Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on May 24, 2023 23:40 EDT   Verified By: MD on May 24, 2023 23:40 EDT   Encounter Info: Hospital, Observation, 05/25/23 - 05/29/23    * Final Report *  Document Has Been Revised        Chief Complaint   Cough  History of Present Illness/Subjective     81-year-old female with dementia coming from skilled nursing facility with cough.  Cough, nonproductive, x1 week, mild to moderate, with associated decreased activity and lethargy.  Right basilar infiltrate noted on CT.  White blood cell count is normal but there are increased polymorphonuclear cells.  Serum bicarbonate 31, mildly elevated AST and ALT as well as alkaline phosphatase.  Troponin is 18 and flat.  Serum bicarbonate 28, renal function normal.    CT  1.  Abdominal aorta: Again seen is a penetrating atherosclerotic ulcer at the descending thoracic aorta which has enlarged since 7/6/2022. Recommend consideration for endovascular repair. 2.  Severe atherosclerotic calcifications through the major arteries in the abdomen and pelvis without definite critical stenosis or occlusion within limitations of the exam.  The ascending aorta measures 3.4 x 3.5 cm in diameter. Aneurysmal dilatation of the proximal descending thoracic aorta to 3.5 cm is noted. There is a penetrating ulcer of the lower descending thoracic aorta  measuring 1.2 x 1.6 x 2.6 cm. Previously, this measured 1.2 x 1.6 x 2.3 cm.     There has been interval enlargement from 2022 but statistically speaking, minimal enlargement.  The ED provider reached out to regional hospital, vascular surgery, declined patient transfer as not indicated, nothing to do related to the above findings regarding the aorta, at least not in an acute or emergent fashion.   Quit smoking about 3 years ago.  Not on home oxygen.  No recent antibiotics.  She does come from skilled nursing facility.  No history of coughing or choking while eating or drinking.  No history of dysphagia.  Review of Systems     Denies fever, chills, chest pain, hemoptysis.  No abdomen pain nausea vomiting.  Remaining 10 point review of systems negative except as noted above.  Physical Exam/Objective Vitals & Measurements most recent past 24 hours   Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA normal conjunctiva ENMT: Mucous membranes are dry Neck:  Supple, no JVD Respiratory: Good airflow, rales on the right side Cardiovascular:  Regular rate and rhythm 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. Healthcare-associated pneumonia   J18.9  Nontoxic, no acute distress, infiltrate throughout the right lung.  Does not describe history of dysphagia, however, will treat as healthcare associated pneumonia which will also cover for possible aspiration.  Will cover with Zosyn, vancomycin, doxycycline for atypicals.  Urine antigens.  Cultures.  Although the patient's daughter denies any history of aspiration or signs suggestive of aspiration/dysphagia, we will go ahead and cover accordingly given age, dementia, radiographic findings.   2. Abnormal CT scan   R93.89  Only slight interval increase in known aneurysm, outside vascular surgery indicates no acute needs.  Noted.  Follow-up as outpatient.   3. Hypertension   I10  Blood pressure soft, will gently hydrate and hold antihypertensives   4. Dementia   F03.90  Actually does fairly well, she is at the nursing home, uses a walker for ambulation, gets around okay.  She actually has decent recollection and is alert and oriented at this time.  Of note, the family is somewhat dissatisfied with Facility and would like to look at alternate options, will request case management consultation.   5. Hypoxia   R09.02  Supplement and titrate, goal 90% or greater   6. Benign essential hypertension   I10  Hold antihypertensives, gently hydrate   7.  Paroxysmal atrial fibrillation: Continue amiodarone, apixaban   Full code  Apixaban 2.5 mg twice daily  Code Status   Full code   Chronic Problem List    Abnormal CT scan  Alkaline phosphatase raised  Bleeding nose  Compression fracture of lumbar spine, non-traumatic  Compression fracture of spine  Cough  Elevated alkaline phosphatase level  Elevated liver function tests  Elevated tumor markers  Falling episodes  Health care maintenance  History of seizures  Hypertension  Hypotension  Hypoxia  Low blood pressure reading  Memory loss  Osteopenia  Ovarian ca  Ovarian cyst  Weight loss       Medications   Home Medications (27) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  Advair HFA 115mCg-21mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  albuterol HFA MDI 90mCg/puff inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily  amiodarone 200 mg oral tablet 200 mg = 1 Tablet, Orally, Daily  apixaban 2.5 mg oral tablet 2.5 mg = 1 Tablet, Orally, BID  Aricept 5 mg oral tablet 5 mg = 1 Tablet, Orally, At Bedtime  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, QHS  benzonatate 200 mg oral capsule 200 mg = 1 Capsule, PRN, Orally, TID  bisacodyl 10 mg rectal suppository 10 mg = 1 Suppository, Rectally, Daily  Breo Ellipta 100 mCg-25 mCg inhalation powder   Breo Ellipta 100 mCg-25 mCg inhalation powder   Breo Ellipta 100 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  cetirizine 10 mg oral capsule   dextromethorphan-guaiFENesin-PE 10 mg-100 mg-5 mg/5 mL oral syrup 5 mL, Orally, Q4H  ergocalciferol (vitamin D2) 1.25 mg (50,000 intl units) oral capsule 50,000 Units = 1 Capsule, Orally, Every Month  furosemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  guaiFENesin-dextromethorphan 200 mg-10 mg/5 mL oral liquid 5 mL, PRN, Orally, Q4H  leveTIRACetam 100 mg/mL intravenous solution 500 mg, Orally, BID  metHIMazole 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  metoPROLOL tartrate , Give 12.5 miligram by mouth three timesa day  MiraLax oral powder for reconstitution 17 GM, Orally, Daily, dissolve in water before taking  Potassium Chloride (Eqv-K-Tab) 8 mEq, Orally, BID  senna 8.8 mg/5 mL syrup , Orally, Daily  Spiriva Respimat 2.5 mCg/inh inhalation aerosol  (60 actuations) 5 mCg = 2 Puff, Inhalation, Daily, 2 puffs daily  Synthroid 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Daily  Zoloft 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 05/23/23 00:00:00 TO 05/24/23 23:40:43  None Reported  PRN Medications (0600 - 0559) from 05/23 - 05/24  None Reported  Allergies   Flexeril (confusion/hallucinations)  Thimerosal (unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Facility   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Breast cancer: Grandmother (M).  Cerebrovascular accident: Mother.  Colorectal cancer: Father.  High blood pressure: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.2 k/cumm (05/24/23 13:30:00)  RBC: 4.23 million/cumm (05/24/23 13:30:00)  Hgb: 12.3 GM/dL (05/24/23 13:30:00)  Hct: 38.1 % (05/24/23 13:30:00)  MCV: 90 fL (05/24/23 13:30:00)  MCH: 29.1 pg (05/24/23 13:30:00)  MCHC: 32.2 GM/dL (05/24/23 13:30:00)  RDW: 15.9 % High (05/24/23 13:30:00)  Platelet: 377 k/cumm (05/24/23 13:30:00)  MPV: 8.2 fL (05/24/23 13:30:00)  Neutrophils %: 79 % (05/24/23 13:30:00)  Lymphocytes %: 7 % (05/24/23 13:30:00)  Monocytes %: 12 % (05/24/23 13:30:00)  Eosinophils %: 1 % (05/24/23 13:30:00)  Basophils %: 1 % (05/24/23 13:30:00)  Absolute Neutrophil: 8.1 k/cumm High (05/24/23 13:30:00)  Absolute Lymphocyte: 0.7 k/cumm Low (05/24/23 13:30:00)  Absolute Monocyte: 1.2 k/cumm (05/24/23 13:30:00)  Absolute Eosinophil: 0.1 k/cumm (05/24/23 13:30:00)  Absolute Basophil: 0.1 k/cumm (05/24/23 13:30:00)  Chemistry:  Sodium SerPl QN: 140 mmol/L (05/24/23 13:30:00)  Potassium SerPl QN: 3.7 mmol/L (05/24/23 13:30:00)  Chloride SerPl QN: 101 mmol/L (05/24/23 13:30:00)  Carbon Dioxide SerPl QN: 28 mmol/L (05/24/23 13:30:00)  Anion Gap: 11 mmol/L (05/24/23 13:30:00)  BUN SerPl QN: 31 mg/dL High (05/24/23 13:30:00)  Creatinine SerPl QN: 1.13 mg/dL (05/24/23 13:30:00)  Estimated GFR (CKD-EPI, no race): 49 mL/min/1.73m2 Low (05/24/23 13:30:00)  Estimated CRCL (CG): 26 mL/min Low (05/24/23 13:30:00)  Glucose SerPl QN: 116 mg/dL High (05/24/23 13:30:00)  Calcium Total SerPl QN: 9.8 mg/dL (05/24/23 13:30:00)  Alkaline Phos SerPl QN: 140 Units/L High (05/24/23 13:30:00)  ALT SerPl QN: 98 Units/L High (05/24/23 13:30:00)  AST SerPl QN: 92 Units/L High (05/24/23 13:30:00)  Bilirubin Total SerPl QN: 1 mg/dL (05/24/23 13:30:00)  Total Protein SerPl QN: 7.4 GM/dL (05/24/23 13:30:00)  Albumin SerPl QN: 3.9 GM/dL (05/24/23 13:30:00)  Troponin-I High Sensitivity: 15 ng/L High (05/24/23 14:14:00)  Coagulation:  D-Dimer Pl QN: 323 ng/mL DDU High (05/24/23 13:30:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 05/24/2023 13:50 - XR Chest PA or AP Portable  IMPRESSION:Mild, stable cardiomegaly.Mild interstitial changes in the lungs appear chronic.No consolidating infiltrates or other acute findings.    05/24/2023 15:34 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for pulmonary embolism.2.  Bilateral lower peri-bronchial thickening consistent with largeairway disease, likely infectious/inflammatory.3.  Right lower lobe airspace disease suggestive of pneumonia4.  Cardiomegaly5.  Interval enlargement of penetrating ulcer of the descendingthoracic aorta. Consideration should be given to endovascular repair.Thank you for consulting our team of subspecialty radiologists Radiology.      05/24/2023 19:01 - CTA Aorta Runoff W/IV Contrast  IMPRESSION:1.  Abdominal aorta: Again seen is a penetrating atheroscleroticulcer at the descending thoracic aorta which has enlarged since7/6/2022. Recommend consideration for endovascular repair.2.  Severe atherosclerotic calcifications through the major arteriesin the abdomen and pelvis without definite critical stenosis orocclusion within limitations of the exam.3.  Lower extremities: Limited study due to venous contamination,motion degradation, and extensive atherosclerotic calcifications. Nofrank occlusion within the major vessels of the thigh or poplitealarteries. Limited assessment of the popliteal artery branches in thecalf. Conventional angiography may be more appropriate for assessingsignificant stenosis.Thank you for consulting our team of subspecialty radiologists Radiology.                  Signature Line Electronically Signed on 05/24/23 23:40 EDT ________________________________________________________ MD  Electronically Signed on 05/25/23 01:26 EDT ________________________________________________________ MD  Electronically Signed on 05/25/23 01:36 EDT ________________________________________________________ MD