Age: 52.0
Sex: M
Vaccine: COVID19
Symptoms: Urinary sediment present, Urine analysis, Urine ketone body absent, Urine leukocyte esterase positive, Urobilinogen urine
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Encounter Info: Hospital, Inpatient, 11/15/22 -     * Final Report *        Chief Complaint   respiratory arrest  History of Present Illness/Subjective     53-year-old male with a past medical history of Charcot-Marie-Tooth and diaphragmatic paralysis who was supposed to use Trelegy at night, among other conditions listed below who was intubated in the field for respiratory arrest and inability to protect his airway as per EMS.  The patient is following with pulmonology outpatient who he saw last month, and according to chart review of the visit note, the patient has been experiencing worsening difficulty breathing due to his diaphragmatic dysfunction/paralysis and the plan was to follow-up with a neurologist for his progressively worsening condition.  According to the ED provider, his mother stated he was not wearing his trilogy device when she found him not breathing, she states that some nights he enjoys falling asleep without having to use it. She also notes it has been increasingly difficult for him to ambulate independently.   In the ED the patient was found to have high lactate, elevated troponin, however CT head and CTA of chest were negative.  He was also found to have mild leukocytosis as well as a anion gap of 18 and elevated glucose in the 250s.  Patient is being accepted to ICU for continued ventilatory support, close monitoring, and possible initiation of insulin drip.  Patient may need a neurology evaluation in the a.m., if the neurologist feels an in person evaluation is passed then patient may need to be transferred to another facility at that time however patient is currently appropriate for our ICU.   Mother is at bedside and states she is not aware of an active advanced directive and believes her son would want cpr and mechanical vent if required and therefore patient is full code.  This patient is critically ill due to metabolic, hemodynamic and/or respiratory instability. They require high complexity evaluation, decision making, and care. They require ICU level of care and monitoring due to high risk of clinical decompensation with high risk of morbidity and mortality. Critical care time includes, but is not limited to, bedside assessment, review of medical record, radiographic and laboratory results, ventilator and/or respiratory management, review of ekg and/or cardiac monitoring, critical decision making, coordination of care with consultants and/or care team, and documentation of critical intervention/plans, and consultation with patient and/or family. Time excludes any procedural time.  I spent greater than 65 minutes in the evaluation and management of this patient with more than 50% of the time spent counseling and/or coordinating care.  I counseled the patient and/or family about the findings, differential diagnoses, my assessment, recommendations, and plan.  I coordinated care with the multidisciplinary healthcare team.  Review of Systems     Unable to assess due to patient being intubated and sedated on ventilator  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.5 (36.5-36.5)  Temp (FAHR) 97.7 (97.7-97.7), BP 130/76 (121-191)/(73-101), HR 75 (75-83), RR 18 (18-20), O2Sat 92 (90-92)     Patient Weight  Current Daily Weight:    82.6 kg    11/15/22  Previous Daily Weight:    82.6 kg    11/15/22    Patient Height        General: Intubated, eyes spontaneously open, not following commands Eye: no conjunctival injection  Pupils 2 mm and minimally reactive Cardiovascular: rhythm regular, S1S2 within normal limits Respiratory: Mechanical breath sounds bilaterally with good air entry, tolerating vent, no obvious wheezes or rales Gastrointestinal:  soft, non-distended, nontender, no guarding  Msk:  NC/AT, extremities without deformity Skin:  warm, dry Psych: Unable to assess Neurological: Eyes are spontaneously open, moving upper extremities symmetrically, not following commands    Assessment/Plan      1. Respiratory arrest   R09.2  likely 2/2 #6 and #5, possibly some underlying pna but exam and imaging did not suggest pneumonia and hx supports noncompliance with night time Trelegy device at time of arrest    2. Severe sepsis   R65.20   3. Elevated lactic acid level   R79.89  met severe sepsis criteria but likely explained by demand ischemia from resp failure rather than infectious etiology  however will panculture and cont broad spectrum abx for now  iv hydration, serial lactates  trend procal, maintain map >65   4. Acute respiratory failure   J96.00   5. Chronic respiratory failure   J96.10   6. Diaphragmatic paresis   J98.6   7. Charcot-Marie-Tooth disease   G60.0  #4 and #5 likely related to #6 and #7, will likely need neurology evaluation and possibly pulm opinion on ventillatory weaning in the setting of diaphragmatic paresis/dysfunction  made need evaluation for trach if not able to wean from vent  trend abd, adjust vent prn  cont fentanyl and propofol for now to rass -1   8. Hyperglycemia   R73.9   9. DM (diabetes mellitus), type 2   E11.9  q2h poc glucose checks, iss  hold oral meds for now  long acting insulin as needed  anion gap initially elevated, will repeat bmp stat and determine if initiation of insulin drip is required vs subcu insulin   10. Elevated troponin   R77.8  likely related to hypoxic event and subsequent demand ischemia   11. Hyperlipidemia   E78.5  resume home meds when able to   12. Hypertension   I10  resume home meds as able to   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 11/15/22 6:06:00   cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), 11/15/22 15:00:00, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 11/15/22 7:19:00, PRN - See Comments  fentaNYL 2,500 mCg + Sodium Chloride 0.9% 250 mL, Total Volume (mL) = 250, IV, 11/15/22 6:32:00, Titrate - See Comments  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 11/15/22 7:19:00   glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 11/15/22 7:19:00   heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 11/15/22 7:00:00   insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 11/15/22 7:19:00   Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 11/15/22 6:07:00, 75 mL/hr, Clinical Weight  metroNIDAZOLE, 500 mg, IVPB, Infusion, Q8H, 11/15/22 15:00:00, 100 mL/hr, Infuse Over 60 minutes, Total Volume (mL) = 100  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 11/15/22 6:06:00   propofol 1,000 mg + Premix Solution 100 mL, Total Volume (mL) = 100, IV, 11/15/22 6:48:00, Titrate - See Comments  propofol infusion bolus dose, 10 mg, Via Infusion Pump, Infusion, Q5min, PRN, Agitation, 11/15/22 6:48:00  vancomycin, 2 GM, IVPB, Injection, ONCE, Indication: Sepsis (Update Indication in 36-48 hrs), 11/15/22 7:00:00, 11/15/22 7:00:00, 250 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 500  Admit to Inpatient CAH  Aspiration Precautions  Basic Metabolic Panel  Call (Specify)  Call (Specify)  Call Blood Glucose  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mean Arterial Pressure  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  Call Urine Output  CBC w/Differential  Comp Metabolic Panel  Continuous Oxygen Saturation  Conventional Ventilator  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Document per Nursing (Specify)  Dysphagia Screen by RN  End Tidal CO2 Monitor Continuous  Fall Precautions  Fluid Intake Requirement  Gluc-Strip POC  Gluc-Strip POC  Glucose POC  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Oxygen Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  Lactate Pl Venous QN  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Maintain (Specify)  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  Notify Provider  Notify Provider  Notify Provider  NPO Except Medications  Peripheral IV Insertion  Peripheral IV Insertion  Pharmacy Review/Follow-Up  Phosphorus SerPl QN  Procalcitonin  Procalcitonin  RCP Airway Assessment  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Strep pneumoniae Ag Urine  Telemetry Class III 24hr Recommendation  Titrate FiO2 to Keep O2 Sat  Troponin-I High Sensitivity  TSH w FreeT4 reflex  Urinary Catheter Routine Care  Vancomycin Pharmacy Dosing Consult  Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 11/15/22 6:06:00, Full Code   Chronic Problem List    Charcot-Marie-Tooth atrophy  Chronic respiratory failure  Diabetic neuropathy  DM (diabetes mellitus), type 2  Foot pain, bilateral  Hyperlipidemia  Hypertension  Neuropathy  Onychogryphosis  Onychomycosis of toenail  Paralysis, diaphragm  Schizophrenia  Seasonal allergies  Procedure/Surgical History  ?Unknown     Medications   Home Medications (10) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  Basaglar (insulin glargine) KwikPen 100 units/mL subcutaneous solution See Instructions, 40 units in the AM60 units in the PM  fluticasone 50 mCg/inh nasal spray 1 Spray, intraNASAL, BID, pt needs annual for further refills  Geodon 40 mg oral capsule 40 mg = 1 Capsule, Orally, BID  Januvia 100 mg oral tablet   lisinopril 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  loratadine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  metFORMIN 1, Orally, BID, unsure of dose  omega-3 polyunsaturated fatty acids 1200 mg oral capsule 2,400 mg = 2 Capsule, Orally, QAM  simvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  Active Scheduled Inpatient Medications  cefePIME, Injection, 1 GM, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 11/15/22 15:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 11/15/22 07:00:00  metroNIDAZOLE, Infusion, 500 mg, IVPB, Q8H, Start: 11/15/22 15:00:00  vancomycin, Injection, 2 GM, IVPB, ONCE, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 11/15/22 07:00:00  fentaNYL PREMIX + Sodium Chloride 0.9% PREMIX IV Titrate - See Commnets 50 mCg/hr  11/15/22  Propofol + Solution PREMIX IV Titrate - See Comments 40.008 mCg/kg/min  11/15/22  NORepinephrine PREMIX + Sodium Chloride 0.9% PREMIX IV Titrate - See Comments 0 mCg/min  11/15/22  Lactated Ringers  1,000 mL IV  75 mL/hr     fentaNYL PREMIX + Sodium Chloride 0.9% PREMIX IV Titrate - See Comments     Propofol + Solution PREMIX IV Titrate - See Comments 39.9919 mCg/kg/min    Dextrose 10% in Water 500 mL IV PRN - See Comments       One-Time Medications Given 11/14/22 00:00:00 TO 11/15/22 07:39:15  None Reported  PRN Medications (0600 - 0559) from 11/14 - 11/15  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)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   propofol infusion bolus dose, 10 mg, Via Infusion Pump, Q5min, 0  Dose(s)   Allergies   Seldane  aspirin  Social History    Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Mother.   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Family history is negative  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 13.5 k/cumm High (11/15/22 02:52:00)  RBC: 4.2 million/cumm (11/15/22 02:52:00)  Hgb: 10.9 GM/dL Low (11/15/22 02:52:00)  Hct: 35.3 % Low (11/15/22 02:52:00)  MCV: 84 fL (11/15/22 02:52:00)  MCH: 25.9 pg Low (11/15/22 02:52:00)  MCHC: 30.7 GM/dL Low (11/15/22 02:52:00)  RDW: 16.9 % High (11/15/22 02:52:00)  Platelet: 238 k/cumm (11/15/22 02:52:00)  MPV: 8.3 fL (11/15/22 02:52:00)  Neutrophils %: 90 % (11/15/22 02:52:00)  Lymphocytes %: 5 % (11/15/22 02:52:00)  Monocytes %: 5 % (11/15/22 02:52:00)  Eosinophils %: 0 % (11/15/22 02:52:00)  Basophils %: 0 % (11/15/22 02:52:00)  Absolute Neutrophil: 12.1 k/cumm High (11/15/22 02:52:00)  Absolute Lymphocyte: 0.6 k/cumm Low (11/15/22 02:52:00)  Absolute Monocyte: 0.7 k/cumm (11/15/22 02:52:00)  Absolute Eosinophil: 0.1 k/cumm (11/15/22 02:52:00)  Absolute Basophil: 0 k/cumm (11/15/22 02:52:00)  Chemistry:  Sodium SerPl QN: 149 mmol/L High (11/15/22 06:59:00)  Potassium SerPl QN: 4 mmol/L (11/15/22 06:59:00)  Chloride SerPl QN: 100 mmol/L (11/15/22 06:59:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (11/15/22 06:59:00)  Anion Gap: 19 mmol/L High (11/15/22 06:59:00)  BUN SerPl QN: 31 mg/dL High (11/15/22 06:59:00)  Creatinine SerPl QN: 1.14 mg/dL (11/15/22 06:59:00)  Estimated GFR (CKD-EPI, no race): 77 mL/min/1.73m2 (11/15/22 06:59:00)  Estimated CRCL (CG): 83 mL/min (11/15/22 06:59:00)  Glucose SerPl QN: 133 mg/dL High (11/15/22 06:59:00)  Calcium Total SerPl QN: 8.8 mg/dL (11/15/22 06:59:00)  Alkaline Phos SerPl QN: 70 Units/L (11/15/22 02:52:00)  ALT SerPl QN: 21 Units/L (11/15/22 02:52:00)  AST SerPl QN: 25 Units/L (11/15/22 02:52:00)  Bilirubin Total SerPl QN: 0.2 mg/dL (11/15/22 02:52:00)  Total Protein SerPl QN: 6 GM/dL Low (11/15/22 02:52:00)  Albumin SerPl QN: 3.7 GM/dL (11/15/22 02:52:00)  Troponin-I High Sensitivity: 475 ng/L High (11/15/22 04:38:00)  BNP Pl QN: 51 pg/mL (11/15/22 02:52:00)  Lactate Venous Pl QN: 8.4 mmol/L High (11/15/22 02:52:00)  Gluc-Strip, POC: 121 mg/dL High (11/15/22 06:53:00)  pH Bld Arterial QN: 7.44 (11/15/22 04:36:00)  PCO2 Bld Arterial QN: 37 mmHg (11/15/22 04:36:00)  PO2 Bld Arterial QN: 100 mmHg (11/15/22 04:36:00)  Base Excess Bld Arterial: 1 mmol/L (11/15/22 04:36:00)  Bicarb Bld Arterial Calc: 25 mmol/L (11/15/22 04:36:00)  O2 Sat Bld Arterial Calc: 98 % (11/15/22 04:36:00)  FIO2: 50% vent (11/15/22 04:36:00)  Patient Temperature: 37 DegC (11/15/22 04:36:00)  Coagulation:  PT: 10.8 seconds (11/15/22 02:52:00)  INR: 0.95 (11/15/22 02:52:00)  Urine Studies:  Color: Yellow (11/15/22 04:38:00)  Clarity: Clear (11/15/22 04:38:00)  Specific Gravity: 1.015 (11/15/22 04:38:00)  pH: 6.0 (11/15/22 04:38:00)  Protein: 30 Abnormal (11/15/22 04:38:00)  Glucose: 500 Abnormal (11/15/22 04:38:00)  Ketones: NEGATIVE (11/15/22 04:38:00)  Bilirubin: NEGATIVE (11/15/22 04:38:00)  Hgb Ur: TRACE. Abnormal (11/15/22 04:38:00)  Nitrite: NEGATIVE (11/15/22 04:38:00)  Urobilinogen: NormalUro (11/15/22 04:38:00)  Leukocyte Esterase Ur: TRACE. Abnormal (11/15/22 04:38:00)  WBC: 21-50 Abnormal (11/15/22 04:38:00)  RBC: 3-5 Abnormal (11/15/22 04:38:00)  Bacteria: Many Abnormal (11/15/22 04:38:00)  Squamous Epithelial: Few (11/15/22 04:38:00)  Granular Casts: 0-2 Abnormal (11/15/22 04:38:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/15/22 04:24:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/15/22 04:24:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/15/2022 03:20 - XR Chest PA or AP Portable  IMPRESSION:1.  Endotracheal tube as described above.2.  Low lung volumes. No focal pulmonary consolidation, pleuraleffusion or pneumothorax. Thank you for consulting our team of subspecialty radiologists.    11/15/2022 04:02 - CT Head W/o IV Contrast  IMPRESSION: 1.  No acute intracranial hemorrhage or obvious infarct.2.  No skull fracture or pneumocephalus.3.  Mastoid air cells are clear.Thank you for consulting our team of subspecialty radiologists.    11/15/2022 04:06 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for pulmonary embolism.2.  No focal pulmonary consolidation, pleural effusion orpneumothorax.Thank you for consulting our team of subspecialty radiologists.    11/15/2022 04:53 - XR Chest PA or AP Portable  IMPRESSION:1.  Lines and tubes as Described Above.2.  Otherwise, No Significant Interval Change When Compared to priorstudy.Thank you for consulting our team of subspecialty radiologists.                Signature Line Electronically Signed on 11/15/22 07:43  ________________________________________________________