Document Type: History and Physical   Document Subject: History & Physical Note   Performed: December 06, 2022 19:13 EST   Verified: December 06, 2022 19:13 EST     * Final Report *  Document Contains Addenda          History of Present Illness/Subjective     71 year old male presents to the ED from home via EMS for AMS and respiratory distress. bilateral wheezes, and increased weakness with last known normal Saturday.   HPI limited due to AMS.   ???????Upon ER evaluation his vital signs were stable with a temperature of 97, heart rate was 96, respiratory rate was 20 and room air sat was 96%.  Initial blood pressure was 12 over 72.  Lab work was completed which showed a normal white blood cell count of 6.5, hemoglobin was 10.9, sodium was elevated at 150 with repeat being 147.  Initial potassium was 2.9 which was replaced and then came down to 2.8.  His renal function was declined initially with a GFR of 24 which did come up to 27 after fluids.  Patient's baseline is CKD stage III with a creatinine of 1.55, lactate initially was four-point 1 repeat was 1.5, troponin was 52 with repeat pending, BNP was 271, urinalysis revealed hematuria, no signs of acute infection.  COVID SARS was positive flu was negative,.  Due to altered mental status head CT was completed did not show any acute intracranial findings did show chronic small vessel ischemic disease.  This was followed up with an MRI of the brain which did not show any acute infarction small focal acute left frontal deep white matter infarction at the level of the body of the left lateral ventricle, moderate volume loss with moderate chronic microvascular ischemia and diffuse para nasal sinus mucosal disease with bilateral mucosal disease with partial opacification of mastoid air cells.  Chest x-ray showed   ???????No acute findings in the chest.  We will bring patient in for further evaluation management inpatient status for acute CVA, COVID, dehydration, AKI, hypokalemia and hyponatremia.  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)  None reported this timeframe     Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Breathing comfortably on room air Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: AMS, mild deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Acute CVA (cerebrovascular accident)    -Will start ASA,  statin and plavix  -Monitor neuro status  MRI Brain W/O IV Contrast    12/06/22 17:09:57  IMPRESSION:  1. Small focal acute left frontal deep white matter infarction at  the level of the body of left lateral ventricle.  2. Moderate volume loss with moderate chronic microvascular ischemic  disease.  3. Diffuse paranasal sinus mucosal disease with bilateral mucosal  disease with partial opacifications of mastoid air cells.     Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss  this case further can contact the Reading Room.       ************************************************** CT Head W/o IV Contrast    12/06/22 12:25:30  IMPRESSION:   No evidence of acute intracranial hemorrhage or mass effect.   Moderate to severe likely chronic small vessel ischemic disease and  diffuse volume loss, progressed compared to 2017.    Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss  this case further can contact the Reading Room.       2. COVID-19   -on RA, monitor, RT protocol, monitor labs   3. Hypokalemia    Replacement protocol   4. Hypernatremia   Free water deficit 1.8L   5. AKI (acute kidney injury)   Give IV fluids  -Monitor labs daily   6. Chronic kidney disease, stage 3   noted   7. Dehydration   noted   8. Cardiomyopathy   noted   9. HTN (hypertension)   Resume home meds   10. Mixed bipolar affective disorder, mild (disorder)    resume home meds   11. Elevated troponin    Repeating, elevated, NO ST elevation on EKG   12. Hematuria   Renal US in am   13. Sinusitis, acute    Start zosyn   14. CAD (coronary artery disease)    resume home meds   Orders:   piperacillin-tazobactam, 3.375 GM, IVPB, Injection, Q8H, Indication: Other (MUST specify in Comments), 12/06/22 19:00:00 EST, Total Volume (mL) = 50  CK SerPl QN  Troponin-I High Sensitivity  US Renal and Bladder  Pt is a full code status  DVT prophylaxis with lovenox  Code Status   None Recorded   Chronic Problem List    Acute CVA (cerebrovascular accident)  AKI (acute kidney injury)  Alzheimer's dementia  Bursitis  CAD (coronary artery disease)  Cardiomyopathy  Charcot-Marie-tooth disease  Chronic back pain  Chronic kidney disease, stage 3  Chronic, continuous use of opioids  COPD (chronic obstructive pulmonary disease)  COVID-19  Dehydration  Edema  Elevated PSA  Elevated troponin  Heart disease  Hematuria  HTN (hypertension)  Hypernatremia  Hypokalemia  Hypoxemia  Major depression  Mixed bipolar affective disorder, mild (disorder)  Neck pain, chronic  Onychogryphosis  Prostate asymmetry  Sinusitis, acute  Tobacco use  Procedure/Surgical History  ?Colonoscopy (02/17/2022) ?Excision skin lesion chest (07/01/2020) ?Open heart surgery (01/01/1998) ?Amputated toe ?Appendectomy ?Tonsillectomy   Surgical History Internal  02/17/2022    Colonscpy Snare Tmr Polyp Lsn      07/01/2020    Lesion Mass Excision     06/12/2020    Femur Proximal Neck Fracture Open Red  (Right)    Medications   Home Medications (18) Active  albuterol 2.5 mg/0.5mL (0.5%) inhalation solution 2.5 mg = 0.5 mL, Neb Inhal, Q6H  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, Neb Inhal, Q6H  albuterol 90 mCg/inh inhalation powder 2 Puff, PRN, Inhalation, Q4H  atorvastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, QHS  calcium (as carbonate)-vitamin D3 600 mg-10 mCg (400 intl units) oral tablet 1 Tablet, Orally, BID  cetirizine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Coreg 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, Daily  DME Oximeter Not Applicable, Other, Unscheduled  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, BID  fluticasone-vilanterol 100 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  hydroCODONE-acetaminophen 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, BID  Misc Supplies See Instructions, elevated toilet seat with arm rest  Misc Supplies See Instructions, Tub transfer bench  Nephrocaps oral capsule 1 Capsule, Orally, Daily  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, Sublingually, Q5min  predniSONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  Prozac 40 mg oral capsule 40 mg = 1 Capsule, Orally, Daily  umeclidinium 62.5 mCg inhalation powder 62.5 mCg = 1 Puff, Inhalation, Daily  Active Scheduled Inpatient Medications  Zosyn, Injection, 3.375 GM, IVPB, Q8H, Indication: Other (MUST specify in Comments), Start: 12/06/22 19:00:00    One-Time Medications Given 12/05/22 00:00:00 TO 12/06/22 19:12:43  None Reported  PRN Medications (0600 - 0559) from 12/05 - 12/06  None Reported  Allergies   Bee Stings (critical)  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Disability   Home/Environment   divorced, 3 children   Substance Abuse   Denies   Tobacco   Tobacco Use: 5-9 cigarettes (between 1/4 to 1/2 pack)/day in last 30 days.  Family History   CMT - Charcot-Marie-Tooth disease: Father and Sister.  Heart attack..: Father.  Heart disease..: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.5 k/cumm (12/06/22 11:08:00)  RBC: 3.11 million/cumm Low (12/06/22 11:08:00)  Hgb: 10.9 GM/dL Low (12/06/22 11:08:00)  Hct: 32.4 % Low (12/06/22 11:08:00)  MCV: 104 fL High (12/06/22 11:08:00)  MCH: 35.2 pg High (12/06/22 11:08:00)  MCHC: 33.7 GM/dL (12/06/22 11:08:00)  RDW: 16.2 % High (12/06/22 11:08:00)  Platelet: 112 k/cumm Low (12/06/22 11:08:00)  MPV: 8.3 fL (12/06/22 11:08:00)  # WBC Counted in Diff: 100 (12/06/22 11:08:00)  Neutrophil: 68 % (12/06/22 11:08:00)  Lymphocyte: 31 % (12/06/22 11:08:00)  Monocyte: 1 % (12/06/22 11:08:00)  Absolute Neutrophil: 4.4 k/cumm (12/06/22 11:08:00)  Abs Lymphocyte: 2 k/cumm (12/06/22 11:08:00)  Absolute Monocyte: 0.1 k/cumm (12/06/22 11:08:00)  RBC Morphology: See description UC (12/06/22 11:08:00)  Hypochromasia: Moderate (2+), (12/06/22 11:08:00)  Microcyte: Few (1+). (12/06/22 11:08:00)  Platelet Estimate: Adequate. (12/06/22 11:08:00)  Platelet Morphology: Normal, (12/06/22 11:08:00)  Chemistry:  Sodium SerPl QN: 147 mmol/L High (12/06/22 17:04:00)  Potassium SerPl QN: 2.8 mmol/L Critical (12/06/22 17:04:00)  Chloride SerPl QN: 111 mmol/L High (12/06/22 17:04:00)  Carbon Dioxide SerPl QN: 26 mmol/L (12/06/22 17:04:00)  Anion Gap: 10 mmol/L (12/06/22 17:04:00)  BUN SerPl QN: 25 mg/dL High (12/06/22 17:04:00)  Creatinine SerPl QN: 2.49 mg/dL High (12/06/22 17:04:00)  Estimated GFR (CKD-EPI, no race): 27 mL/min/1.73m2 Low (12/06/22 17:04:00)  Estimated CRCL (CG): 29 mL/min Low (12/06/22 17:04:00)  Glucose SerPl QN: 96 mg/dL (12/06/22 17:04:00)  Calcium Total SerPl QN: 7.9 mg/dL Low (12/06/22 17:04:00)  Phosphorus SerPl QN: 2.2 mg/dL Low (12/06/22 12:54:00)  Alkaline Phos SerPl QN: 76 Units/L (12/06/22 12:54:00)  ALT SerPl QN: 10 Units/L (12/06/22 12:54:00)  AST SerPl QN: 15 Units/L (12/06/22 12:54:00)  Bilirubin Total SerPl QN: 1.3 mg/dL High (12/06/22 12:54:00)  Total Protein SerPl QN: 5.1 GM/dL Low (12/06/22 12:54:00)  Albumin SerPl QN: 3 GM/dL Low (12/06/22 12:54:00)  Magnesium SerPl QN: 2.1 mg/dL (12/06/22 12:54:00)  Troponin-I High Sensitivity: 52 ng/L High (12/06/22 11:08:00)  BNP Pl QN: 271 pg/mL High (12/06/22 11:08:00)  Lactate Venous Pl QN: 1.5 mmol/L (12/06/22 14:47:00)  Urine Studies:  Color: Yellow (12/06/22 12:12:00)  Clarity: Clear (12/06/22 12:12:00)  Specific Gravity: >=1.030 (12/06/22 12:12:00)  pH: 5.5 (12/06/22 12:12:00)  Protein: 100 Abnormal (12/06/22 12:12:00)  Glucose: NEGATIVE (12/06/22 12:12:00)  Ketones: TRACE. Abnormal (12/06/22 12:12:00)  Bilirubin: SC Small Abnormal (12/06/22 12:12:00)  Hgb Ur: LARGE. Abnormal (12/06/22 12:12:00)  Nitrite: NEGATIVE (12/06/22 12:12:00)  Urobilinogen: NormalUro (12/06/22 12:12:00)  Leukocyte Esterase Ur: NEGATIVE (12/06/22 12:12:00)  WBC: 0-5 (12/06/22 12:12:00)  RBC: 3-5 Abnormal (12/06/22 12:12:00)  Bacteria: TRACE. (12/06/22 12:12:00)  Squamous Epithelial: NONE (12/06/22 12:12:00)  Mucous: PRESENT. (12/06/22 12:12:00)  Granular Casts: 3-5 Abnormal (12/06/22 12:12:00)  Amorphous Crys Ur: PRESENT. (12/06/22 12:12:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (12/06/22 10:59:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (12/06/22 10:59:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/06/22 10:59:00)  Rapid Influenza A PCR: Not Detected (12/06/22 10:59:00)  Rapid Influenza B PCR: Not Detected (12/06/22 10:59:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/06/2022 11:35 - XR Chest PA or AP Portable  IMPRESSION: No acute findings in the chest.Thank you for consulting withRadiology. If you are a clinicianand would like to discuss this case further, please contact the Hospital reading room.     12/06/2022 11:52 - CT Head W/o IV Contrast  IMPRESSION:   No evidence of acute intracranial hemorrhage or mass effect.Moderate to severe likely chronic small vessel ischemic disease anddiffuse volume loss, progressed compared to 2017. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Reading Room.  12/06/2022 16:57 - MRI Brain W/O IV Contrast  IMPRESSION:  1.  Small focal acute left frontal deep white matter infarction atthe level of the body of left lateral ventricle.2.  Moderate volume loss with moderate chronic microvascular ischemicdisease.3.  Diffuse paranasal sinus mucosal disease with bilateral mucosaldisease with partial opacifications of mastoid air cells.Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Reading Room.                    I saw and evaluated the patient in addition to other provider.  I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care.  General:  Alert and oriented, No acute distress. Eyes:   Extraocular movements are intact, no scleral icterus HEENT:  Normocephalic, Normal hearing, Moist oral mucosa Respiratory:  Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness. Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, nontender, nondistended, normal bowel sounds Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: Alert, no focal deficits Psychiatric:  Cooperative, appropriate mood and affect