Age: 63.0
Sex: F
Vaccine: COVID19
Symptoms: Hyperglycaemia, Hyperhidrosis, Hypovolaemia, Hypoxia, Illness
Clinical narrative: Document Type: History and Physical, Document Subject: History & Physical Note, Performed on February 13, 2023 23:46 EST, Verified on February 14, 2023 05:34, Encounter Info: hospital, Inpatient, 02/13/23 - * Final Report *. Chief Complaint, shortness of breath, History of Present Illness/Subjective, This is a 65-year-old woman past medical history of diabetes mellitus, depression, hypertension, and obesity. She now presents to Hospital on 2/13/2023. Primary complaints on presentation are surrounding weakness, cough, and shortness of breath.  All persistent progressive over the 72 hours prior to presentation. Also endorses yellow sputum production with chills, sweats, and headache.  On initial evaluation, hemogram values show leukocytosis of 11,000, absolute neutrophils 9.7 thousand. Electrolyte analysis relatively within normal limits. Renal function analysis within normal limits. Beta biliary labs within normal limits. Troponin and BNP negative. Initial lactate 2.7, down trended to 1.8.  Venous blood gas non actionable. Urinalysis insignificant for acute infectious process. SARS-CoV-2 analysis negative. Vital signs show the patient to be persistently tachycardic and tachypneic, afebrile, initially hypoxic, now saturating well on 2 L nasal cannula, remains relatively normotensive throughout. Chest x-ray was performed showing patchy nonspecific bilateral airspace disease right greater than left, consistent with multifocal pneumonia. At this time the patient will be placed on inpatient status for ongoing evaluation and treatment. Review of Systems. Constitutional: No fevers,  + chills,  + sweats, Eyes:  No changes in vision, Ears, Nose, Mouth, Throat: No ear pain, no nasal congestion, no sore throat, Respiratory: + Shortness of breath, + cough, no wheeze sputum production with yellow sputum, Cardiovascular:  No chest pain, no palpitations, no edema, Gastrointestinal: No abdominal pain, no nausea, no vomiting, no diarrhea, no constipation, Genitourinary: No frequency, no urgency, no dysuria,  no hematuria, Hematologic/Lymphatic: No bruising, no enlarged lymph nodes, Allergic/Immunologic: No hives, Endocrine: No cold intolerance, no heat intolerance, no polyuria, no polydipsia. Musculoskeletal: No arthralgia, no myalgia, Skin: No rash, no pruritus, Neurological: + Headache, no focal weakness, no numbness, Psychiatric: No anxiety, no depression. Physical Exam/Objective, Vital Signs (most recent and range for last 24 hours), Temp (CEL) 37.4 (37.4-37.4)  Temp (FAHR) 99.3 (99.3-99.3), BP 142/95 (132-179)/(74-95), HR 96 (96-121), RR 11 (11-32), O2Sat 93 (68-93), Patient Weight, Current Daily Weight: 128 kg 02/13/23, Patient Height, Current Height: 160 cm 02/13/23, Constitutional: No acute distress,  well-nourished, Eyes:  PERRLA,  EOMI,  normal conjunctiva, no scleral icterus, ENMT: Moist oral mucosa, Neck: Supple, non-tender, intact range of motion, Respiratory: no acute resp distress, non labored resp pattern, no overt wheezing or stridor, Cardiovascular: Tachycardic no JVD or edema, Gastrointestinal: Soft, non-tender, non-distended, Musculoskeletal: No joint swelling, no deformity, intact ROM, Integumentary: Intact, warm, dry no rashes, Neurologic: Alert & Oriented x 3, no cognitive impairment, no focal deficits, Psychiatric: Cooperative, appropriate mood and affect, Assessment/Plan: 1. Severe sepsis without septic shock, Present on admission, adequate capillary refill/perfusing pressure on repeat examination, imaging positive for infiltrate, at low risk for hemodynamic and respiratory instability, placing in med/surg status with low threshold to transfer to ICU. Blood cultures, respiratory culture/stain, Legionella antigen, strep pneumoniae antigen, procalcitonin, all pending, lactate repeat pending.  Continue empiric coverage with Unasyn and doxycycline. De-escalate therapy as appropriate. 2. Sepsis due to pneumonia J18.9, Evaluation and treatment as noted in #1, 3. Acute respiratory failure with hypoxia J96.01, evaluation and treatment as noted above, RT eval and treat, supplement BIPAP/O2 as tolerated and required, 4. Lactic acidosis E87.20, 2/2 to intravascular volume depletion in the setting of severe sepsis and reflective of severity with potential development of end organ damage with underlying reduction in baseline perfusion status, trend q 6h until normalized, 5. Elevated white blood cell count D72.829. Likely reactive vs infectious. Follow up Cultures and Continue IV Abx. Continue Daily trends. 6. Diabetes mellitus with hyperglycemia E11.65. Continue subcutaneous sliding scale and carb controlled diet for tight glycemic control. Initiate basal/bolus regimen as indicated by clinical course with appropriate titration, 7. Depression F32.9, continue current,  anxiolytics/antidepressants. 8. Hypertension I10. Relatively normotensive and stable, continue to trend, continue home regimen with titration as appropriate. 9. Obesity E66.9. Would benefit from dietary and exercise modification following resolution of acute illness. Code Status, Full Code, Chronic Problem List, Depression, DM2 (diabetes mellitus, type 2), History of endometrial hyperplasia, Hypertension, Hypokalemia, Obese, Postmenopausal bleeding, Procedure/Surgical History, Hysterectomy and bilateral salpingo-oophorectomy sample, (08/11/2016), Diagnostic hysteroscopy and endometrial biopsy (03/21/2016), Appendectomy, Bilateral Tubal Ligation, C-Section, Cholecystectomy, Foot, Surgical History Internal 08/11/2016 Hysterectomy Total Laparoscopic, 03/21/2016 Hysteroscopy Myomectomy, 09/25/2015 Coloscopy Diagnostic/Screen. Medications Home Medications (8) Active Active Scheduled Inpatient Medications, Piperacillin-Tazobactam, Injection, 3.375 GM, IVPB, ONCE, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 02/14/23 01:00:00. Lactated Ringers 1,000 mL IV 125 mL/hr. One-Time Medications Given 02/12/23 00:00:00 TO 02/13/23 23:45:47, Azithromycin, Tablet, 500 mg, Orally, ONCE, (1 DOSE 02/13/23 23:16:00), Lactated Ringers (LR Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 02/13/23 22:51:00), MethylPREDNISolone (soluMEDROL), Injection, 125 mg, IV Push, ONCE, (1 DOSE 02/13/23 21:41:00),  piperacillin-tazobactam, Injection, 4.5 GM, IV Push, ONCE, (1 DOSE 02/13/23 21:41:00), RN Medications (0600 - 0559) from 02/12 - 02/13. None Reported Allergies, No Known Medication Allergies. Social History, Alcohol, Denies, Electronic Cigarette/Vaping, E-Cigarette Use Never. Substance Abuse, Denies Tobacco Use: Never (less than 100 in lifetime). Family History, Diabetes...: Grandmother (M). Lung cancer.. Mother. Lab Results,  All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 11 k/cumm High (02/13/23 21:38:00), RBC: 5.32 million/cumm High (02/13/23 21:38:00), Hgb: 15.1 GM/dL High (02/13/23 21:38:00), Hct: 46.9 % (02/13/23 21:38:00), MCV: 88 fL (02/13/23 21:38:00), MCH: 28.4 pg (02/13/23 21:38:00), MCHC: 32.1 GM/dL (02/13/23 21:38:00), RDW: 14.2 % (02/13/23 21:38:00), Platelet: 248 k/cumm (02/13/23 21:38:00), MPV: 9.8 fL (02/13/23 21:38:00),  Neutrophils %: 88 % (02/13/23 21:38:00), Lymphocytes %: 9 % (02/13/23 21:38:00), Monocytes %: 3 % (02/13/23 21:38:00).  Eosinophils %: 0 % (02/13/23 21:38:00), Basophils %: 0 % (02/13/23 21:38:00),  Absolute Neutrophil: 9.7 k/cumm High (02/13/23 21:38:00).  Lymphocyte: 1 k/cumm (02/13/23 21:38:00), Absolute Monocyte: 0.4 k/cumm (02/13/23 21:38:00). Absolute Eosinophil: 0 k/cumm (02/13/23 21:38:00), Absolute Basophil: 0 k/cumm (02/13/23 21:38:00), Chemistry: Sodium SerPl QN: 138 mmol/L (02/13/23 21:38:00)  Potassium SerPl QN: 4 mmol/L (02/13/23 21:38:00), Chloride SerPl QN: 96 mmol/L Low (02/13/23 21:38:00), Carbon Dioxide SerPl QN: 29 mmol/L (02/13/23 21:38:00). Anion Gap: 13 mmol/L High (02/13/23 21:38:00), BUN SerPl QN: 19 mg/dL (02/13/23 21:38:00), Creatinine SerPl QN: 0.67 mg/dL (02/13/23 21:38:00), Estimated GFR (CKD-EPI, no race): >90 (02/13/23 21:38:00), Estimated CRCL (CG): 109 mL/min (02/13/23 21:38:00). Glucose SerPl QN: 327 mg/dL High (02/13/23 21:38:00) Calcium Total SerPl QN: 9.4 mg/dL (02/13/23 21:38:00), Alkaline Phos SerPl QN: 74 Units/L (02/13/23 21:38:00), ALT SerPl QN: 40 Units/L (02/13/23 21:38:00), AST SerPl QN: 31 Units/L (02/13/23 21:38:00), Bilirubin Total SerPl QN: 0.4 mg/dL (02/13/23 21:38:00), Total Protein SerPl QN: 7.7 GM/dL (02/13/23 21:38:00), Albumin SerPl QN: 4.4 GM/dL (02/13/23 21:38:00) Troponin-I High Sensitivity: 6 ng/L (02/13/23 22:34:00), BNP Pl QN: 32 pg/mL (02/13/23 21:38:00), Lactate Venous Pl QN: 2.7 mmol/L High (02/13/23 21:38:00), pH Bld Venous QN: 7.4 (02/13/23 21:38:00), PCO2 Bld Venous QN: 50 mmHg (02/13/23 21:38:00), PO2 Bld Venous QN: 68 mmHg High (02/13/23 21:38:00),  Base Excess BId Venous: 5 mmol/L High (02/13/23 21:38:00), Bicarb Bld Venous Calc: 31 mmol/L High (02/13/23 21:38:00), O2 Sat Bld Venous Calc: 93 % (02/13/23 21:38:00), Patient Temperature: 37 Deg C (02/13/23 21:38:00), Coagulation: PT: 10.5 seconds (02/13/23 21:38:00), INR: 0.92 (02/13/23 21:38:00, Urine Studies:- Color: Yellow (02/13/23 23:32:00), Clarity: Clear (02/13/23 23:32:00). Specific Gravity: 1.025 (02/13/23 23:32:00), pH: 5.5 (02/13/23 23:32:00), Protein: NEGATIVE (02/13/23 23:32:00), Glucose: 500 Abnormal (02/13/23 23:32:00), Ketones: TRACE. Abnormal (02/13/23 23:32:00, Bilirubin: NEGATIVE (02/13/23 23:32:00), Hgb Ur: TRACE. Abnormal (02/13/23 23:32:00). Nitrite: NEGATIVE (02/13/23 23:32:00), Urobilinogen:  NormalUro (02/13/23 23:32:00), Leukocyte Esterase Ur: NEGATIVE (02/13/23 23:32:00), All Other Labs: COVID 19 Specimen Source: Nasopharyngeal (02/13/23 21:55:00) Coronavirus SARS-CoV2 Rapid: Not Detected (02/13/23 21:55:00). Diagnostics, Radiology Results - Last 24 hours Across Visits, 02/13/2023 21:20 - XR Chest PA or AP Portable IMPRESSION:1. Patchy nonspecific bilateral airspace disease, right greater than left, and concerning for multifocal pneumonia. Thank you for consulting our team of subspecialty radiologists. Please contact us at with any questions.