Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on January 19, 2023 06:30   Verified By: DO on January 19, 2023 06:30   Encounter Info: Hospital, Inpatient, 01/18/23 -     * Final Report *        Chief Complaint   flu-like symptoms  History of Present Illness/Subjective     A 95 year old male w/ hx of atrial fibrillation, dementia, stroke, recurrent/chronic UTI presents to the ED via EMS from assisted living facility c/o cough, fever, and generalized pain. Patient denies any dyspnea, chest pain, vomiting or diarrhea. In the ED he was found to be Influenza A positive and have evidence of uti on U/A, with recent hx of ESBL.   HPI limited due to the patient being a poor historian, given it is difficult to determine if he is having urinary symptoms will cont treatment with Merrem and consider obtaining ID consult to help ascertain if this more likely represents colonization vs recurrent uti.  Review of Systems     unable to obtain ros due to the patient dementia.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.8 (36.9-37.8)  Temp (FAHR) 100.0 (98.4-100.0), BP 135/64 (95-135)/(54-70), HR 103 (103-115), RR 18 (18-18), O2Sat 93 (91-93) Neurologic (most recent and range for last 24 hours)  GCS 14(14-14)     Patient Weight  Current Daily Weight:    86.5 kg    01/19/23    Patient Height        Constitutional: No acute distress, ill appearing, elderly male Eyes: no scleral icterus, no conjunctival injection HENT: no edema, atraumatic Neck:  normal ROM Cardiovascular: tachycardic, regular rhythm, No edema Pulmonary: no respiratory distress, overall poor tidal volume, scattered fine crackles Abdomen: nondistended, no tenderness, no rebound, no guarding MSK: atraumatic, no deformities, no cyanosis Neurologic: motor function grossly intact, sensation grossly intact Skin: dry, warm Psych: calm and cooperative  Assessment/Plan      1. Sepsis   A41.9   2. Influenza A   J10.1   3. BPH with obstruction/lower urinary tract symptoms   N40.1   4. Recurrent UTI   N39.0  most likely 2/2 influenza however cannot rule out acute on chronic UTI 2/2 esbl  cover with merrem and tamiflu for now as symptoms began on day of presentation according to NH  follow pancx  maintain map >65  bladder scans prn monitor urine output  supplemental O2 prn  nebulizers prn   5. Atrial fibrillation   I48.91  cont rate control  patient is not on anticoag, possibly due to his age and risks of ich in the event of a fall   6. GERD (gastroesophageal reflux disease)   K21.9  cont ppi   7. Hyperlipemia, mixed   E78.2  cont statin   8. Dementia   F03.90  cont home meds   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 01/18/23 23:13:00   albuterol-ipratropium, 3 mL, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, PRN, Shortness of Breath/Wheezing, 01/18/23 23:13:00   aspirin, 325 mg, Orally, Tab, Delayed Rel, Daily, 01/19/23 9:00:00   atenolol, 12.5 mg, Orally, Tablet, BID, 01/19/23 9:00:00  cetirizine, 10 mg, Orally, Tablet, QAM, PRN, Allergy Symptoms, 01/19/23 6:05:00   Dextrose 5% in Water 500 mL, Total Volume (mL) = 500, IV, 01/19/23 1:12:00, Other - See Comments, Clinical Weight  finasteride, 5 mg, Orally, Tablet, Daily, 01/19/23 9:00:00  heparin, 5,000 Units, Subcutaneous, Injection, Q12, 01/19/23 6:00:00  Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 01/18/23 23:13:00, 50 mL/hr, Clinical Weight  meropenem, 500 mg, IVPB, Injection, Q6H, Indication: Sepsis (ESBL or MDR History), 01/19/23 1:00:00, 200 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 100  mirtazapine, 7.5 mg, Orally, Tablet, At Bedtime, 01/19/23 21:00:00   morphine, 2 mg, IV Push, Injection, Q4H, PRN, Pain Moderate IV (4-6 out of 10), 01/18/23 23:13:00  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 01/18/23 23:13:00   oseltamivir, 30 mg, Orally, Capsule, BID, 01/19/23 9:00:00  pantoprazole, 20 mg, Orally, Tab, Delayed Rel, Daily, 01/19/23 9:00:00  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, 01/19/23 9:00:00   pravastatin, 40 mg, Orally, Tablet, At Bedtime, 01/19/23 21:00:00   Sodium Chloride 0.9% 250 mL, Total Volume (mL) = 250, IV, 01/19/23 1:12:00, Other - See Comments, Clinical Weight  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV, 01/19/23 1:12:00, Other - See Comments, Clinical Weight  2000 mg Sodium, 225 gm Carb, 20 gm Saturated Fat Diet  Admit to Inpatient  Aspiration Precautions  Auto Diff  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  CBC w/Differential  Comp Metabolic Panel  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  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  Intermittent Catheterization  Lactate Pl Venous QN  Level of Care  Magnesium SerPl QN  Medical Service  Meropenem Pharmacy Dosing Consult  OT Evaluation and Treatment  Patient Isolation  Peripheral IV Insertion  Procalcitonin  PT Evaluation and Treatment  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Telemetry Class III 24hr Recommendation  Titrate FiO2 to Keep O2 Sat  TSH w FreeT4 reflex  Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 01/18/23 23:13:00, Full Code   Chronic Problem List    Atherosclerosis of native artery of right lower extremity with rest pain  Atrial fibrillation  Balanoposthitis  Bladder neck contracture  BPH with obstruction/lower urinary tract symptoms  Cholelithiasis  Chronic UTI  Colon polyps  Critical lower limb ischemia  Dementia  Dysuria  Exudative age-related macular degeneration of left eye with active choroidal neovascularization  GERD (gastroesophageal reflux disease)  History of stroke in adulthood  Hyperlipemia, mixed  Incomplete bladder emptying  Lumbosacral disc disease  Neurogenic bladder  OSA (obstructive sleep apnea)  Osteoarthritis  Psoriasis  PVC (premature ventricular contraction)  Recurrent UTI  Spondylolisthesis  Tobacco use  Urinary retention  Procedure/Surgical History  ?TURP (11/2018) ?Rt knee peroneal nerve release (07/22/2015) ?Bone density scan (06/24/2014) ?Colonoscopy (12/18/2012) ?Rt TKA (2000) ?Colonoscopy ?Dental implants ?EGD- bleeding ulcer with clamp ?Hemorroid surgery ?Inguinal Hernia Repair   Surgical History Internal  09/11/2019    Bladder Neck Repair   MD  11/28/2018    TUR Prostate    MD  07/22/2015    Nerve Repair Peroneal  (Right)   MD  Medications   Home Medications (14) Active  aspirin 325 mg oral delayed release tablet 325 mg = 1 Tablet, Orally, Daily  atenolol 25 mg oral tablet 0.5 Tablet, Orally, BID  cetirizine 10 mg oral tablet 10 mg = 1 Tablet, PRN, Orally, QAM  Cranberry oral capsule 300 mg, Orally, BID  finasteride 5 mg oral tablet See Instructions, Take 1 tablet by mouth once daily  lactobacillus acidophilus oral capsule 1 Capsule, Orally, Daily  mirtazapine 7.5 mg oral tablet 7.5 mg = 1 Tablet, Orally, At Bedtime  Misc Supplement See Instructions, Australian Dream  Cream for his back, uses PRN  family sts it is an antihistamine and has herbs.  From Pharmacy  multivitamin Multiple Vitamins oral tablet 1 Tablet, Orally, Daily  omeprazole 20 mg oral delayed release capsule 1 Capsule, Orally, Daily  polyethylene glycol 3350 oral powder for reconstitution 17 GM, Orally, Daily  pravastatin 40 mg oral tablet See Instructions, TAKE 1 TABLET BY MOUTH AT BEDTIME  PreserVision AREDS 2 1 Capsule, Orally, BID  triamcinolone 0.1% topical cream 1 App, Topical, TID, apply a thin film  Active Scheduled Inpatient Medications  aspirin, Tab, Delayed Rel, 325 mg, Orally, Daily, Start: 01/19/23 09:00:00  atenolol, Tablet, 12.5 mg, Orally, BID, Start: 01/19/23 09:00:00  finasteride, Tablet, 5 mg, Orally, Daily, Start: 01/19/23 09:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q12, Start: 01/19/23 06:00:00  meropenem, Injection, 500 mg, IVPB, Q6H, Indication: Sepsis (ESBL or MDR History), Start: 01/19/23 01:00:00  mirtazapine, Tablet, 7.5 mg, Orally, At Bedtime, Start: 01/19/23 21:00:00  oseltamivir (Tamiflu), Capsule, 30 mg, Orally, BID, Start: 01/19/23 09:00:00  pantoprazole, Tab, Delayed Rel, 20 mg, Orally, Daily, Start: 01/19/23 09:00:00  polyethylene glycol 3350 (polyethylene glycol 3350 oral powder for reconstitution), Powder, 17 GM, Orally, Daily, Start: 01/19/23 09:00:00  pravastatin, Tablet, 40 mg, Orally, At Bedtime, Start: 01/19/23 21:00:00  Lactated Ringers  1,000 mL IV  50 mL/hr     Sodium Chloride 0.9%  500 mL IV  Other - See Comments     Dextrose 5% in Water  500 mL IV  Other - See Comments     Sodium Chloride 0.9%  250 mL IV  Other - See Comments       One-Time Medications Given 01/18/23 00:00:00 TO 01/19/23 06:29:39  None Reported  PRN Medications (0600 - 0559) from 01/18 - 01/19  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol-ipratropium, 3 mL, Neb Inhal, Q6H, 0  Dose(s)   cetirizine, 10 mg, Orally, QAM, 0  Dose(s)   morphine, 2 mg, IV Push, Q4H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   Allergies   Restoril (Difficulty Breathing)  codeine (breathing difficulty, Vomiting)  lovastatin (weakness)  Social History    Alcohol   Current, Daily   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse. Living situation: Home with assistance. Home equipment: Walker/Cane. Family/Friends available for support: Yes. Major illness in household: Yes.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   High blood pressure..: Father.  Stroke: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.4 k/cumm (01/19/23 06:07:00)  RBC: 4.44 million/cumm (01/19/23 06:07:00)  Hgb: 13.7 GM/dL (01/19/23 06:07:00)  Hct: 41.3 % (01/19/23 06:07:00)  MCV: 93 fL (01/19/23 06:07:00)  MCH: 30.8 pg (01/19/23 06:07:00)  MCHC: 33.1 GM/dL (01/19/23 06:07:00)  RDW: 14.2 % (01/19/23 06:07:00)  Platelet: 209 k/cumm (01/19/23 06:07:00)  MPV: 8 fL (01/19/23 06:07:00)  Neutrophils %: 73 % (01/19/23 06:07:00)  Lymphocytes %: 14 % (01/19/23 06:07:00)  Monocytes %: 12 % (01/19/23 06:07:00)  Eosinophils %: 1 % (01/19/23 06:07:00)  Basophils %: 0 % (01/19/23 06:07:00)  Absolute Neutrophil: 5.4 k/cumm (01/19/23 06:07:00)  Absolute Lymphocyte: 1 k/cumm (01/19/23 06:07:00)  Absolute Monocyte: 0.9 k/cumm (01/19/23 06:07:00)  Absolute Eosinophil: 0.1 k/cumm (01/19/23 06:07:00)  Absolute Basophil: 0 k/cumm (01/19/23 06:07:00)  Chemistry:  Sodium SerPl QN: 141 mmol/L (01/18/23 18:55:00)  Potassium SerPl QN: 3.8 mmol/L (01/18/23 18:55:00)  Chloride SerPl QN: 102 mmol/L (01/18/23 18:55:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (01/18/23 18:55:00)  Anion Gap: 9 mmol/L (01/18/23 18:55:00)  BUN SerPl QN: 12 mg/dL (01/18/23 18:55:00)  Creatinine SerPl QN: 0.97 mg/dL (01/18/23 18:55:00)  Estimated GFR (CKD-EPI, no race): 72 mL/min/1.73m2 (01/18/23 18:55:00)  Estimated CRCL (CG): 50 mL/min Low (01/18/23 18:55:00)  Glucose SerPl QN: 152 mg/dL High (01/18/23 18:55:00)  Calcium Total SerPl QN: 10 mg/dL (01/18/23 18:55:00)  Alkaline Phos SerPl QN: 76 Units/L (01/18/23 18:55:00)  ALT SerPl QN: 20 Units/L (01/18/23 18:55:00)  AST SerPl QN: 23 Units/L (01/18/23 18:55:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (01/18/23 18:55:00)  Total Protein SerPl QN: 7.4 GM/dL (01/18/23 18:55:00)  Albumin SerPl QN: 4 GM/dL (01/18/23 18:55:00)  Troponin-I High Sensitivity: 8 ng/L (01/18/23 20:00:00)  BNP Pl QN: 68 pg/mL (01/18/23 18:55:00)  Lactate Venous Pl QN: 3.1 mmol/L High (01/18/23 22:10:00)  pH Bld Venous QN: 7.38 (01/18/23 18:55:00)  PCO2 Bld Venous QN: 49 mmHg (01/18/23 18:55:00)  PO2 Bld Venous QN: <34 Low (01/18/23 18:55:00)  Base Excess Bld Venous: 3 mmol/L High (01/18/23 18:55:00)  Bicarb Bld Venous Calc: 29 mmol/L (01/18/23 18:55:00)  O2 Sat Bld Venous Calc: 41 % (01/18/23 18:55:00)  Patient Temperature: 37 DegC (01/18/23 18:55:00)  Urine Studies:  Color: Yellow (01/18/23 19:32:00)  Clarity: Clear (01/18/23 19:32:00)  Specific Gravity: 1.020 (01/18/23 19:32:00)  pH: 6.0 (01/18/23 19:32:00)  Protein: TRACE. Abnormal (01/18/23 19:32:00)  Glucose: NEGATIVE (01/18/23 19:32:00)  Ketones: NEGATIVE (01/18/23 19:32:00)  Bilirubin: NEGATIVE (01/18/23 19:32:00)  Hgb Ur: TRACE. Abnormal (01/18/23 19:32:00)  Nitrite: POSITIVE Abnormal (01/18/23 19:32:00)  Urobilinogen: NormalUro (01/18/23 19:32:00)  Leukocyte Esterase Ur: MODERATE. Abnormal (01/18/23 19:32:00)  WBC: 11-20 Abnormal (01/18/23 19:32:00)  RBC: 3-5 Abnormal (01/18/23 19:32:00)  Bacteria: Many Abnormal (01/18/23 19:32:00)  Squamous Epithelial: Few (01/18/23 19:32:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (01/18/23 18:55:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (01/18/23 18:55:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (01/18/23 18:55:00)  Rapid Influenza A PCR: Detected Abnormal (01/18/23 18:55:00)  Rapid Influenza B PCR: Not Detected (01/18/23 18:55:00)  Urine CX: POS Critical (01/14/23 15:58:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 01/18/2023 19:31 - XR Chest PA or AP Portable  IMPRESSION: No acute findings.Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the ER Reading Room.                Signature Line Electronically Signed on 01/19/23 06:30 ________________________________________________________ DO