Age: 49.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin decreased, Haemoglobin urine present, Intellectual disability, Intentional medical device removal by patient, International normalised ratio normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 20, 2023 18:43   Verified By: MD on February 20, 2023 18:43   Encounter Info: Hospital, Inpatient, 02/20/23 -     * Final Report *          History of Present Illness/Subjective     This is a 49-year-old male with severe mental retardation presents to the emergency department from group home after pulling Foley's catheter.  The patient has been not in his usual state of health in the past 2 days and noticed to be more altered.  And less verbal.  He was recently discharged from the hospital on 2/8/2023.  At that time he was treated for a UTI and urine culture grew Klebsiella.  Patient then had a post discharge follow-up with his PCP and then had a follow-up with urology as well/patient would complete his antibiotic he was discharged on and then resume weekly fosfomycin/and indwelling catheter was anchored at that time.  Then patient had some panic values relating to his blood counts.  There was a concern at that time of him having a UTI as well and Bactrim was given empirically.  He continued to be altered and presented to the ED  The patient's urine culture from 2/17/2023 is growing Enterobacter pansensitive   The patient's initial blood counts were very soft but now is maintaining MAP, O2 saturation is 93% on 2 L of oxygen x-ray shows no acute cardiopulmonary process.      Review of Systems     13 point review of system is unobtainable  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.4 (33-36.4)  Temp (FAHR) 97.5 (91.4-97.5), BP 108/69 (68-136)/(49-106), HR 83 (57-91), RR 15 (3-26), O2Sat 93 (62-93) Neurologic (most recent and range for last 24 hours)  GCS 11(11-15)     Patient Weight  Current Daily Weight:    67.4 kg    02/20/23  Previous Daily Weight:    67.4 kg    02/20/23  BMI:    29    02/20/23    Overweight (BMI 25-29.9) Patient Height  Current Height:    152.4 cm    02/20/23        Constitutional:  No acute distress,  Eyes:  PERRLA,    ENMT:  Moist oral mucosa  Neck:  Supple,  Respiratory: clear  Cardiovascular:  Regular rate and rhythm  Gastrointestinal:  Soft, non-tender, non-distended  Musculoskeletal:  No joint swelling,  Integumentary:  Intact, warm, dry no rashes  Neurologic: Alert  Psychiatric:  Cooperative,    Assessment/Plan       1. UTI (urinary tract infection)    - RECURRENT UTIS,  - ceftriaxone 1g q24. for 5 to 7 days    - follow blood cultures   2. Esophageal stricture    - noted,  - barium swallow   3. Pancytopenia     - he is being evaluated by Dr, the patient needs a bone marrow biopsy.   4. Intellectual disability     - noted   5. Epilepsy   - the mother told me the patient had a seizure episode today,  - resume home meds   6. Type 2 diabetes mellitus    - noted resume meds,   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/20/23 16:40:00   heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 02/20/23 17:00:00   labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 02/20/23 16:40:00   Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 02/20/23 16:40:00, 100 mL/hr, Clinical Weight  Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 02/20/23 16:40:00, for 1 Days, 02/21/23 16:39:00, 100 mL/hr, Clinical Weight  meropenem, 1 GM, IVPB, Injection, Q8H, Indication: Sepsis (ESBL or MDR History), 02/20/23 17:00:00, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 02/20/23 16:40:00  vancomycin, 1 GM, IVPB, Injection, Q18H, Indication: Sepsis (Update Indication in 36-48 hrs), 02/21/23 11:00:00, 125 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 250  vancomycin, 1.5 GM, IVPB, Injection, ONCE, Indication: Sepsis (Update Indication in 36-48 hrs), 02/20/23 17:00:00, 02/20/23 17:00:00, 125 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 250  Admit to Inpatient   Auto Diff  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  CBC w/Differential  Comp Metabolic Panel  Comp Metabolic Panel  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Dysphagia Diet Minced & Moist IDDSI Food 5  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Lactate Pl Venous QN  Level of Care  Nasal Cannula  OT Evaluation and Treatment  Peripheral IV Insertion  Pharmacy Dosing Consult  Procalcitonin  Procalcitonin  PT Evaluation and Treatment  PTINR  Resuscitation Status  Titrate FiO2 to Keep O2 Sat  Urinalysis w Culture Rflx  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  70 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 section and the rest of this note for further information on patient assessment and treatment.  Code Status   Resuscitation Status - Ordered    -- 02/20/23 16:40:00, Full Code   Chronic Problem List    Abnormal liver enzymes  Aggression  Anemia  Anemia of chronic disease  Arthritis  Asthma  Bradycardia  Conductive hearing loss in left ear  Constipation  Constipation  Dependent edema  Encounter for long-term current use of medication  Epilepsy  Esophageal stricture  Gall stone pancreatitis  GERD (gastroesophageal reflux disease)  Hearing loss  Hematochezia  Hematuria  History of seizure  Hospital discharge follow-up  Hyperglycemia  Hypothermia  Hypothyroidism  Idiopathic neuropathy  Idiopathic progressive neuropathy  Impaired mobility  Insomnia  Intermittent explosive disorder  Leukopenia  MR (mental retardation), severe  Obstructive sleep apnea  Onychomycosis  Osteoarthritis of knee  Other secondary thrombocytopenia  Pancytopenia  Pneumonia  Right foot pain  Seizure disorder  Seizures  Skin candidiasis  Swelling of right side of face  Thrombocytopenia  Tinea pedis  Tourette's syndrome  Type 2 diabetes mellitus  Type 2 diabetes mellitus with peripheral neuropathy  Urinary retention  Urine incontinence  Weakness  Procedure/Surgical History  ?Esophagogastroduodenoscopy (02/14/2006) ?Deviated nasal septum ?Hip Fracture & Surgery - Both ?pacemaker insertion 2017   Surgical History Internal  12/16/2022    ERCP Sphincterotomy Pappillotomy      10/25/2017    Cholecystectomy Laparoscopic               Medications   Home Medications (42) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  acetic acid 2% otic solution See Instructions, 2 drops each ear Mon, Wed, Fri.  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H  Aquaphor ointment , PRN, Topical, 4 Times Daily  atropine 1% ophthalmic solution 1 Drop, Eye, Left, BID  Bactrim DS 800 mg-160 mg oral tablet 1 Tablet, Orally, BID  Benadryl 25 mg, PRN, Orally, 4 Times Daily  benzonatate 100 mg oral capsule 200 mg = 2 Capsule, PRN, Orally, TID  Bisco-Lax 10 mg rectal suppository 10 mg = 1 Suppository, PRN, Rectally, Daily  calamine topical lotion , PRN, Topical, Q8H  Calmoseptine 0.44%-20.6% topical ointment See Instructions, 1 application to area of diaper rash at each diaper change  Chloraseptic 1 Lozenge, PRN, Orally, Q2H  Citrate of Magnesia 1.745 g/30 mL oral liquid 1.745 GM = 30 mL, PRN, Orally, Every Other Day  clotrimazole-betamethasone cream 1 App, PRN, Topical, BID  Colace 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  diclofenac 1% topical gel 2 GM, PRN, Topical, 4 Times Daily  Durezol , Eye, Left, BID  fexofenadine 180 mg oral tablet 180 mg = 1 Tablet, Orally, Daily  Fleet Enema for Adults 1 enema, PRN, Rectally  Flomax 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily, 30 minutes after evening meal  Flonase 50 mCg/inh nasal spray 100 mCg = 2 Spray, intraNASAL, Daily  Florastor 250 mg oral capsule 250 mg = 1 Capsule, Orally, Daily  fosfomycin 3 g oral granule for reconstitution 3 GM = 1 Each, Orally, Every Week  glycerin suppository adult 1 Suppository, PRN, Rectally, Daily  Keppra 750 mg oral tablet 1,500 mg = 2 Tablet, Orally, BID  Lasix 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  loperamide 2 mg, PRN, Orally, Use if more than 3 loose stools in a three hour period. Do not use if abdominal swelling noted.not to exceed 8 capsules, or 16 mg, in 24 hours. Use after each loose stool.  mineral oil See Instructions, Place 3-4 drops in each ear daily, have patient lay on his side with the effected ear up for 10-20 minutes to allow the oil to penetrate ear canal.  MiraLax oral powder for reconstitution 17 GM, Orally, Daily, dissolve in water/ or juice or mountain dew before takingHold for diarrhea  nystatin 100,000 units/g topical cream 1 App, Topical, BID  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  pimozide 2 mg oral tablet 2 mg = 1 Tablet, Orally, 4 Times Daily  risperiDONE 1 mg, Orally, With Breakfast and Lunch  risperiDONE 2 mg oral tablet 2 mg = 1 Tablet, Orally, At Bedtime  Rozerem 8 mg oral tablet 8 mg = 1 Tablet, Orally, At Bedtime  Senokot S 50 mg-8.6 mg tablet 1 Tablet, Orally, At Bedtime  SF 5000 Plus 1.1% topical cream , Brush twice daily for 2 minutes each time spit do not rinse  Singulair 10 mg oral tablet 10 mg = 1 Tablet, Orally, Every PM  Symbicort 160 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  Synthroid 112 mCg (0.112 mg) oral tablet 112 mCg = 1 Tablet, Orally, Daily  traZODONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, At Bedtime  Vimpat 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID  Active Scheduled Inpatient Medications  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 02/20/23 17:00:00  meropenem, Injection, 1 GM, IVPB, Q8H, Indication: Sepsis (ESBL or MDR History), Start: 02/20/23 17:00:00  vancomycin, Injection, 1 GM, IVPB, Q18H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 02/21/23 11:00:00  vancomycin, Injection, 1.5 GM, IVPB, ONCE, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 02/20/23 17:00:00  Lactated Ringers  1,000 mL IV  100 mL/hr     Lactated Ringers  1,000 mL IV  100 mL/hr       One-Time Medications Given 02/19/23 00:00:00 TO 02/20/23 18:43:48  cefePIME, Injection, 1 GM, IV Push, ONCE, (1 DOSE 02/20/23 12:00:00)  Lactated Ringers (LR - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 02/20/23 11:30:00)  PRN Medications (0600 - 0559) from 02/19 - 02/20  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   labetalol, 10 mg, IV Push, Q6H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   Allergies   Unlisted Material/Environmental Allergy (Rash)  ketolides  macrolide antibiotics  NSAIDS (see note)  erythromycin (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   On disability   Home/Environment   Lives with Group home.   Other   Right Handed   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Asthma: Father.  Bladder cancer: Father.  Cancer: Father.  Heart disease..: Grandfather (P) and Grandmother (M).  Hypertension..: Father.  Hypothyroidism: Grandmother (M).  Leukemia: Grandfather (P).  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 1.2 k/cumm Critical (02/20/23 17:01:00)  RBC: 2.85 million/cumm Low (02/20/23 17:01:00)  Hgb: 8.2 GM/dL Low (02/20/23 17:01:00)  Hct: 25.1 % Low (02/20/23 17:01:00)  MCV: 88 fL (02/20/23 17:01:00)  MCH: 28.9 pg (02/20/23 17:01:00)  MCHC: 32.9 GM/dL (02/20/23 17:01:00)  RDW: 20.8 % High (02/20/23 17:01:00)  Platelet: 53 k/cumm Low (02/20/23 17:01:00)  MPV: 7.5 fL (02/20/23 17:01:00)  Neutrophils %: 68 % (02/20/23 17:01:00)  Lymphocytes %: 17 % (02/20/23 17:01:00)  Monocytes %: 9 % (02/20/23 17:01:00)  Eosinophils %: 4 % (02/20/23 17:01:00)  Basophils %: 1 % (02/20/23 17:01:00)  Absolute Neutrophil: 0.8 k/cumm Low (02/20/23 17:01:00)  Absolute Lymphocyte: 0.2 k/cumm Low (02/20/23 17:01:00)  Absolute Monocyte: 0.1 k/cumm (02/20/23 17:01:00)  Absolute Eosinophil: 0.1 k/cumm (02/20/23 17:01:00)  Absolute Basophil: 0 k/cumm (02/20/23 17:01:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (02/20/23 17:01:00)  Potassium SerPl QN: 5.1 mmol/L (02/20/23 17:01:00)  Chloride SerPl QN: 106 mmol/L (02/20/23 17:01:00)  Carbon Dioxide SerPl QN: 26 mmol/L (02/20/23 17:01:00)  Anion Gap: 7 mmol/L (02/20/23 17:01:00)  BUN SerPl QN: 22 mg/dL High (02/20/23 17:01:00)  Creatinine SerPl QN: 1.14 mg/dL (02/20/23 17:01:00)  Estimated GFR (CKD-EPI, no race): 79 mL/min/1.73m2 (02/20/23 17:01:00)  Estimated CRCL (CG): 63 mL/min (02/20/23 17:01:00)  Glucose SerPl QN: 67 mg/dL Low (02/20/23 17:01:00)  Calcium Total SerPl QN: 9.4 mg/dL (02/20/23 17:01:00)  Alkaline Phos SerPl QN: 137 Units/L High (02/20/23 17:01:00)  ALT SerPl QN: 23 Units/L (02/20/23 17:01:00)  AST SerPl QN: 20 Units/L (02/20/23 17:01:00)  Bilirubin Direct SerPl QN: 0.1 mg/dL (02/20/23 07:46:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (02/20/23 17:01:00)  Total Protein SerPl QN: 6.1 GM/dL Low (02/20/23 17:01:00)  Albumin SerPl QN: 3.6 GM/dL (02/20/23 17:01:00)  Lipase SerPl QN: 18 Units/L (02/20/23 07:46:00)  Lactate Venous Pl QN: 0.5 mmol/L (02/20/23 17:01:00)  pH Bld Venous QN: 7.39 (02/20/23 11:04:00)  PCO2 Bld Venous QN: 52 mmHg (02/20/23 11:04:00)  PO2 Bld Venous QN: 97 mmHg High (02/20/23 11:04:00)  Base Excess Bld Venous: 6 mmol/L High (02/20/23 11:04:00)  Bicarb Bld Venous Calc: 32 mmol/L High (02/20/23 11:04:00)  O2 Sat Bld Venous Calc: 98 % (02/20/23 11:04:00)  Patient Temperature: 37 DegC (02/20/23 11:04:00)  Coagulation:  PT: 11.3 seconds (02/20/23 11:04:00)  INR: 0.99 (02/20/23 11:04:00)  Urine Studies:  Color: Yellow (02/20/23 07:46:00)  Clarity: Clear (02/20/23 07:46:00)  Specific Gravity: 1.025 (02/20/23 07:46:00)  pH: 6.0 (02/20/23 07:46:00)  Protein: 100 Abnormal (02/20/23 07:46:00)  Glucose: NEGATIVE (02/20/23 07:46:00)  Ketones: NEGATIVE (02/20/23 07:46:00)  Bilirubin: NEGATIVE (02/20/23 07:46:00)  Hgb Ur: MODERATE. Abnormal (02/20/23 07:46:00)  Nitrite: NEGATIVE (02/20/23 07:46:00)  Urobilinogen: NormalUro (02/20/23 07:46:00)  Leukocyte Esterase Ur: SMALL. Abnormal (02/20/23 07:46:00)  WBC: 11-20 Abnormal (02/20/23 07:46:00)  RBC: 6-10 Abnormal (02/20/23 07:46:00)  WBC Clumps: PRESENT. Abnormal (02/20/23 07:46:00)  Bacteria: Few Abnormal (02/20/23 07:46:00)  Squamous Epithelial: Few (02/20/23 07:46:00)  Mucous: PRESENT. (02/20/23 07:46:00)  Hyaline Casts: 0-2 (02/20/23 07:46:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/20/2023 07:54 - XR Chest PA or AP Portable  IMPRESSION:Implanted cardiac pacemaker.Limited inspiratory effort.No acute cardiopulmonary findings.                Signature Line Electronically Signed on 02/20/23 18:43  ________________________________________________________ MD