Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on February 12, 2023 00:45  Verified By: DO on February 12, 2023 00:45 Encounter Info: Hospital, Inpatient, 02/11/23 -     * Final Report *        Chief Complaint   AMS  History of Present Illness/Subjective     Patient presents via private vehicle due to AMS. Patient was released from facility weeks ago to home. He lives at home alone, but per close friend the plan was for his son to stay with him. This has not been happening according to friend. Today patient drove to his friends house. When he arrived he was honked his horn and was unable to get out of the car per self due to weakness. He was disheveled, shoes on the wrong feet and begging for food and water. He told her "I'm so thirsty and hungry, I haven't had food for days".  Bruising noted to right shoulder and lumbar back. Hematoma to posterior head. Patient is not supposed to be driving due to new onset seizure disorder. Patient has 2 sons, one of his sons manages his finances and the other was supposed to be living with him. Neither have POA. the house he drove to is his "lady friend" who is 88 years old. She had cared for him in her home for a few months last year but is unable to do so anymore. Patient complains of "pain all over" and hunger and thirst on arrival.   In the ED labs revealed likely pre-renal azotemia suggesting that the patient's dehydration is the likely culprit ok his AKI on CKD. no obvious source of infection precipitating encephalopathy, possibly 2/2 increased ketones and/or uremia.  Review of Systems     unable to obtain due to AMS  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.4 (36.4-36.4)  Temp (FAHR) 97.5 (97.5-97.5), BP 99/70 (99-99)/(70-70), HR 97 (79-97), RR 16 (16-16), O2Sat 97 (93-97)     Patient Weight    Patient Height  None Reported     General:  Alert, confused, poor historian, lethargic Eye:  Pupils are equal, round and reactive to light, Normal conjunctiva.   HENT: hematoma to posterior scalp, Tympanic membranes are clear.   Neck:  Non-tender, No jugular venous distention, no bony C spine tenderness, full ROM Cardiovascular:  tachy rate, Normal rhythm, S1, S2.  No LE edema Respiratory:  Lungs are coarse, diminished to auscultation, Respirations are non-labored.   Gastrointestinal:  Soft, Non-tender, Non-distended, Normal bowel sounds, Integumentary:  Ecchymosis to RUE, shoulder to elbow; ecchymosis to midline lumbar back. Neurologic:  Alert, confused Normal sensory, Normal motor function, No focal defects, Psychiatric:  Cooperative  Assessment/Plan       1. AMS (altered mental status)   R41.82  Likely multifactorial encephalopathy in combination with advancing dementia, will treat AKI and dehydration and reassess for further work-up  Will likely need long-term care facility, case management and social work consults would be appreciated   2. Acute kidney injury   N17.9  Continue gentle IV hydration monitor renal function avoid nephrotoxic medications   3. CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min   N18.4  See above   4. Dehydration   E86.0  Gentle IV hydration in view of reduced EF monitor electrolytes, encourage oral rehydration   5. HFrEF (heart failure with reduced ejection fraction)   I50.20  Continue home meds, recent echo showed EF of 30%   6. HTN (hypertension)   I10  Continue home meds, blood pressure goals 1 40-1 81 patient will further normalize outpatient with PMD or an ECF   7. Pulmonary edema   J81.1  Continue diuresis, BiPAP if needed   8. Emphysema lung   J43.9  Continue home meds, respiratory evaluation, SVNs, does not appear to be in acute exacerbation   9. GERD (gastroesophageal reflux disease)   K21.9  Continue home meds   10. BPH (benign prostatic hyperplasia)   N40.0  Continue home medications bladder scan as needed   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/11/23 22:30:00  albuterol, 2 Puff, Inhalation, Aerosol, MDI/DPI Inhaler Treatment, Q4H, PRN, Dyspnea, 02/12/23 0:28:00  heparin, 5,000 Units, Subcutaneous, Injection, Q12H, Routine, 02/11/23 23:00:00  OXYcodone, 5 mg, Orally, Tablet, Q4H, PRN, Pain Moderate PO (4-6 out of 10), 02/11/23 22:30:00  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 02/11/23 22:30:00  2000 mg Sodium Diet  Admit to Inpatient CAH  Bladder Scan  BNP Pl QN  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  Care Management Consult  CBC w/Differential  Comp Metabolic Panel  Dysphagia Screen by RN  Fall Precautions  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Level of Care  Lipid Panel SerPl QN  Medical Service  OT Evaluation and Treatment  PT Evaluation and Treatment  Resp Evaluation or Assessment  Seizure Precautions  Sequential Compression Device  Social Work Consult  Telemetry Class III 24hr Recommendation  TSH w FreeT4 reflex  Vital Signs  Weight   Code Status   None Recorded   Chronic Problem List    Abnormal thyroid function test  Asthma  BPH (benign prostatic hyperplasia)  Cavus foot, acquired  Chronic pain  CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min  Congenital foot deformity  Deformity of toe  Diarrhea  Elevated PSA  Emphysema lung  Essential hypertension, benign  Exertional dyspnea  Failed back syndrome  GERD (gastroesophageal reflux disease)  HFrEF (heart failure with reduced ejection fraction)  High cholesterol  HTN (hypertension)  Hyperlipoproteinemia  Hypertension  Hypotension  Idiopathic neuropathy  Impingement syndrome of right shoulder  Intervertebral disc disease  Lumbar neuritis  Lumbar radiculopathy  Metatarsalgia  Mononeuritis  Neuropathy  Onychogryphosis  Onychomycosis  Pacemaker  Pain in limb  Peripheral neuropathy  Persistent proteinuria  Plantar fasciitis  Pneumonia  Presence of combination internal cardiac defibrillator (ICD) and pacemaker  Right shoulder pain  Sciatica of left side  Seizure disorder  Unstable gait  Urinary frequency  Vitamin D deficiency  Vomiting  Procedure/Surgical History  oBack surgery obilateral hand surgery oCataract oHemorrhoidectomy olami opacemaker osinus   Surgical History Internal  06/01/2017    Laparotomy Exploratory    MD  Medications   Home Medications (13) Active  acetaminophen 500 mg oral tablet 1,000 mg = 2 Tablet, PRN, Orally, Q6H, not to exceed 4000 mg/day from all sources.  Aspirin Low Dose 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, Daily  furosemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  gabapentin 100 mg oral capsule 200 mg = 2 Capsule, Orally, TID  leveTIRACetam 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  loratadine 10 mg oral tablet 10 mg = 1 Tablet, PRN, Orally, Daily  metoPROLOL succinate 25 mg oral tablet, extended release 75 mg = 3 Tablet, Orally, Daily  Norco 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, BID  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  rosuvastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, QHS  Senna 8.6 mg, Orally, At Bedtime  Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q6H  Active Scheduled Inpatient Medications  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q12H, Start: 02/11/23 23:00:00    One-Time Medications Given 02/11/23 00:00:00 TO 02/12/23 00:45:02  None Reported  PRN Medications (0600 - 0559) from 02/11 - 02/12  OXYcodone, 5 mg, Orally, Q4H, 0  Dose(s)   acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2 Puff, Inhalation, Q4H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   Losartan Potassium (dry skin)  Lyrica (Tearful, Unknown)  Cortisone Acetate (Unknown)  Neurontin (Unknown)  amitriptyline (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Alone.   Nutrition/Health   Caffeine intake amount: 1-2 diet cokes/daily.   Other   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Coronary artery disease: Negative: Mother and Father.  Diabetes: Negative: Mother and Father.  Hypertension: Mother and Father.  Kidney disease: Negative: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.6 k/cumm (02/11/23 19:07:00)  RBC: 5.17 million/cumm (02/11/23 19:07:00)  Hgb: 13.6 GM/dL (02/11/23 19:07:00)  Hct: 42.6 % (02/11/23 19:07:00)  MCV: 82 fL (02/11/23 19:07:00)  MCH: 26.4 pg Low (02/11/23 19:07:00)  MCHC: 32 GM/dL (02/11/23 19:07:00)  RDW: 17.1 % High (02/11/23 19:07:00)  Platelet: 299 k/cumm (02/11/23 19:07:00)  MPV: 8.5 fL (02/11/23 19:07:00)  Neutrophils %: 64 % (02/11/23 19:07:00)  Lymphocytes %: 18 % (02/11/23 19:07:00)  Monocytes %: 15 % (02/11/23 19:07:00)  Eosinophils %: 2 % (02/11/23 19:07:00)  Basophils %: 1 % (02/11/23 19:07:00)  Absolute Neutrophil: 4.8 k/cumm (02/11/23 19:07:00)  Absolute Lymphocyte: 1.3 k/cumm (02/11/23 19:07:00)  Absolute Monocyte: 1.2 k/cumm (02/11/23 19:07:00)  Absolute Eosinophil: 0.2 k/cumm (02/11/23 19:07:00)  Absolute Basophil: 0.1 k/cumm (02/11/23 19:07:00)  Chemistry:  Sodium SerPl QN: 137 mmol/L (02/11/23 19:07:00)  Potassium SerPl QN: 3.7 mmol/L (02/11/23 19:07:00)  Chloride SerPl QN: 101 mmol/L (02/11/23 19:07:00)  Carbon Dioxide SerPl QN: 24 mmol/L (02/11/23 19:07:00)  Anion Gap: 12 mmol/L High (02/11/23 19:07:00)  BUN SerPl QN: 60 mg/dL High (02/11/23 19:07:00)  Creatinine SerPl QN: 2.74 mg/dL High (02/11/23 19:07:00)  Estimated GFR (CKD-EPI): 22 mL/min/1.73m2 Low (02/11/23 19:07:00)  Estimated CRCL (CG): 18 mL/min Low (02/11/23 19:07:00)  Glucose SerPl QN: 105 mg/dL High (02/11/23 19:07:00)  Calcium Total SerPl QN: 9.4 mg/dL (02/11/23 19:07:00)  Alkaline Phos SerPl QN: 79 Units/L (02/11/23 19:07:00)  ALT SerPl QN: 27 Units/L (02/11/23 19:07:00)  AST SerPl QN: 24 Units/L (02/11/23 19:07:00)  Bilirubin Total SerPl QN: 1.9 mg/dL High (02/11/23 19:07:00)  Total Protein SerPl QN: 6.9 GM/dL (02/11/23 19:07:00)  Albumin SerPl QN: 3.5 GM/dL (02/11/23 19:07:00)  CK SerPl QN: 79 Units/L (02/11/23 19:07:00)  Troponin-I High Sensitivity: 19 ng/L (02/11/23 20:54:00)  BNP Pl QN: 1643 pg/mL High (02/11/23 19:07:00)  Lactate Venous Pl QN: 1.5 mmol/L (02/11/23 19:07:00)  pH Bld Venous QN: 7.36 (02/11/23 19:07:00)  PCO2 Bld Venous QN: 45 mmHg (02/11/23 19:07:00)  PO2 Bld Venous QN: <34 Low (02/11/23 19:07:00)  Base Excess Bld Venous: 0 mmol/L (02/11/23 19:07:00)  Bicarb Bld Venous Calc: 25 mmol/L (02/11/23 19:07:00)  O2 Sat Bld Venous Calc: 47 % (02/11/23 19:07:00)  Patient Temperature: 37 DegC (02/11/23 19:07:00)  Carboxyhemoglobin Bld QN: 2.9 % High (02/11/23 19:07:00)  Urine Studies:  Color: Yellow (02/11/23 20:54:00)  Clarity: Clear (02/11/23 20:54:00)  Specific Gravity: 1.015 (02/11/23 20:54:00)  pH: 5.5 (02/11/23 20:54:00)  Protein: 30 Abnormal (02/11/23 20:54:00)  Glucose: NEGATIVE (02/11/23 20:54:00)  Ketones: TRACE. Abnormal (02/11/23 20:54:00)  Bilirubin: SC Small Abnormal (02/11/23 20:54:00)  Hgb Ur: TRACE. Abnormal (02/11/23 20:54:00)  Nitrite: NEGATIVE (02/11/23 20:54:00)  Urobilinogen: NormalUro (02/11/23 20:54:00)  Leukocyte Esterase Ur: NEGATIVE (02/11/23 20:54:00)  WBC: 0-5 (02/11/23 20:54:00)  RBC: 3-5 Abnormal (02/11/23 20:54:00)  Bacteria: Few Abnormal (02/11/23 20:54:00)  Squamous Epithelial: Few (02/11/23 20:54:00)  Hyaline Casts: 0-2 (02/11/23 20:54:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/11/23 19:07:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/11/23 19:07:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/11/2023 20:35 - CT Cervical Spine W/o IV Contrast  IMPRESSION:   1.  No evidence of acute intracranial hemorrhage or mass effect. Nocalvarial fracture.2.  Mild likely chronic small vessel ischemic disease and moderatediffuse volume loss.3.  No evidence of an acute fracture or traumatic subluxationinvolving the cervical spine.4.  Multilevel spondylotic change of the cervical spine with up tomild to moderate spinal canal stenosis at the C3-C4 level secondaryto a disc osteophyte complex. There is also up to moderate to severebilateral neural foraminal narrowing at C6-C7 level.5.  New small bilateral right greater than left pleural effusions.6.  Emphysema.Thank you for consulting our team. Please contact us with any questions.I have personally reviewed the image(s) and theprepared and signed interpretation. Based on myreview, I agree with the findings.    02/11/2023 20:35 - CT Head W/o IV Contrast  IMPRESSION:   1.  No evidence of acute intracranial hemorrhage or mass effect. Nocalvarial fracture.2.  Mild likely chronic small vessel ischemic disease and moderatediffuse volume loss.3.  No evidence of an acute fracture or traumatic subluxationinvolving the cervical spine.4.  Multilevel spondylotic change of the cervical spine with up tomild to moderate spinal canal stenosis at the C3-C4 level secondaryto a disc osteophyte complex. There is also up to moderate to severebilateral neural foraminal narrowing at C6-C7 level.5.  New small bilateral right greater than left pleural effusions.6.  Emphysema.Thank you for consulting our team. Please contact uswith any questions.I have personally reviewed the image(s) and theprepared and signed interpretation. Based on myreview, I agree with the findings.    02/11/2023 20:36 - XR Chest PA or AP  IMPRESSION:1.  Mild to moderate pulmonary edema with small bilateral pleuraleffusions.Thank you for consulting our team. Please contact us with any questions.    02/11/2023 20:37 - XR Spine Lumbar 2 or 3 View  IMPRESSION:1.  No acute lumbar spine findings.Thank you for consulting our team. Please contact us with any questions.    02/11/2023 20:38 - XR Shoulder 2 View Min Left  IMPRESSION:1.  No acute osseous abnormalities.Thank you for consulting our team. Please contact uswith any questions.                Signature Line Electronically Signed on 02/12/23 00:45 ________________________________________________________ DO