Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 05, 2023 05:09 EST   Verified By: MD on November 05, 2023 05:09 EST   Encounter Info: Hospital, Inpatient, 11/05/23 -     * Final Report *  Document Has Been Revised        Chief Complaint   Cough  History of Present Illness/Subjective     This is an 88-year-old female with advanced Parkinson's disease with dementia, history of CHF, chronic atrial fibrillation, chronic anticoagulation on Eliquis, stage III chronic disease, hypertension, hyperlipidemia, presents with complaint of cough and generalized malaise and myalgias over about the past 24 hours.  The daughter described the patient's cough as productive of clear sputum.  Also some diarrhea reportedly.  Episode of emesis earlier in the day, nonbloody and nonbilious.  Blood pressure elevated at 153/119 and heart rate up around 115-120 which concerned the daughter as well.  The daughter is from state but has been living with her mother lately to provide care as her Parkinson's disease advances.  Patient was treated for urinary tract infection last week with Keflex, today was to be the final dose.    White blood cell count normal,absent lymphocyte count 900.Creatinine 1.29, glucose 128, alkaline phosphatase 258, AST 311 and ALT 47.  BNP is 500, troponin 56 initially, 124 on repeat.Serum lactate 1.6.  Urine is bland.  COVID-19 positive.    Chest x-ray shows no acute cardiopulmonary abnormality.  Moderate hiatal hernia on CT but otherwise nothing acute.   Blood pressure labile, room systolic ranging from 86-1 59, likely some of that reactive, patient with dementia, her sleep-wake cycles of disturbed, is poor in the morning, etc.That being said, the patient does experience sleep disturbances as expected with Parkinson's disease, sometimes with insomnia, sometimes prolonged sleeping.  Incomplete voiding.  No history of significant constipation.  Chronic tremor.  The patient is pleasant and cooperative, however, the patient's daughter does describe progressive dementia.      Review of Systems     Unable to obtain outside of what was provided by the daughter 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:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB, good airflow Cardiovascular:  Regular rate and rhythm no peripheral edema Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert, moves all extremities, chronic pill-rolling tremor and masked facies.       Assessment/Plan       1. COVID-19   U07.1   Chest x-ray clear.  Will check inflammatory markers, started on Dex and remdesivir as she is requiring supplemental oxygen.  Check procalcitonin levels, no antibiotics indicated at this time however.   2. Acute respiratory failure with hypoxia   J96.01   Mild, in fact, no lower than 89% in the emergency department.  This was in the middle of the night and she does have a history of sleep apnea, could be related to that.  RT and OT protocol, wean as able.   3. Atrial fibrillation   I48.91   Continue propranolol.  Monitor.  May need to add and/or titrate additional AV nodal blocking medication.  Monitor electrolytes.  Check thyroid function.   4. Elevated troponin   R79.89   No distress, not a great historian but does not appear to be in any discomfort of any kind.  Likely supply demand ischemia in the setting of tachycardia, COVID-19 infection, and delayed renal clearance.  Trend until stable and flat.   5. Elevated brain natriuretic peptide (BNP) level   R79.89   Exacerbated most likely by kidney disease and chronic diastolic heart failure.  Continue the patient's home diuretic.   6. Elevated LFTs   R79.89   Uncertain what to make of this, isolated elevation of AST and minimal elevation of alkaline phosphatase with normal total bilirubin and prior cholecystectomy.  Suspect this is secondary to viral infection.  Monitor during hospitalization.   7. CAD (coronary artery disease)   I25.10   Continue aspirin and long-acting nitrate.   8. COPD mixed type   J44.9   Overall good airflow, does not appear to be on home respiratory medication, will add as needed nebulizers.   9. Urinary retention   R33.9   Monitor for retention   10. Stage 3a chronic kidney disease (CKD)   N18.31   At or near baseline, continue diuretic, monitor   11. Parkinson disease   G20   Continue carbidopa levodopa   12. Diastolic heart failure   I50.30   Continue home diuretic, monitor intake and output, low-sodium diet   13. Hx of long-term (current) use of anticoagulants   Z92.29   Age-adjusted Eliquis   14. Hypertension   I10   Coreg, isosorbide   15. Hyperlipemia   E78.5   Noted   Full code   Eliquis  Code Status   Full Code   Chronic Problem List    Anxiety  Atrial fibrillation  Bilateral bunions  Bunion of right foot  CAD (coronary artery disease)  Chronic diarrhea  Chronic rhinitis  COPD mixed type  Depression  Diastolic heart failure  Goiter  Gout  Hammertoes of both feet  Hernia, hiatal  Hx of long-term (current) use of anticoagulants  Hyperlipemia  Hypertension  Long term use of drug  Mixed conductive and sensorineural hearing loss of both ears  Neck pain  Onychogryphosis  OSA on CPAP  Parkinson disease  Peripheral vascular disease  Plantar callus  Sensorineural hearing loss, bilateral  Stage 3a chronic kidney disease (CKD)  Thrush  Type 2 diabetes mellitus with peripheral neuropathy  Urinary retention  Procedure/Surgical History  ?Cholecystectomy Laparoscopic (08/31/2010) ?Colonoscopy (08/28/2008) ?Cataract ?exploratory laparotomy ?Hysterectomy   Surgical History Internal  10/06/2017    EGD Bx    MD  Medications   Home Medications (18) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily  carbidopa-levodopa 25 mg-100 mg oral tablet 1 Tablet, Orally, TID  cloNIDine 0.1 mg oral tablet 0.1 mg = 1 Tablet, Orally, QHS  Eliquis 2.5 mg oral tablet 2.5 mg = 1 Tablet, Orally, BID  febuxostat 40 mg oral tablet 40 mg = 1 Tablet, Orally, QAM  Fish Oil 1000 mg oral capsule 1,000 mg = 1 Capsule, Orally, BID  gabapentin 100 mg oral capsule 100 mg = 1 Capsule, Orally, At Bedtime  isosorbide mononitrate 60 mg oral tablet, extended release 60 mg = 1 Tablet, Orally, QAM  Keflex 500 mg oral capsule 500 mg = 1 Capsule, Orally, BID, for UTI  levothyroxine 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Daily  Lipitor 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  memantine 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  multivitamin 1 Tablet, Orally, QAM  PARoxetine 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  propranolol 80 mg oral tablet 80 mg = 1 Tablet, Orally, BID  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, BID  spironolactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, QAM  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 11/04/23 00:00:00 TO 11/05/23 05:09:14  None Reported  PRN Medications (0600 - 0559) from 11/04 - 11/05  None Reported  Allergies   Benadryl (Confusion)  Social History    Alcohol   Past, 1-2 times per year   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives in state 5 months out of the year starting in Nov., Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   DM - Diabetes mellitus: Mother.  Heart disease: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 8.1 k/cumm (11/04/23 21:51:00)  RBC: 4.9 million/cumm (11/04/23 21:51:00)  Hgb: 15.4 GM/dL High (11/04/23 21:51:00)  Hct: 45.3 % (11/04/23 21:51:00)  MCV: 92 fL (11/04/23 21:51:00)  MCH: 31.4 pg (11/04/23 21:51:00)  MCHC: 34 GM/dL (11/04/23 21:51:00)  RDW: 14.5 % (11/04/23 21:51:00)  Platelet: 249 k/cumm (11/04/23 21:51:00)  MPV: 8.2 fL (11/04/23 21:51:00)  Neutrophils %: 84 % (11/04/23 21:51:00)  Lymphocytes %: 11 % (11/04/23 21:51:00)  Monocytes %: 4 % (11/04/23 21:51:00)  Eosinophils %: 0 % (11/04/23 21:51:00)  Basophils %: 0 % (11/04/23 21:51:00)  Absolute Neutrophil: 6.8 k/cumm (11/04/23 21:51:00)  Absolute Lymphocyte: 0.9 k/cumm Low (11/04/23 21:51:00)  Absolute Monocyte: 0.3 k/cumm (11/04/23 21:51:00)  Absolute Eosinophil: 0 k/cumm (11/04/23 21:51:00)  Absolute Basophil: 0 k/cumm (11/04/23 21:51:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (11/04/23 21:51:00)  Potassium SerPl QN: 4 mmol/L (11/04/23 21:51:00)  Chloride SerPl QN: 105 mmol/L (11/04/23 21:51:00)  Carbon Dioxide SerPl QN: 25 mmol/L (11/04/23 21:51:00)  Anion Gap: 9 mmol/L (11/04/23 21:51:00)  BUN SerPl QN: 14 mg/dL (11/04/23 21:51:00)  Creatinine SerPl QN: 1.29 mg/dL High (11/04/23 21:51:00)  Estimated GFR (CKD-EPI, no race): 40 mL/min/1.73m2 Low (11/04/23 21:51:00)  Estimated CRCL (CG): 33 mL/min Low (11/04/23 21:51:00)  Glucose SerPl QN: 128 mg/dL High (11/04/23 21:51:00)  Calcium Total SerPl QN: 9.9 mg/dL (11/04/23 21:51:00)  Alkaline Phos SerPl QN: 258 Units/L High (11/04/23 21:51:00)  ALT SerPl QN: 47 Units/L (11/04/23 21:51:00)  AST SerPl QN: 311 Units/L High (11/04/23 21:51:00)  Bilirubin Total SerPl QN: 0.9 mg/dL (11/04/23 21:51:00)  Total Protein SerPl QN: 7.3 GM/dL (11/04/23 21:51:00)  Albumin SerPl QN: 4.6 GM/dL (11/04/23 21:51:00)  Lipase SerPl QN: 14 Units/L (11/04/23 21:51:00)  Troponin-I High Sensitivity: 124 ng/L High (11/04/23 23:46:00)  BNP Pl QN: 505 pg/mL High (11/04/23 21:51:00)  Lactate Venous Pl QN: 1.6 mmol/L (11/04/23 21:51:00)  Urine Studies:  Color: Yellow (11/05/23 00:51:00)  Clarity: Clear (11/05/23 00:51:00)  Specific Gravity: 1.018 (11/05/23 00:51:00)  pH: 5.5 (11/05/23 00:51:00)  Protein: 100 Abnormal (11/05/23 00:51:00)  Glucose: Normal (11/05/23 00:51:00)  Ketones: NEGATIVE (11/05/23 00:51:00)  Bilirubin: NEGATIVE (11/05/23 00:51:00)  Hgb Ur: NEGATIVE (11/05/23 00:51:00)  Nitrite: NEGATIVE (11/05/23 00:51:00)  Urobilinogen: Normal (11/05/23 00:51:00)  Leukocyte Esterase Ur: NEGATIVE (11/05/23 00:51:00)  WBC: 0-5 (11/05/23 00:51:00)  RBC: 0-2 (11/05/23 00:51:00)  Bacteria: NONE (11/05/23 00:51:00)  Squamous Epithelial: Few (11/05/23 00:51:00)  Hyaline Casts: 3-5 (11/05/23 00:51:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/04/23 22:18:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (11/04/23 22:18:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (11/04/23 22:18:00)  Rapid Influenza A PCR: Not Detected (11/04/23 22:18:00)  Rapid Influenza B PCR: Not Detected (11/04/23 22:18:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/04/2023 23:10 - XR Chest PA or AP Portable  IMPRESSION: 1.  No obvious infiltrate or effusion.2.  Mild cardiomegaly.3.  Moderate hiatal hernia.Template Version: IUHPR_STRThank you for consulting our team of subspecialty radiologists at Physicians Radiology.     11/04/2023 23:11 - CT Abd/Pelvis W/O IV Contrast  IMPRESSION: 1.  There is a normal appendix.2.  Moderate hiatal hernia.3.  Status post hysterectomy.4.  No suspicious adnexal mass.5.  No nephrolith, ureterolith or hydronephrosis.6.  Status post cholecystectomy.7.  No evidence of calcified choledocholithiasis or acutepancreatitis.Template Version: IUHPR_STRThank you for consulting our team of subspecialty radiologists at Physicians Radiology.                  Signature Line Electronically Signed on 11/05/23 05:09 EST ________________________________________________________ MD  Electronically Signed on 11/05/23 05:12 EST ________________________________________________________ MD