Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 13, 2023 19:00   Verified By: MD on February 13, 2023 19:00   Encounter Info: Hospital, Observation, 02/13/23 -     * Final Report *        Chief Complaint   Cough  History of Present Illness/Subjective     Patient is an 82 year old man w/ recent hospitalization for self-inflicted gun shot wound to chest w/ flail chest complicated by C diff infection who presents w/ 1 week of productive cough and pleuritic L sided pain. The patient states that these symptoms have worsened over the last few days. He denies any fever, chills, NVD. Upon arrival to the Hospital he was tachypneic in the mid 20s and tachycardic in the 110s. He was afebrile and normotensive and satting normally on RA. WBC count was 23K which is around his recent baseline given his h/o MDS. D-dimer was positive. CTA showed a L sided PE. CTA also showed a L sided loculated pleural effusion. Lactate and trop were normal. Patient was subsequently started on a heparin gtt. He was transferred to hospital for US guided thoracentesis and PE management. Upon arrival his vitals are stable. He has no new complaints.  Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective     Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Increased WOB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan     Patient is an 82 year old man who presents w/ loculated pleural effusion and PE.      1. Loculated pleural effusion   J90  -Will order US guided thoracentesis  -Cover w/ Zosyn for now      2. Sepsis   A41.9  -Sepsis power plan initiated  -Possibly due to parapneumonic effusion  -Will cover w/ Zosyn for now and check procal for abx de-escalation  -Normotensive so will hold off on fluids  -Lactate is normal  -Per Dr. will cover w/ PO vanc while patient is on Zosyn given recent and recurrent C diff infection      3. Pulmonary emboli   I26.99  -Apixaban  -TTE to assess for RH strain      4. MDS/MPN (myelodysplastic/myeloproliferative neoplasms)   D47.1  -Continue hydroxyurea      5. C. difficile colitis   A04.72  -Completed treatment course for this recently      6. CAD in native artery   I25.10  -Continue statin and ASA      7. Seizure   R56.9  -Continue home AED regimen      8. Leukocytosis   D72.89  -Due to MDS/MPN  -See problem #3  -Monitor for now      9. Hypokalemia   E87.6  -Electrolyte repletion protocol        Code Status   Resuscitation Status - Ordered    -- 02/13/23 18:29:00, Full Code   Chronic Problem List    C. difficile colitis  CAD in native artery  Colon polyp  Hip pain  IDA (iron deficiency anemia)  Leukocytosis  Loculated pleural effusion  MDS/MPN (myelodysplastic/myeloproliferative neoplasms)  Pulmonary emboli  Seizure  Severe obesity  Weakness  Weight loss  Procedure/Surgical History  oColonoscopy (08/30/2021) oEGD - Esophagogastroduodenoscopy (08/30/2021) oAppendectomy oGallbladder oHeart attack oPROSTATECTOMY ospinal surgery oTonsillectomy   Surgical History Internal  08/30/2021    Colonscpy Diagnostic/Screen    MD  Medications   Home Medications (17) Active  acetaminophen 650 mg rectal suppository 650 mg = 1 Suppository, PRN, Rectally, Q4H  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 1 Tablet, Orally, Daily  calcium (as carbonate)-vitamin D3 600 mg-10 mCg (400 intl units) oral tablet 1 Tablet, Orally, Daily  carBAMazepine 300 mg oral capsule, extended release 300 mg = 1 Capsule, Orally, BID  Claritin 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Euthyrox 25 mCg (0.025 mg) oral tablet 25 mCg = 1 Tablet, Orally, Daily  hydroxyurea 500 mg oral capsule 500 mg = 1 Capsule, Orally, Daily  ibuprofen 200 mg oral tablet 200 mg = 1 Tablet, Orally, At Bedtime  isosorbide mononitrate 60 mg oral tablet, extended release 1 Tablet, Orally, Daily  melatonin 3 mg oral tablet 3 mg = 1 Tablet, Orally, At Bedtime  multivitamin 1 Tablet, Orally, Daily  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  OXYcodone 5 mg oral tablet 5 mg = 1 Tablet, PRN, Orally, Q4H  PARoxetine 30 mg oral tablet 30 mg = 1 Tablet, Orally, Daily  propranolol 10 mg oral tablet 10 mg = 1 Tablet, Orally, BID  thiamine 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  apixaban, Tablet, 10 mg, Orally, BID, Start: 02/13/23 21:00:00  apixaban, Tablet, 5 mg, Orally, BID, Start: 02/20/23 21:00:00  vancomycin (vancomycin 125 mg oral capsule), Capsule, 125 mg, Orally, Q6, Indication: C. difficile Infection, Start: 02/14/23 00:00:00  Heparin PREMIX + Sodium Chloride 0.45% IV Per Nomogram 90,000 Units/hr      One-Time Medications Given 02/12/23 00:00:00 TO 02/13/23 18:54:40  None Reported  PRN Medications (0600 - 0559) from 02/12 - 02/13  magnesium sulfate, 2 GM, IVPB, Q12H, 0  Dose(s)   magnesium sulfate, 4 GM, IVPB, Q12H, 0  Dose(s)   potassium chloride, 20 mEq, IVPB, Unscheduled, 0  Dose(s)   potassium chloride, 20 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 30 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 40 mEq, Orally, Unscheduled, 0  Dose(s)   potassium phosphate-sodium phosphate, 250 mg, Orally, Unscheduled, 0  Dose(s)   sodium phosphate, 21 mmol, IVPB, Unscheduled, 0  Dose(s)   sodium phosphate, 28 mmol, IVPB, Unscheduled, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Current, Liquor, 1-2 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse, spouse's sister.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Heart attack..: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 23.1 k/cumm High (02/13/23 10:50:00)  RBC: 3.25 million/cumm Low (02/13/23 10:50:00)  Hgb: 11.1 GM/dL Low (02/13/23 10:50:00)  Hct: 33.4 % Low (02/13/23 10:50:00)  MCV: 103 fL High (02/13/23 10:50:00)  MCH: 34.1 pg High (02/13/23 10:50:00)  MCHC: 33.2 GM/dL (02/13/23 10:50:00)  RDW: 16 % High (02/13/23 10:50:00)  Platelet: 563 k/cumm High (02/13/23 10:50:00)  MPV: 9 fL (02/13/23 10:50:00)  Neutrophils %: 74 % (02/13/23 10:50:00)  Lymphocytes %: 3 % (02/13/23 10:50:00)  Monocytes %: 21 % (02/13/23 10:50:00)  Eosinophils %: 0 % (02/13/23 10:50:00)  Basophils %: 1 % (02/13/23 10:50:00)  Absolute Neutrophil: 17.1 k/cumm High (02/13/23 10:50:00)  Absolute Lymphocyte: 0.8 k/cumm Low (02/13/23 10:50:00)  Absolute Monocyte: 4.9 k/cumm High (02/13/23 10:50:00)  Absolute Eosinophil: 0.1 k/cumm (02/13/23 10:50:00)  Absolute Basophil: 0.3 k/cumm High (02/13/23 10:50:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (02/13/23 10:50:00)  Potassium SerPl QN: 3.2 mmol/L Low (02/13/23 10:50:00)  Chloride SerPl QN: 102 mmol/L (02/13/23 10:50:00)  Carbon Dioxide SerPl QN: 23 mmol/L (02/13/23 10:50:00)  Anion Gap: 11 mmol/L (02/13/23 10:50:00)  BUN SerPl QN: 14 mg/dL (02/13/23 10:50:00)  Creatinine SerPl QN: 1.01 mg/dL (02/13/23 10:50:00)  Estimated GFR (CKD-EPI, no race): 74 mL/min/1.73m2 (02/13/23 10:50:00)  Estimated CRCL (CG): 50 mL/min Low (02/13/23 10:50:00)  Glucose SerPl QN: 98 mg/dL (02/13/23 10:50:00)  Calcium Total SerPl QN: 8.5 mg/dL (02/13/23 10:50:00)  Alkaline Phos SerPl QN: 128 Units/L High (02/13/23 10:50:00)  ALT SerPl QN: 14 Units/L (02/13/23 10:50:00)  AST SerPl QN: 26 Units/L (02/13/23 10:50:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (02/13/23 10:50:00)  Total Protein SerPl QN: 6.4 GM/dL (02/13/23 10:50:00)  Albumin SerPl QN: 3.5 GM/dL (02/13/23 10:50:00)  Troponin-I High Sensitivity: 13 ng/L (02/13/23 10:50:00)  Lactate Venous Pl QN: 1.5 mmol/L (02/13/23 10:50:00)  Coagulation:  aPTT: 30.7 seconds (02/13/23 10:50:00)  D-Dimer Pl QN: 440 ng/mL DDU High (02/13/23 10:50:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/13/23 12:27:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (02/13/23 12:27:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/13/2023 11:03 - XR Chest PA or AP Portable  Impression:1.  Small left pleural effusion with a similar appearance to theprevious study. No pneumothorax. No change tiny metallic foreignbodies of the lateral lower left thorax and lower left neck. 2.  Otherwise, no active intrathoracic process.    02/13/2023 12:33 - CTA Chest Pulm Embolism W/IV Contrast  Impression:1. Left lower lobe pulmonary emboli. Dr. was notified ofthe findings by me with a telephone call at approximately 12:44 PM.2. The previously seen left-sided chest tube has been removed, aloculated lateral posterior effusion has accumulated.3. Emphysema.             Signature Line Electronically Signed on 02/13/23 19:00  ________________________________________________________ MD