Age: 67.0
Sex: M
Vaccine: COVID19-2
Symptoms: Computerised tomogram head abnormal, Computerised tomogram neck, Condition aggravated, Creatinine renal clearance decreased, Depressed level of consciousness
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 15, 2023 20:37   Verified By: MD on February 15, 2023 20:37   Encounter Info: Hospital, Inpatient, 02/15/23 -     * Final Report *          History of Present Illness/Subjective     Patient is a 77-year-old male with past history significant for glioblastoma multiforme a present emergency room with after being found at home unresponsive and later with seizure activity.  Patient states that he has had intermittent symptoms of unsteadiness with ambulation that have been transient over the course of last several months.  On this morning he is not sure how he felt early on but a family member came home to find him at home alone staring off and having a shaking episode involving his right upper and later his left lower extremity.  He continued to remain poorly responsive with movement of the right upper and lower extremity and with this shaking EMS was called.  This event was terminated by EMS using intranasal Versed.  Afterwards patient was sedated and unresponsive.  Upon arousing he had slurred speech and generalized malaise and fatigue.  He was unable to follow commands initially.  Later began developing symptoms of dysarthria as well.  No noted bowel or bladder incontinence.  In ER stroke alert was paged and CT as well as CTA of the head and neck were performed.   CT showed prior left temporal inferior parietal craniotomy for tumor resection with similar posttreatment changes of the left temporal lobe.  There were no acute intracranial abnormalities noted.  CTA of the neck was otherwise unremarkable.  There is however poor arterial opacification of the head CTA due to delayed timing.  As time in the emergency room he became increasingly more lucid and regained complete function of both upper and lower extremities.  His mentation has continued to improve with still some residual cloudiness over the events that ensued.   In the emergency room his blood pressure was 171/81 heart rate 115 respiratory rate 16 oxygen saturation 97% on 3 L.  He was afebrile.   Serology: White count 6400 with normal differential hemoglobin 15.7 hematocrit 48.7 platelet count of 135,000.  Sodium 135 potassium 4.2 chloride of 99 bicarb 25 BUN 13 creatinine 1.14 and a blood sugar of 114.  Calcium 8.6 alkaline phosphatase 42 ALT 24 AST 27 total bilirubin 0.6 total protein 6.2 albumin 4.1 lipase 44 troponin I of 10 serum lactate 3.2.  Venous blood gas pH 7.34 PCO2 49 PO2 39.  Urinalysis was unremarkable.  MRI brain showed new focus of enhancement along the left lateral periatrial region measuring 0.9 x 1.2 cm with associated increased flair abnormality in this region and within the superior most aspect of the left temporal lobe.  There is no associated diffusion restriction.  Findings suspicious for possible progressive disease which can better evaluated with an MR brain perfusion study or PET MRI study.  BT RADS equal 3C which indicates concern for progressive disease and recommendation of shorter interval imaging perhaps with more advanced brain imaging.  There is improvement of the previous enhancement of the left temporal lobe with stable appearance of the FLAIR abnormality in the mid to inferior temporal lobe region.   Head CT and CT angiogram as noted above.   Past medical history: Glioblastoma multiforme status postcraniotomy and resection in March/2021, hypertension, lumbar disc disease, GERD with esophagitis, hyperlipidemia, impaired glucose tolerance, osteoarthritis, chronic renal insufficiency, thrombocytopenia.  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)  Temp (CEL) 36.9 (36.8-36.9)  Temp (FAHR) 98.4 (98.2-98.4), BP 142/74 (105-147)/(61-82), HR 87 (67-87), RR 14 (12-19), O2Sat 93 (91-93) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    98.8 kg    02/15/23  BMI:    30.4    02/15/23    Obese (BMI 30-39.9) Patient Height  Current Height:    180.3 cm    02/15/23             General:  Alert and oriented, No acute distress.  Reported some cloudiness regarding recent recall       Eye:  Extraocular movements are intact, Vision unchanged       HEENT:  Normocephalic, Normal hearing       Neck:  Supple, Non-tender       Respiratory:  Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness.         Cardiovascular:  Regular rate, Normal rhythm, No murmur, No gallop, Normal peripheral perfusion, Good pulses equal in all extremities, No edema.          Gastrointestinal:  Soft, nontender, nondistended, normal bowel sounds, no evidence of hepatosplenomegaly.       Lymphatics:  No lymphadenopathy neck       Musculoskeletal:  Normal range of motion, Normal strength       Integumentary:  Warm, Dry, No rash.         Feet:  Normal by visual exam, Normal pulses, Sensation intact.         Neurologic:  Alert, Oriented, Normal motor function       Psychiatric:  Cooperative, Appropriate mood & affect, Normal judgment.      Assessment/Plan       1. Status epilepticus   G40.901  Patient actually presented at home and status epilepticus that was aborted by intranasal Versed.  Now in the emergency room postictal.  Neurology has been consulted.  He was recommended that he be loaded with IV Keppra and started on oral Keppra therapy.  Initially was to be transferred to a tertiary facility where neurology was present however there were no beds available at any facility in the region.  That being said I spoke with neurology personally and discussed the case with them.  The plan is to start him on Keppra 750 mg p.o. twice daily and we also addressed starting him on low-dose Decadron 2 mg p.o. twice daily to be tapered as an outpatient.  I have asked oncology to see him in consultation as well to assist with guidance of our future plan.  He does have an established oncologist as well.  We will continue to monitor him with neurochecks and seizure precautions.  I addressed obtaining an EEG with neurology and they felt that was not necessary at this time.  If patient has any further decline in mentation or change in motor activity will consult neurology and make a transition to a tertiary care facility immediately.   2. Acute repetitive seizure   G40.909  As above.   3. Brain mass   G93.89  There is a new brain mass that likely represents a recurrence of glioblastoma multiform as before.  Further imaging may be performed during this visit but likely will be performed as an outpatient.  I have asked oncology to see patient in consultation and assist in guiding our future treatment plan.   4. Glioblastoma multiforme   C71.9  Status post resection in 2021.  Potential recurrence on most recent MRI.  Ongoing follow-up with oncology.   5. Hyperglycemia   R73.9  Blood sugars been relatively stable as an outpatient.  Given the fact for starting him on Decadron we will continue to monitor him with sliding scale insulin and frequent Accu-Cheks.  A1c pending at this time.   6. Hypertension   I10  Blood pressure was elevated up initially now better.  We will continue to monitor closely.  We will titrate his home regimen accordingly.   7. GERD (gastroesophageal reflux disease)   K21.9  Continue reflux precautions and PPI therapy.   8. Chronic renal insufficiency   N18.9  Renal function remained stable at this time.  We will avoid nephrotoxic agents and maintain adequate hydration.   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/15/23 12:00:00   acetaminophen, 1,000 mg, Orally, Tablet, Q8H, PRN, Pain Mild PO (1-3 out of 10), 02/15/23 12:00:00   dexamethasone, 2 mg, Orally, Tablet, BID, 02/15/23 12:30:00   Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 02/15/23 12:00:00, PRN - See Comments, Clinical Weight  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 02/15/23 12:00:00  glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 02/15/23 12:00:00   hydroCODONE-acetaminophen, 1 Tablet, Orally, Tablet, Q6H, PRN, Pain Moderate PO (4-6 out of 10), 02/15/23 12:00:00   insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 02/15/23 12:00:00   leveTIRACetam, 750 mg, Orally, Tablet, BID, 02/15/23 12:30:00   melatonin, 9 mg, Orally, Tablet, At Bedtime, PRN, Insomnia, 02/15/23 16:43:00   ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 02/15/23 12:00:00   pantoprazole, 40 mg, Orally, Tab, Delayed Rel, Daily, NOW, 02/15/23 11:58:00   Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 02/15/23 12:00:00, 60 mL/hr, Clinical Weight  2000 mg Sodium, 20 gm Saturated Fat Diet  Admit to Inpatient CAH  Call (Specify)  Call Blood Glucose  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  Call Urine Output  CBC w/Differential  CK SerPl QN  Comp Metabolic Panel  Fluid Intake Requirement  Gluc-Strip POC  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Lactate Pl Venous QN  Level of Care  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  Notify Provider  Notify Provider  Notify Provider  OT Evaluation and Treatment  Peripheral IV Insertion  PT Evaluation and Treatment  Resp Evaluation or Assessment  Resuscitation Status  Seizure Precautions  Sequential Compression Device  Speech for Communication/Cognition Eval and Treat  TSH w FreeT4 reflex  Vital Signs  Weight  GI and DVT prophylaxis have been addressed.   Home medications were reviewed and appropriate medications ordered at this time.   Total critical care time: Approximately 50 minutes?status epilepticus/new brain mass/glioblastoma multiforme  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 this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers.  This 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.  Code Status   Resuscitation Status - Ordered    -- 02/15/23 12:00:00, Full Code   Chronic Problem List    Acute repetitive seizure  Allergic rhinitis  Allergic rhinitis  Anxiety  Benign essential hypertension  Benign neoplasm of ascending colon  Benign neoplasm of transverse colon  Brain mass  Chronic renal insufficiency  Degeneration of lumbar intervertebral disc  Edema  GERD (gastroesophageal reflux disease)  GERD with esophagitis  Glioblastoma multiforme  Hyperglycemia  Hyperlipidemia  Hypertension  Impaired fasting glucose  Malaise and fatigue  Nephrolithiasis  Osteoarthritis of hand  Recurrent sinusitis  Renal insufficiency  Status epilepticus  Testicular failure  Thrombocytopenia  Well adult exam  Procedure/Surgical History  ?Craniotomy (03/09/2021) ?Colonoscopy (06/14/2018) ?Index finger (1990) ?Shoulder (1982) ?Tonsillectomy with adenoidectomy (1966) ?Hernia repair ?History of cholecystectomy ?Orthopedic Surgery ?left bicep procedure   Surgical History Internal  03/09/2021    Craniotomy Brain Tumor Excision  (Left)   MD  Medications   Home Medications (8) Active  anastrozole 1 mg oral tablet , TAKE 1 TABLET BY MOUTH ON MONDAY, WEDNESDAY, AND FRIDAY  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily, to REPLACE simvastatin.  Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, Every Other Day  Testosterone Cypionate 200 mg/mL intramuscular solution 100 mg, IM, Every Friday  Valium 10 mg oral tablet See Instructions, take 1 tab 30 minutes prior to MRI  valsartan-hydroCHLOROthiazide 320 mg-12.5 mg oral tablet 1 Tablet, Orally, Daily  Vitamin B-12 1 Tablet, Orally, QAM  Vitamin C 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  dexamethasone, Tablet, 2 mg, Orally, BID, Start: 02/15/23 12:30:00  leveTIRACetam (Keppra), Tablet, 750 mg, Orally, BID, Start: 02/15/23 12:30:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 02/15/23 11:58:00  Sodium Chloride 0.9%  1,000 mL IV  60 mL/hr     Dextrose 10% in Water  500 mL IV  PRN - See Comments       One-Time Medications Given 02/14/23 00:00:00 TO 02/15/23 20:36:50  None Reported  PRN Medications (0600 - 0559) from 02/14 - 02/15  acetaminophen, 1,000 mg, Orally, Q8H, 0  Dose(s)   acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q6H, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   melatonin, 9 mg, Orally, At Bedtime, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   Allergies   No Known Medication Allergies  Social History    Alcohol   Current, Beer, 3-5 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Previous employment/school: retired 1 year ago.   Hobbies/Interests   Golf Sports/Fitness.   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   CVA - Cerebrovascular accident: Father.  Cancer: Father.  HTN - Hypertension: Father.  Myocardial infarction: Father.  Stroke: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.5 k/cumm (02/15/23 06:00:00)  RBC: 5.08 million/cumm (02/15/23 06:00:00)  Hgb: 16.2 GM/dL (02/15/23 06:00:00)  Hct: 48.5 % (02/15/23 06:00:00)  MCV: 96 fL (02/15/23 06:00:00)  MCH: 31.8 pg (02/15/23 06:00:00)  MCHC: 33.3 GM/dL (02/15/23 06:00:00)  RDW: 13.9 % (02/15/23 06:00:00)  Platelet: 129 k/cumm Low (02/15/23 06:00:00)  MPV: 8.5 fL (02/15/23 06:00:00)  Neutrophils %: 62 % (02/15/23 06:00:00)  Lymphocytes %: 22 % (02/15/23 06:00:00)  Monocytes %: 14 % (02/15/23 06:00:00)  Eosinophils %: 1 % (02/15/23 06:00:00)  Basophils %: 0 % (02/15/23 06:00:00)  Absolute Neutrophil: 4 k/cumm (02/15/23 06:00:00)  Absolute Lymphocyte: 1.4 k/cumm (02/15/23 06:00:00)  Absolute Monocyte: 0.9 k/cumm (02/15/23 06:00:00)  Absolute Eosinophil: 0.1 k/cumm (02/15/23 06:00:00)  Absolute Basophil: 0 k/cumm (02/15/23 06:00:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (02/15/23 06:00:00)  Potassium SerPl QN: 3.8 mmol/L (02/15/23 06:00:00)  Chloride SerPl QN: 101 mmol/L (02/15/23 06:00:00)  Carbon Dioxide SerPl QN: 29 mmol/L (02/15/23 06:00:00)  Anion Gap: 9 mmol/L (02/15/23 06:00:00)  BUN SerPl QN: 11 mg/dL (02/15/23 06:00:00)  Creatinine SerPl QN: 1.11 mg/dL (02/15/23 06:00:00)  Estimated GFR (CKD-EPI, no race): 73 mL/min/1.73m2 (02/15/23 06:00:00)  Estimated CRCL (CG): 77 mL/min (02/15/23 06:00:00)  Glucose SerPl QN: 100 mg/dL High (02/15/23 06:00:00)  Calcium Total SerPl QN: 8.8 mg/dL (02/15/23 06:00:00)  Alkaline Phos SerPl QN: 39 Units/L (02/15/23 06:00:00)  ALT SerPl QN: 23 Units/L (02/15/23 06:00:00)  AST SerPl QN: 22 Units/L (02/15/23 06:00:00)  Bilirubin Total SerPl QN: 0.7 mg/dL (02/15/23 06:00:00)  Total Protein SerPl QN: 6.3 GM/dL Low (02/15/23 06:00:00)  Albumin SerPl QN: 4 GM/dL (02/15/23 06:00:00)  Gluc-Strip, POC: 119 mg/dL High (02/15/23 20:08:00)  Urine Studies:  Color: Yellow (02/14/23 20:54:00)  Clarity: Clear (02/14/23 20:54:00)  Specific Gravity: <=1.005 (02/14/23 20:54:00)  pH: 7.0 (02/14/23 20:54:00)  Protein: NEGATIVE (02/14/23 20:54:00)  Glucose: NEGATIVE (02/14/23 20:54:00)  Ketones: 15 Abnormal (02/14/23 20:54:00)  Bilirubin: NEGATIVE (02/14/23 20:54:00)  Hgb Ur: NEGATIVE (02/14/23 20:54:00)  Nitrite: NEGATIVE (02/14/23 20:54:00)  Urobilinogen: NormalUro (02/14/23 20:54:00)  Leukocyte Esterase Ur: NEGATIVE (02/14/23 20:54:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.             Signature Line Electronically Signed on 02/15/23 20:37  ________________________________________________________ MD