Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on October 31, 2023 15:43    Verified By: NP on October 31, 2023 15:43   Encounter Info: Hospital, Inpatient, 10/31/23 -     * Final Report *  Document Contains Addenda        Chief Complaint   AMS  History of Present Illness/Subjective     This is a 66 year old patient with a past medical history significant for alcoholism, ascites, anemia, and tobacco use that presented to ED on 10/31/2023 from home via pov with c/o AMS and is being admitted to inpatient for sepsis, AMS, suspected SBP.   This patient was seen and evaluated after arrival to the unit.  He was found to be lying in bed, alert and in no distress.  Patient presents after he has not been taking his Lactulose as prescribed. Wife describes progressive weakness over the past 3-4 months with new onset of confusion yesterday. Over the past couple days he has gotten a little bit more confused, and last night did not realize that he needed to go to the bathroom and urinate in his bed which is unusual for him. This morning appear confused. The wife brings him in. He has an elevated ammonia at 150. White count is normal. Abdomen is soft. He has no fever. Bedside paracentesis was done removing 1650 mL of fluid, which was sent to the lab to rule out infection. Patient's lactic acid has improved to 1.7 after hydration.   afebrile. saturations wnl.  Blood pressures slightly hypertensive with SBP in the 140s.  HR tachy in the low 100s.    Review of Systems     Constitutional:  No fevers,  no chills Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No sore throat Respiratory:  No shortness of breath,  no cough Cardiovascular:  No chest pain,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea Genitourinary:  No dysuria,  no hematuria Endocrine:  No polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  hip wound chronic Neurologic:  No headache,  no focal weakness  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  WT: 79.70 kg (WFC)  BMI: 24.5   Hemodynamics   Neurologic   Patient Weight  Current Daily Weight:    79.7 kg    10/31/23  BMI:    24.5    10/31/23    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    180.3 cm    10/31/23        Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB 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  Present on Admission  hip wound  Assessment/Plan     This is a 66 year old patient with a past medical history significant for alcoholism, ascites, anemia, and tobacco use that presented to ED on 10/31/2023 from home via pov with c/o AMS and is being admitted to inpatient for sepsis, AMS, suspected SBP.    1. Sepsis   A41.9  SIRS criteria met, Heart rate greater than 90 and lactate greater than 3.  likely not a true sepsis but cannot r/o.  lactate likely elevated d/t liver disease. repeat lactate wnl   Suspected source- SBP.  UA and cxr negative  No hypotension. Blood cultures pending , IV ceftx 2gram started.  holding off on IV fluids given he is currently overloaded     2. Alcoholic cirrhosis of liver with ascites   K70.31  as above  paracentesis completed -- > yielded 1650 ml of yellow fluid   appropriate labs sent    3. Anemia   D64.9   stable for baseline, monitor    4. Pressure sore of hip   L89.209  noted on admission   daily wound care    5. Tobacco use   Z72.0   will encourage cessation    inpatient, medical floor  Daily labs - CBC, CMP Daily   Low Sodium Diet  IV fluids SL   Telemetry  Full Code Status  VTE Prophylaxis - heparin     Code Status   Resuscitation Status - Ordered    -- 10/31/23 15:09:00, Full Code   Chronic Problem List    Alcoholic cirrhosis of liver with ascites  Alcoholism  Anemia  Ascites  Cholelithiasis  Coagulation defect  Compression fracture of L4 vertebra  Macrocytic anemia  Portal vein thrombosis  Pressure sore of hip  Thrombocytopenia  Tobacco use  Procedure/Surgical History  ?EGD - Esophagogastroduodenoscopy (07/30/2021) ?right hip replacement   Surgical History Internal  07/30/2021    EGD Diagnostic    MD  11/15/2019    Hip Arthroplasty Hemi  (Right)   MD      Hip Arthroplasty Hemi  (Right)   MD  Medications   Home Medications (8) Active  lactulose 10 GM/15 mL oral syrup 20 GM = 30 mL, Orally, TID  Multiple Vitamins oral gum , Orally, Daily  potassium gluconate 595 mg oral tablet 595 mg = 1 Tablet, Orally  spironolactone 100 mg oral tablet 1 Tablet, Orally, Daily  traMADOL 50 mg, Orally, Q4H  Vitamin D3 25 mCg (1,000 intl units) oral tablet 1 Tablet, Orally, Daily  Xifaxan 550 mg oral tablet 550 mg = 1 Tablet, Orally, BID  zinc sulfate 220 mg oral capsule 220 mg = 1 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  ceftRIAXone, Injection, 2 GM, IVPB, Q24H, Indication: Prophylaxis - SBP, Start: 10/31/23 16:00:00  cholecalciferol (Vitamin D3 (cholecalciferol)), Tablet, 25 mCg, Orally, Daily, Start: 11/01/23 09:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 10/31/23 16:00:00  lactulose (lactulose 10 GM/15 mL oral syrup), Syrup, 20 GM, Orally, TID, Start: 10/31/23 21:00:00  rifaXIMin (Xifaxan), Tablet, 550 mg, Orally, BID, Start: 10/31/23 21:00:00  spironolactone, Tablet, 100 mg, Orally, Daily, Start: 11/01/23 09:00:00  zinc sulfate, Capsule, 220 mg, Orally, Daily, Start: 11/01/23 09:00:00    One-Time Medications Given 10/30/23 00:00:00 TO 10/31/23 15:42:43  None Reported  PRN Medications (0600 - 0559) from 10/30 - 10/31  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   Allergies   NKA  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Family history is unknown  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.5 k/cumm (10/31/23 08:11:00)  RBC: 3.07 million/cumm Low (10/31/23 08:11:00)  Hgb: 11.5 GM/dL Low (10/31/23 08:11:00)  Hct: 33.5 % Low (10/31/23 08:11:00)  MCV: 109 fL High (10/31/23 08:11:00)  MCH: 37.4 pg High (10/31/23 08:11:00)  MCHC: 34.3 GM/dL (10/31/23 08:11:00)  RDW: 15.4 % High (10/31/23 08:11:00)  Platelet: 185 k/cumm (10/31/23 08:11:00)  MPV: 8.8 fL (10/31/23 08:11:00)  Neutrophils %: 66 % (10/31/23 08:11:00)  Lymphocytes %: 14 % (10/31/23 08:11:00)  Monocytes %: 15 % (10/31/23 08:11:00)  Eosinophils %: 4 % (10/31/23 08:11:00)  Basophils %: 1 % (10/31/23 08:11:00)  Absolute Neutrophil: 5 k/cumm (10/31/23 08:11:00)  Absolute Lymphocyte: 1.1 k/cumm (10/31/23 08:11:00)  Absolute Monocyte: 1.1 k/cumm (10/31/23 08:11:00)  Absolute Eosinophil: 0.3 k/cumm (10/31/23 08:11:00)  Absolute Basophil: 0.1 k/cumm (10/31/23 08:11:00)  Chemistry:  Sodium SerPl QN: 134 mmol/L Low (10/31/23 08:11:00)  Potassium SerPl QN: 4.2 mmol/L (10/31/23 08:11:00)  Chloride SerPl QN: 103 mmol/L (10/31/23 08:11:00)  Carbon Dioxide SerPl QN: 23 mmol/L (10/31/23 08:11:00)  Anion Gap: 8 mmol/L (10/31/23 08:11:00)  BUN SerPl QN: 16 mg/dL (10/31/23 08:11:00)  Creatinine SerPl QN: 0.93 mg/dL (10/31/23 08:11:00)  Estimated GFR (CKD-EPI, no race): >90 (10/31/23 08:11:00)  Estimated CRCL (CG): 85 mL/min (10/31/23 08:11:00)  Glucose SerPl QN: 124 mg/dL High (10/31/23 08:11:00)  Calcium Total SerPl QN: 8.8 mg/dL (10/31/23 08:11:00)  Alkaline Phos SerPl QN: 190 Units/L High (10/31/23 08:11:00)  ALT SerPl QN: 19 Units/L (10/31/23 08:11:00)  AST SerPl QN: 42 Units/L High (10/31/23 08:11:00)  Bilirubin Total SerPl QN: 6.1 mg/dL High (10/31/23 08:11:00)  Total Protein SerPl QN: 7 GM/dL (10/31/23 08:11:00)  Albumin SerPl QN: 2.6 GM/dL Low (10/31/23 08:11:00)  Lipase SerPl QN: 29 Units/L (10/31/23 08:11:00)  Troponin-I High Sensitivity: 7 ng/L (10/31/23 09:03:00)  BNP Pl QN: 80 pg/mL (10/31/23 08:11:00)  Ammonia Pl QN: 156 mCmol/L High (10/31/23 08:11:00)  Lactate Venous Pl QN: 1.7 mmol/L (10/31/23 10:09:00)  Gluc-Strip, POC: 95 mg/dL (10/31/23 07:53:00)  Coagulation:  PT: 19.4 seconds High (10/31/23 08:11:00)  INR: 1.74 High (10/31/23 08:11:00)  Urine Studies:  Color: Yellow (10/31/23 10:24:00)  Clarity: Clear (10/31/23 10:24:00)  Specific Gravity: 1.021 (10/31/23 10:24:00)  pH: 6 (10/31/23 10:24:00)  Protein: NEGATIVE (10/31/23 10:24:00)  Glucose: Normal (10/31/23 10:24:00)  Ketones: NEGATIVE (10/31/23 10:24:00)  Bilirubin: NEGATIVE (10/31/23 10:24:00)  Hgb Ur: NEGATIVE (10/31/23 10:24:00)  Nitrite: NEGATIVE (10/31/23 10:24:00)  Urobilinogen: 6.0 6 Abnormal (10/31/23 10:24:00)  Leukocyte Esterase Ur: NEGATIVE (10/31/23 10:24:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (10/31/23 08:11:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (10/31/23 08:11:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 10/31/2023 09:03 - CT Head W/o IV Contrast  IMPRESSION:Diffuse cortical atrophy with chronic small vessel ischemic changes.No acute intracranial findings.    10/31/2023 09:03 - XR Chest PA or AP Portable  IMPRESSION:Limited inspiratory effort.No acute cardiopulmonary findings.    10/31/2023 10:50 - US Guided Paracentesis  IMPRESSION: Successful ultrasound guided paracentesis yielding 1650 mL of fluid.                Signature Line Electronically Signed on 10/31/23 15:43  ________________________________________________________ NP     Addendum by MD on November 01, 2023 07:19:52 (Verified)    I saw and evaluated the patient in addition to NP. I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care.  Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Breathing comfortably on room air Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  MD, FACP      Signature Line Electronically Signed on 11/01/23 07:20  ________________________________________________________ MD