFORMULARY/HELP MEDICATION- 2 L/min Daily. Portable oxygen. Dx: 496     Current Medications:  Current Medications Current Facility-Administered Medications Medication Dose Route Frequency Provider Last Rate Last Admin ? -PHARMACY TO DOSE DAPTOMYCIN (CUBICIN)- 1 Each  1 Each Does not apply CONSULT      ? DAPTOmycin (CUBICIN) 700 mg in admix syringe 14 mL syringe  6 mg/kg (Adjusted) Intravenous Q24H     ? Warfarin (COUMADIN) tab 4 mg  4 mg Oral ONE TIME     ? insulin aspart U-100 (NovoLOG) injection   Subcutaneous SSI    4 Units at 09/05/22 0557 ? -PHARMACY TO DOSE CEFEPIME (MAXIPIME)- 1 Each  1 Each Does not apply CONSULT      ? cefepime (MAXIPIME) 1 g in NS (sodium chloride 0.9%) 100 mL MINI-BAG PLUS  1 g Intravenous Q6H  200 mL/hr at 09/05/22 1228 1 g at 09/05/22 1228 ? kit prep of Tc-99m-tetrofosmin 10 millicurie  10 millicurie Intravenous Once in imaging      ? kit prep of Tc-99m-tetrofosmin 30 millicurie  30 millicurie Intravenous Once in imaging      ? mirtazapine (REMERON) tab 7.5 mg  7.5 mg Oral QHS    7.5 mg at 09/04/22 2209 ? metroNIDAZOLE (FLAGYL) tab 500 mg  500 mg Oral TID   500 mg at 09/05/22 0929 ? -PHARMACY TO DOSE WARFARIN (COUMADIN)- 1 Each  1 Each Does not apply CONSULT      ? gabapentin (NEURONTIN) cap 300 mg  300 mg Oral TID   300 mg at 09/05/22 0928 ? hydrOXYzine hcl (ATARAX) tab 50 mg  50 mg Oral Q6H PRN    50 mg at 09/03/22 2331 ? SITagliptin (JANUVIA) tab 100 mg  100 mg Oral DAILY    100 mg at 09/05/22 0928 ? [Held by provider] atorvastatin (LIPITOR) tab 80 mg  80 mg Oral QHS    80 mg at 09/04/22 2210 ? losartan (COZAAR) tab 100 mg  100 mg Oral DAILY    100 mg at 09/05/22 0927 ? hydrALAZINE (APRESOLINE) tab 50 mg  50 mg Oral BID    50 mg at 09/05/22 0927 ? albuterol (PROVENTIL) neb soln 2.5 mg  2.5 mg Inhalation Q4H PRN      ? guaiFENesin (MUCINEX) ER tab 600 mg  600 mg Oral BID    600 mg at 09/05/22 0927 ? famotidine (PEPCID) tab 20 mg  20 mg Oral BID    20 mg at 09/05/22 0928 ? insulin detemir U-100 (LEVEMIR) injection 50 Units  50 Units Subcutaneous BID    50 Units at 09/04/22 2210 ? insulin aspart U-100 (NovoLOG) injection 30 Units  30 Units Subcutaneous TIDAC    30 Units at 09/03/22 1154 ? docusate sodium (COLACE) cap 100 mg  100 mg Oral DAILY    100 mg at 09/05/22 0927 ? polyethylene glycol 3350 (MIRALAX) packet 17 g  17 g Oral DAILY    17 g at 09/05/22 0929 ? senna (SENOKOT) tab 8.6 mg  8.6 mg Oral DAILY    8.6 mg at 09/05/22 0927 ? furosemide (LASIX) tab 40 mg  40 mg Oral DAILY    40 mg at 09/05/22 0927 ? HYDROcodone-acetaminophen (NORCO) 5-325 mg per tab 1 Tablet  1 Tablet Oral Q6H PRN   1 Tablet at 09/05/22 0033 ? potassium chloride SA (KLOR-CON) tab 20 mEq  20 mEq Oral DAILY    20 mEq at 09/05/22 0927 ? pantoprazole (PROTONIX) DR tab 40 mg  40 mg Oral BID   40 mg at 09/05/22 0927 ? DULoxetine (CYMBALTA) DR cap 60 mg  60 mg Oral BID   60 mg at 09/05/22 0928        Review of Systems: the rest of 12 point ros negative except for the ones in the HPI and as stated below Review of Systems - Negative except as above          Estimated body mass index is 44.62 kg/m² as calculated from the following:   Height as of this encounter: 6' 3" (190.5 cm).   Weight as of this encounter: 161.9 kg (357 lb).   Last Recorded Vital Signs:  Vitals Vitals:   09/04/22 2348 09/05/22 0440 09/05/22 0721 09/05/22 1110 BP: 118/70 122/83 134/80 128/78 BP Location: Right Upper Extremity Right Upper Extremity     Patient Position: Lying Left Side Lying Left Side     Pulse: 98 82 88 97 Resp: 18 20     Temp: 98.1 °F (36.7 °C)   97.8 °F (36.6 °C) 97.4 °F (36.3 °C) TempSrc: Oral Oral     SpO2: 91% 93% 96% 97% Weight:         Height:              Physical Exam: General Appearance: alert, no distress, oriented  HEENT: Normocephalic, Eyes: PERLA, EOMI, no icterus,Ears:no external lesions and Nose: no external lesions Mouth: no thrush , no oral lesions or any obvious abscess Neck: supple, no masses, symmetrical, trachea midline Lungs:  No retractions,clear to auscultation bilaterally, no wheezing,no rales ,no crackles Heart: PMI normal,  regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop, no JVD Abdomen: soft, non-tender.  Bowel sounds normal.  No masses,  no organomegaly, cva nontender Neuro: grossly normal  Lymphatics no cervical, axillary lyphadenopathy Extremities:Yellow wound bed no drainage mild cellulitis     Independent review of Meds and labs  Labs: CBC:   Recent Labs   09/05/22 0127 09/04/22 0531 09/03/22 0222 WBC 5.3 4.5 5.2 RBC 4.40* 4.36* 4.42* HGB 11.9* 11.8* 11.9* HCT 35.5* 35.3* 35.8* MCV 80.8 80.9 81.0 PLATELETCNT 272 237 226     BMP:   Recent Labs   09/05/22 0127 09/04/22 0531 09/03/22 0222 SODIUM 136 130* 134* POTASSIUM 3.8 4.1 3.7 CHLORIDE 98* 97* 98* CO2 32* 28 30 BUN 7 8 8 CREATININE 0.8 0.8 0.8 ESTIMATEDGFR >90 >90 >90 CALCIUM 7.6* 7.4* 7.1* GLUCOSE 235* 191* 156* OSMOLALITY 278 264* 270 TBILIRUBIN 0.4 0.5 0.3 ALP 85 80 74 AST 11 13 13 ALBUMIN 2.5* 2.3* 2.4*     ABG: No results for input(s): PHBLOOD, PCO2ARTERIAL, PO2, HCO3, O2SATURATION, O2, MODE in the last 72 hours.   URINALYSIS No results found for this visit on 08/30/22 (from the past 72 hour(s)). Estimated Creatinine Clearance: 140.4 mL/min (by C-G formula based on SCr of 0.8 mg/dL).    SED RATE (mm/h) Date Value 08/30/2022 96 (H) 08/13/2022 111 (H)    CRP QUANTITATIVE Date Value 08/30/2022 8.9 mg/dL (H) 08/13/2022 20.0 mg/dL (H) 02/06/2020 1.0    PROCALCITONIN, QN, S (ng/mL) Date Value 08/13/2022 0.17     Cultures:  Urine:  Lab Results Component Value Date/Time   URINECULTURE No significant growth. 04/25/2016 1230   Blood:  Lab Results Component Value Date/Time   BLOODCULTURE   08/14/2022 0050     No growth @ 24 hours. No growth @ 48 hours. No growth @ 72 hours. No growth @ 96 hours. No growth @ 120 hours.     BLOODCULTURE   08/14/2022 0050     No growth @ 24 hours. No growth @ 48 hours. No growth @ 72 hours. No growth @ 96 hours. No growth @ 120 hours.     Fluid:No results found for: FLUIDCULTURE Respiratory:  Lab Results Component Value Date/Time   RESPIRATORYC Normal flora with Few Candida albicans. 06/08/2010 2247   RESPIRATORYC Candida albicans 06/08/2010 2247             Old culture data reviewed  Bacteroides vulgatus Abnormal  P      Methicillin resistant staphylococcus aureus Staphylococcus aureus     MIC MIC     Clindamycin 0.25  Sensitive 0.25  Sensitive     Daptomycin 0.25  Sensitive 0.25  Sensitive     Doxycycline <=0.5  Sensitive <=0.5  Sensitive     Inducible Clindamycin Resistance Neg    Neg        Oxacillin MIC >=4  Resistant <=0.25  Sensitive     Trimethoprim/Sulfamethoxazole <=10  Sensitive <=10  Sensitive     Vancomycin 1  Sensitive 1  Sensitive                           nonsusceptibility range due to outdated breakpoints.     GRAM STAIN SMEAR Rare WBC'S. Few Gram positive cocci in pairs.  ROUTINE CULTURE Klebsiella pneumoniae Abnormal   ROUTINE CULTURE Pseudomonas aeruginosa Abnormal   ROUTINE CULTURE Escherichia coli Abnormal   ROUTINE CULTURE Enterobacter cloacae / asburiae Abnormal   ROUTINE CULTURE Enterococcus faecalis Abnormal   ROUTINE CULTURE Methicillin Resistant Staphylococcus aureus Abnormal   ROUTINE CULTURE E. avium - (Group D) Abnormal   Resulting Agency LAB    Susceptibility      Klebsiella pneumoniae Pseudomonas aeruginosa Escherichia coli Enterobacter cloacae / asburiae     MIC MIC MIC MIC     Amoxicillin/Clavulanic Acid <=2  Sensitive     <=2  Sensitive >=32  Resistant     Ampicillin/sulbactam 4  Sensitive     4  Sensitive         Cefazolin <=4  Sensitive     <=4  Sensitive >=64  Resistant     Cefepime <=0.12  Sensitive 2  Sensitive <=0.12  Sensitive <=0.12  Sensitive     Ceftriaxone <=0.25  Sensitive     <=0.25  Sensitive         Ciprofloxacin >=4  Resistant 0.25  Sensitive <=0.06  Sensitive <=0.06  Sensitive     Imipenem <=0.25  Sensitive 2  Sensitive <=0.25  Sensitive 0.5  Sensitive     Levofloxacin 1    1  Sensitive <=0.12  Sensitive <=0.12  Sensitive     Meropenem <=0.25  Sensitive <=0.25  Sensitive <=0.25  Sensitive <=0.25  Sensitive     Piperacill/Tazob <=4  Sensitive 16  Sensitive <=4  Sensitive         Trimethoprim/Sulfamethoxazole <=20  Sensitive     <=20  Sensitive <=20  Sensitive                              Linear View   Estimated Creatinine Clearance: 140.4 mL/min (by C-G formula based on SCr of 0.8 mg/dL).   Susceptibility      Enterococcus faecalis Methicillin resistant staphylococcus aureus E. avium - (group d)     MIC MIC MIC     .Ampicillin <=2  Sensitive     <=2  Sensitive     Clindamycin     0.5  Sensitive         Daptomycin     1  Sensitive         Doxycycline     2  Sensitive         Inducible Clindamycin Resistance     Neg            Oxacillin MIC     >=4  Resistant         Trimethoprim/Sulfamethoxazole     <=10  Sensitive         Vancomycin 2  Sensitive 1  Sensitive <=0.5  Sensitive                              Enterococcus faecium     MIC     .Ampicillin >=32  Resistant     Vancomycin >=32  Resistant                 Previous ID consult data reviewed Reviewed notes of the primary attending and consults.   Imaging:  -reviewed images personally and agree with radiologist findings      XR Foot Left 3+ VW   Result Date: 8/13/2022 PROCEDURE INFORMATION: Exam: XR Left Foot Exam date and time: 8/13/2022 9:51 PM Age: 70 years old Clinical indication: Other: Ulcers; Additional info: Hyperglycemia TECHNIQUE: Imaging protocol: Radiologic exam of the Left foot. Views: 3 or more views. COMPARISON: VASCULAR US VENOUS LOWER EXT BILAT^XCELERA^^VASC US VENO 2/19/2020 3:19 PM FINDINGS: Bones/joints: Calcaneocuboid coalition noted. Small talar beak. Soft tissues: Prominent dorsal soft tissue swelling. No radiopaque foreign body or soft tissue gas.    IMPRESSION: No bony destructive change. Dorsal soft tissue swelling noted without soft tissue gas or radiopaque foreign body. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 08/13/2022 10:30 PM   XR Foot Right 3vw Or More   Result Date: 8/30/2022                         Medical Center                                           Radiology  PROCEDURE DATE:  08/30/2022                                                  ORDERING PHYS:  EXAM: Right foot, 3 views.  CLINICAL INDICATION:  Infection.  COMPARISON:  Prior radiographs, most recent dated 08/13/2022.  PROCEDURE: AP, oblique, lateral views.  FINDINGS: No acute fracture or dislocation is appreciated.  No definite erosive/destructive osseous change or aggressive periosteal reaction to suggest osteomyelitis.  There are stable degenerative changes.  Stable postsurgical changes at the distal tibia are noted.  Tiny posterior and plantar calcaneal enthesophyte formation.  There is stable mild soft tissue swelling.  Area of soft tissue irregularity at the plantar aspect of the heel may correspond to underlying wound/ulceration.  IMPRESSION:  No acute osseous abnormality.  Chronic or degenerative osseous changes as above.  Stable mild soft tissue swelling.  Soft tissue irregularity at the plantar heel may correspond to area of underlying wound/ulceration, correlate with direct inspection.                THIS IS AN ELECTRONICALLY VERIFIED REPORT               8/30/2022 12:25 PM: MD  DD:  08/30/2022 TD:  08/30/2022                                     Radiology Page 1    of   1                                                          COPY   XR Foot Right 3vw Or More   Result Date: 8/13/2022 PROCEDURE INFORMATION: Exam: XR Right Foot Exam date and time: 8/13/2022 9:51 PM Age: 70 years old Clinical indication: Other: Ulcers; Additional info: Hyperglycemia TECHNIQUE: Imaging protocol: Radiologic exam of the Right foot. Views: 3 or more views. COMPARISON: VASCULAR US VENOUS LOWER EXT BILAT^XCELERA^^VASC US VENO 2/19/2020 3:19 PM FINDINGS: Bones/joints: Prior medial malleolar ORIF. No bony destructive change. Talar beak noted. There appears to be calcaneocuboid coalition. Soft tissues: Dorsal soft tissue swelling over the forefoot is nonspecific. No soft tissue gas or radiopaque foreign body.    IMPRESSION: 1. No bony destructive change to suggest osteomyelitis. 2. No significant degenerative change. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 08/13/2022 10:26 PM   CT Head WO Contrast   Result Date: 8/19/2022                         Medical Center                                       Radiology              PROCEDURE DATE:  08/19/2022                                               ORDERING PHYS: EXAM:  CT head without contrast.  INDICATION:  Headache, vision changes.  COMPARISON:  Prior CT scans of the head, most recent dated 04/11/2021.  TECHNIQUE:  Axial imaging of the brain was performed without intravenous contrast.  Coronal and sagittal reformatted images are also provided. Radiation dose reduction methods were employed.  FINDINGS:  Parenchymal volume is within normal limits for age.  The ventricles are normal in size and configuration.  Stable area of mild chronic encephalomalacia within the left parietal region.  No new or additional areas of abnormal attenuation or gray-white matter differentiation loss.  There is no evidence of intracranial hemorrhage.  No evidence of mass effect or midline shift is identified.  The structures of the brain stem and posterior fossa appear grossly unremarkable.  No significant vascular calcification is seen.  The paranasal sinuses appear clear and well-aerated.  The mastoid air cells are well-aerated.  The calvarium is within normal limits.  The extracranial soft tissues demonstrate no significant abnormality.  IMPRESSION:  There are stable chronic changes without acute intracranial process.                 THIS IS AN ELECTRONICALLY VERIFIED REPORT               8/19/2022 12:52 PM: MD DD:  08/19/2022 TD:  08/19/2022                                   Radiology Page 1    of   1                                                          COPY   Stress Test, Pharmacological,w/Myoview (Lexiscan 0.4 mg IV x 1)   Result Date: 9/1/2022 Interpretation Summary Low Risk Study No evidence of ischemia or an old myocardial infarction. ECG AFIB Non-diagnostic Lexiscan stress test. Left Ventricle The LV EF is