Age: 80.0
Sex: F
Vaccine: FLUA4
Symptoms: Acute kidney injury, Alanine aminotransferase normal, Anaemia, Anion gap, Anticoagulant therapy
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on December 10, 2022 06:28 EST   Verified By: DO on December 10, 2022 06:28 EST   Encounter Info: Hospital, Inpatient, 12/09/22 -     * Final Report *        Chief Complaint   AMS  History of Present Illness/Subjective     80 year old male with hx of Parkinson's, HTN, pulmonary edema, anemia, and kidney disease presents to the ED via EMS for evaluation of AMS onset this AM. Per EMS, pt was reportedly able to verbally communicate yesterday. Pt was noted to be globally weak. Pt's VGB is 64 with a carbon dioxide of 68. Troponin is elevated at 718. Pt on BiPAP. CT chest/abdomen/pelvis demonstrate aspiration pneumonia and prominent rectal stool burden concerning impaction. Pt has received vancomycin, Zosyn and azithromycin in the ED.   Subsequently, his troponin trended down, his na was 149 prior to fluid administration. He was discovered to be covid positive. Will take to icu for electrolyte monitoring and bipap.  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 105 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     A complete, 13-system review was performed and was negative except for as noted in the HPI.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.5 (36.5-36.6)  Temp (FAHR) 97.7 (97.7-97.9), BP 132/63 (117-147)/(58-68), HR 65 (65-83), RR 17 (17-39), O2Sat 99 (91-99)     Patient Weight  Current Daily Weight:    89.8 kg    12/10/22    Patient Height        General:  drowsy but arousable Skin:  warm, dry Head:  no trauma, normocephalic Neck:  trachea midline Eye:  normal conjunctiva, clearsclera, pinpoint pupils Cardiovascular:  regularrate and rhythm, normalperipheral pulses normal, 3+ edema in BLE Respiratory:  coarse breath sounds bilaterally, respirations non-labored, tachypneic Chest wall:  no tenderness Gastrointestinal:  soft, non-distended, no tenderness _, no guarding _ Extremities:  no deformity, no trauma Neurological:  not responding to commands, however appeared to shake head to one question Psychiatric:   unable to assess  Assessment/Plan      1. Altered mental status   R41.82  Most likely secondary to hypercapnia, CT head did not demonstrate any acute pathology  The patient's altered mental status does not improve with resolution of hypercapnia we will investigate other sources such as infectious or toxic encephalopathy   2. Hypercapnic respiratory failure   J96.92   3. COVID-19   U07.1   4. Pneumonia   J18.9  Continue BiPAP  Remdesivir and dexamethasone  D-dimer was elevated but not above upper limits normal for age adjustment  CT chest was suggestive of possible pneumonia will cover with antibiotics  Follow cultures   5. CHF exacerbation   I50.9   6. Pulmonary edema   J81.1  Start Lasix drip, patient was retaining urine so we will place Foley monitor I/O's replete lites as needed  Resume home meds as blood pressure allows  Obtain echo  Maintain telemetry   7. Acute on chronic renal insufficiency   N28.9  Versus purely chronic renal insufficiency  Continue to monitor renal function  Avoid nephrotoxic medications  Attempt to obtain records of baseline renal function   8. Hypernatremia   E87.0  Resolved  Continue to monitor throughout diuresis   9. Elevated troponin   R77.8  Trending down, serial EKGs and trops   10. Anemia   D64.9  Maintain hemoglobin greater than 7 transfuse as needed to maintain  Maintain active type and screen  Possibly secondary to underlying CKD no signs of active bleeding   11. Parkinson's disease   G20  Continue home meds as able to   12. Hypertension   I10  Continue home meds as appropriate   13. DVT prophylaxis   Z29.9  Heparin subcu   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 12/09/22 21:07:00 EST  ampicillin-sulbactam, 3 GM, IVPB, Injection, Q8H, 12/10/22 0:00:00 EST, for 14 Doses, 12/14/22 8:00:00 EST, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  dexamethasone, 6 mg, IV Push, Injection, Q24H, NOW, 12/09/22 21:07:00 EST, for 10 Days, 12/18/22 21:07:00 EST  Dextrose 5% in Water 500 mL, Total Volume (mL) = 500, IV, 12/09/22 23:55:00 EST, Other - See Comments, Clinical Weight  docusate-senna, 2 Tablet, Orally, Tablet, BID, 12/10/22 9:00:00 EST  doxycycline, 100 mg, IVPB, Injection, Q12H, 12/10/22 0:00:00 EST, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100  furosemide 400 mg [10 mg/hr] + bag, viaflex 40 mL, Total Volume (mL) = 40, IV, 12/09/22 21:17:00 EST, 1 mL/hr  heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 12/09/22 22:00:00 EST  hydrALAZINE, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 12/09/22 21:07:00 EST  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 12/09/22 21:07:00 EST  remdesivir, 100 mg, IVPB, Injection, At Bedtime, 12/10/22 21:00:00 EST, for 4 Doses, 12/13/22 21:00:00 EST, 500 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 250  Sodium Chloride 0.9% 250 mL, Total Volume (mL) = 250, IV, 12/09/22 23:55:00 EST, Other - See Comments, Clinical Weight  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV, 12/09/22 23:55:00 EST, Other - See Comments, Clinical Weight  Admit to Inpatient CAH  Auto Diff  Bedrest  Bladder Scan  Blood Gas Arterial QN  Blood Gas Arterial QN  BNP Pl QN  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Oxygen Need Greater Than  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  CBC w/Differential  CK SerPl QN  CK SerPl QN  Comp Metabolic Panel  Continuous Oxygen Saturation  CRP SerPl QN  CRP SerPl QN  D-Dimer Pl QN  D-Dimer Pl QN  Dysphagia Screen by RN  Ferritin SerPl QN  Ferritin SerPl QN  Fibrinogen  Initiate IV Care Protocols As Appropriate  Initiate Oxygen Protocol  Initiate Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  LDH SerPl QN  Level of Care  Medical Service  No NSAIDS (includes COX-2 Inhibitors)  NPO Advance as Tolerated  Procalcitonin  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Strep pneumoniae Ag Urine  Telemetry Class III 24hr Recommendation  Titrate FiO2 to Keep O2 Sat  Troponin-I High Sensitivity  Troponin-I High Sensitivity  UA Microscopic  Urinalysis w Culture Rflx  Urinary Catheter Insertion  Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 12/09/22 21:07:00 EST, Full Code   Chronic Problem List    Fall  Forehead laceration       Medications   Home Medications (12) Active  acetaminophen 500 mg, PRN, Orally, Q6H  allopurinol 100 mg oral tablet 100 mg = 1 Tablet, Orally, At Bedtime  buMETAnide 1 mg oral tablet 1 mg = 1 Tablet, Orally, Daily  carbidopa-levodopa 25 mg-100 mg oral tablet 2 Tablet, Orally, TID, TAKE 2 TABLETS BY MOUTH THREE TIMES DAILY, IN THE MORNING, AT NOON AND AT BEDTIME  carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID, TAKE 1 TABLET BY MOUTH IN THE MORNING AND AT BEDTIME  clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily, TAKE 1 TABLET BY MOUTH IN THE MORNING  FeroSul 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, Daily, TAKE 1 TABLET BY MOUTH TWICE DAILY. DO NOT CRUSH, CHEW OR SPLIT  Florastor 250 mg oral capsule 250 mg = 1 Capsule, Orally, BID  lovastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, At Bedtime, TAKE 1 TABLET BY MOUTH AT BEDTIME  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, BID, TAKE 1 TABLET BY MOUTH TWICE DAILY  PreserVision AREDS 1 Tablet, Orally, BID  rOPINIRole 2 mg oral tablet, extended release 2 mg = 1 Tablet, Orally, At Bedtime, TAKE 1 TABLET BY MOUTH AT BEDTIME  Active Scheduled Inpatient Medications  ampicillin-sulbactam, Injection, 3 GM, IVPB, Q8H, Start: 12/10/22 00:00:00  dexamethasone, Injection, 6 mg, IV Push, Q24H, Start: 12/09/22 21:07:00  docusate-senna (docusate-senna tablet 50 mg-8.6 mg), Tablet, 2 Tablet, Orally, BID, Start: 12/10/22 09:00:00  doxycycline, Injection, 100 mg, IVPB, Q12H, Start: 12/10/22 00:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 12/09/22 22:00:00  remdesivir, Injection, 100 mg, IVPB, At Bedtime, Start: 12/10/22 21:00:00  Furosemide + Bag, Viaflex IV 1 mL/hr [10 mg/hr] 10 mg/hr  12/10/22  Sodium Chloride 0.9%  500 mL IV  Other - See Comments 0  12/10/22  Dextrose 5% in Water  500 mL IV  Other - See Comments     Sodium Chloride 0.9%  250 mL IV  Other - See Comments       One-Time Medications Given 12/09/22 00:00:00 TO 12/10/22 06:28:14  None Reported  PRN Medications (0600 - 0559) from 12/09 - 12/10  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   hydrALAZINE, 10 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   NSAIDS  amLODIPine  naproxen  sulfonamides  Social History    Electronic Cigarette/Vaping   E-Cigarette Use Unable to obtain due to cognitive impairment.   Tobacco   Tobacco Use: Not obtained due to cognitive impairment.    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.4 k/cumm (12/10/22 04:09:00)  RBC: 2.43 million/cumm Low (12/10/22 04:09:00)  Hgb: 7.2 GM/dL Low (12/10/22 04:09:00)  Hct: 23.9 % Low (12/10/22 04:09:00)  MCV: 98 fL (12/10/22 04:09:00)  MCH: 29.7 pg (12/10/22 04:09:00)  MCHC: 30.2 GM/dL Low (12/10/22 04:09:00)  RDW: 20.2 % High (12/10/22 04:09:00)  Platelet: 230 k/cumm (12/10/22 04:09:00)  MPV: 8.8 fL (12/10/22 04:09:00)  Neutrophils %: 96 % (12/10/22 04:09:00)  Lymphocytes %: 2 % (12/10/22 04:09:00)  Monocytes %: 2 % (12/10/22 04:09:00)  Eosinophils %: 0 % (12/10/22 04:09:00)  Basophils %: 0 % (12/10/22 04:09:00)  Absolute Neutrophil: 10 k/cumm High (12/10/22 04:09:00)  Absolute Lymphocyte: 0.3 k/cumm Low (12/10/22 04:09:00)  Absolute Monocyte: 0.2 k/cumm (12/10/22 04:09:00)  Absolute Eosinophil: 0 k/cumm (12/10/22 04:09:00)  Absolute Basophil: 0 k/cumm (12/10/22 04:09:00)  Chemistry:  Sodium SerPl QN: 145 mmol/L (12/10/22 04:09:00)  Potassium SerPl QN: 4 mmol/L (12/10/22 04:09:00)  Chloride SerPl QN: 104 mmol/L (12/10/22 04:09:00)  Carbon Dioxide SerPl QN: 37 mmol/L High (12/10/22 04:09:00)  Anion Gap: 4 mmol/L (12/10/22 04:09:00)  BUN SerPl QN: 59 mg/dL High (12/10/22 04:09:00)  Creatinine SerPl QN: 1.47 mg/dL High (12/10/22 04:09:00)  Estimated GFR (CKD-EPI, no race): 48 mL/min/1.73m2 Low (12/10/22 04:09:00)  Estimated CRCL (CG): 44 mL/min Low (12/10/22 04:09:00)  Glucose SerPl QN: 115 mg/dL High (12/10/22 04:09:00)  Calcium Total SerPl QN: 8.6 mg/dL (12/10/22 04:09:00)  Alkaline Phos SerPl QN: 79 Units/L (12/10/22 04:09:00)  ALT SerPl QN: 4 Units/L Low (12/10/22 04:09:00)  AST SerPl QN: 19 Units/L (12/10/22 04:09:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (12/10/22 04:09:00)  Total Protein SerPl QN: 5.8 GM/dL Low (12/10/22 04:09:00)  Albumin SerPl QN: 3.3 GM/dL Low (12/10/22 04:09:00)  Lipase SerPl QN: 137 Units/L High (12/09/22 12:21:00)  CK SerPl QN: 252 Units/L High (12/10/22 04:09:00)  Troponin-I High Sensitivity: 668 ng/L High (12/09/22 21:39:00)  BNP Pl QN: 363 pg/mL High (12/09/22 21:39:00)  Lactate Venous Pl QN: 0.8 mmol/L (12/09/22 11:41:00)  Gluc-Strip, POC: 118 mg/dL High (12/09/22 11:19:00)  pH Bld Arterial QN: 7.4 (12/10/22 04:36:00)  PCO2 Bld Arterial QN: 62 mmHg Critical (12/10/22 04:36:00)  PO2 Bld Arterial QN: 80 mmHg (12/10/22 04:36:00)  Base Excess Bld Arterial: 12 mmol/L High (12/10/22 04:36:00)  Bicarb Bld Arterial Calc: 38 mmol/L High (12/10/22 04:36:00)  O2 Sat Bld Arterial Calc: 96 % (12/10/22 04:36:00)  pH Bld Venous QN: 7.36 (12/09/22 18:20:00)  PCO2 Bld Venous QN: 67 mmHg Critical (12/09/22 18:20:00)  PO2 Bld Venous QN: 43 mmHg (12/09/22 18:20:00)  Base Excess Bld Venous: 10 mmol/L High (12/09/22 18:20:00)  Bicarb Bld Venous Calc: 38 mmol/L High (12/09/22 18:20:00)  O2 Sat Bld Venous Calc: 76 % (12/09/22 18:20:00)  FIO2: 24% bipap (12/10/22 04:36:00)  Patient Temperature: 37 DegC (12/10/22 04:36:00)  C-Reactive Prot SerPl QN: 4.2 mg/dL High (12/10/22 04:09:00)  Coagulation:  PT: 14.8 seconds High (12/09/22 11:41:00)  INR: 1.28 High (12/09/22 11:41:00)  D-Dimer Pl QN: 344 ng/mL DDU High (12/10/22 04:09:00)  Urine Studies:  Color: Yellow (12/10/22 01:43:00)  Clarity: Clear (12/10/22 01:43:00)  Specific Gravity: 1.020 (12/10/22 01:43:00)  pH: 5.0 (12/10/22 01:43:00)  Protein: NEGATIVE (12/10/22 01:43:00)  Glucose: NEGATIVE (12/10/22 01:43:00)  Ketones: NEGATIVE (12/10/22 01:43:00)  Bilirubin: NEGATIVE (12/10/22 01:43:00)  Hgb Ur: SMALL. Abnormal (12/10/22 01:43:00)  Nitrite: NEGATIVE (12/10/22 01:43:00)  Urobilinogen: NormalUro (12/10/22 01:43:00)  Leukocyte Esterase Ur: NEGATIVE (12/10/22 01:43:00)  WBC: 6-10 Abnormal (12/10/22 01:43:00)  RBC: 3-5 Abnormal (12/10/22 01:43:00)  Bacteria: TRACE. (12/10/22 01:43:00)  Squamous Epithelial: Few (12/10/22 01:43:00)  Mucous: PRESENT. (12/10/22 01:43:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (12/09/22 11:41:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (12/09/22 11:41:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/09/22 11:41:00)  Rapid Influenza A PCR: Not Detected (12/09/22 11:41:00)  Rapid Influenza B PCR: Not Detected (12/09/22 11:41:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/09/2022 11:55 - XR Chest PA or AP Portable  IMPRESSION:1.  Overall similar appearance of the chest allowing for technical factors with moderate right pleural effusion and associated basilarairspace disease/compressive atelectasis. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss this case further can contact Reading Room. For after-hours or emergency department cases, please call.    12/09/2022 13:14 - CT Head W/o IV Contrast  IMPRESSION:1.  No acute CT abnormality of the head. No acute intracranialhemorrhage, hydrocephalus, or large mass.Thank you for consulting our team of subspecialty neuroradiologists at Radiology. Healthcareproviders wishing to discuss this case further can contact the Reading Room.    12/09/2022 13:14 - CT Chest Abdomen and Pelvis W/ IV Contr  IMPRESSION:1.  Moderate right and trace left pleural effusions.2.  Mucous visualized within multiple regions of the airway withperibronchial groundglass opacities suspicious for small foci ofaspiration pneumonia with possible lower respiratory tract infectionversus motion artifact obscuring the airways.3.  Prominent rectal stool burden concerning for impaction. Smallfoci of air seen within the rectal wall concerning for stercoralcolitis.4.  Diffuse body wall edema. Considering pleural effusions, historyof volume overload or anasarca could be considered. There is aasymmetric distribution of the edema, right greater than left.Superimposed contusion could be considered. The fluid appearsunorganized suggesting against abscess. However, correlation withclinical exam recommended.5.  Slight thickened appearance of the urinary bladder which may bedue to incomplete distention.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact the Abdominal Imaging Reading Room. For after-hours or emergency department cases, pleasecall.                Signature Line Electronically Signed on 12/10/22 06:28 EST ________________________________________________________ DO  Electronically Signed on 12/10/22 06:28 EST ________________________________________________________ DO