Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on February 15, 2023 17:28   Verified By: NP on February 15, 2023 17:29   Encounter Info: Hospital, Inpatient, 02/14/23 -     * Final Report *  Document Contains Addenda          History of Present Illness/Subjective     25 year old male with past medical Hx of spastic quadriplegic cerebral palsy, Lennox-Gastaut syndrome, developmental delay, and seizure disorder with current tracheostomy and G tube in place presents to the ED with mother complaining of two aspirations and increased tracheostomy secretions onset earlier today, with associated hypoxia. History provided by mother at bedside secondary to patient's current tracheostomy.    Patient was brought to the emergency department.  Upon ED evaluation there is heart rate was elevated at 118, respiratory rate was 22, was placed on 6 L per trach collar with a sat of 80.  Temperature was up to 102.2 in the ER.  Patient met sepsis protocol.  While in the ER he received azithromycin, cefepime, dexamethasone, Vimpat, IV fluids, Keppra, and first dose of remdesivir.  Chest x-ray showed no acute findings in the chest, CTA of the chest was then completed showed mild retrocardiac consolidation , no obvious PE, minimal dependent right upper lobe consolidation favoring atelectasis but aspiration pneumonia cannot be ruled out.  Lab work was obtained.  Patient was positive for COVID-19, procalcitonin was elevated at 0.38, white blood cell count was elevated at 17.2, hemoglobin was stable at 16.1, potassium was low at 3.2 renal function was normal with a GFR greater than 90.  Lactate was 1.5.  Patient was brought in for further evaluation management of sepsis due to aspiration pneumonia, and COVID,  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.9 (36.9-39)  Temp (FAHR) 98.4 (98.4-102.2), BP 108/76 (107-152)/(64-90), HR 88 (87-128), RR 20 (15-45), O2Sat 96 (90-96) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    42.9 kg    02/15/23  Previous Daily Weight:    43.6 kg    02/14/23  Difference from Previous:    -0.700000 kg  BMI:    20.5    02/15/23    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    144.8 cm    02/15/23        Constitutional:   No acute distress ,   well-nourished Eyes:  PEERL,  EOMI,   normal conjunctiva ,   no scleral icterus ENMT:   Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs coarse breath sounds worse on right, on 10 L trach collar Cardiovascular:   Regular rate and rhythm Gastrointestinal:  Soft, non-tender,  non-distended colostomy in place Musculoskeletal:  No joint swelling, no deformity, legs and bilateral arms have some contractures, Integumentary:  Intact, warm, dry no rashes Neurologic:  Moderate cognitive impairment ,   no focal deficits nonverbal Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Sepsis    sepsis orders in place   2. COVID-19 virus infection      Patient with bilateral pneumonia due to COVID-19  - Continue with respiratory protocol, Oxygen supplementation, Incentive Spirometry  - Dexamethasone Day 1 out of 10  - CefepimeD ay 1 out of 5  - Doxycycline Day 1 out of 5  - Remdesevir Day 1 out of 5  - procal elevated, cont abx,  -Blood   3. Aspiration pneumonia     -aspiration precautions  -Will hold feedings tonight and have dietary write manage them tomorrow.  -At home parents do not check residual  -Will have speech therapy see pt although not verbal  -Keep HOB elevated 30deg during feeds.   4. CP (cerebral palsy), spastic, quadriplegic    noted   5. Chromosomal anomaly     noted   6. Colostomy present    noted   7. G tube feedings    resume feeding in am   8. GERD (gastroesophageal reflux disease)    resume feedings in am, resume PPI, simethicone and probiotics   9. History of restrictive pulmonary disease     resume home meds and rt protocol   10. Lennox-Gastaut syndrome, intractable, without status epilepticus    resume home meds vimpat, keppra and topamax   11. Moderate mental retardation    noted   Aspiration of liquid       Pneumonia       Respiratory failure with hypoxia        full code  DVT prophylaxis with lovenox   Orders:   acetaminophen, 750 mg, G Tube, Tablet, Q6H, PRN, Pain, Mild (1-3 out of 10)/Fever, 02/15/23 16:56:00   albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q4H, PRN, Wheezing, 02/15/23 16:56:00, RT Care Assessment and Protocol per Policy  baclofen, 10 mg, G Tube, Tablet, TID, PRN, Muscle Spasm, 02/15/23 16:57:00   cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 02/15/23 17:00:00, for 14 Doses, 02/20/23 1:00:00, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  dexamethasone, 6 mg, IV Push, Injection, Daily, 02/15/23 17:00:00, for 10 Doses, 02/24/23 9:00:00  doxycycline, 100 mg, Orally, Capsule, Q12, Indication: Pneumonia - CAP, 02/15/23 17:00:00, for 10 Doses, 02/19/23 22:00:00  enoxaparin, 30 mg, Subcutaneous, Injection, Daily, 02/16/23 9:00:00  hydroCODONE-acetaminophen, 1 Tablet, Orally, Tablet, Q6H, PRN, Pain, Moderate (4-6 out of 10), 02/15/23 16:32:00  labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 02/15/23 16:32:00  ocular lubricant, 1 App, Eyes, Both, Ophthalmic OINT, Q4H, PRN, Dry Eyes, 02/15/23 16:32:00  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 02/15/23 16:32:00  pantoprazole, 40 mg, Orally, Tab, Delayed Rel, Daily, 02/16/23 9:00:00   polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 02/15/23 16:32:00   remdesivir, 100 mg, IVPB, Injection, At Bedtime, NOW, 02/15/23 17:19:00, for 4 Doses, 02/17/23 21:00:00, 500 mL/hr, Infuse Over 30 minutes  simethicone, 160 mg, G Tube, Tab, Chewable, BID, 02/15/23 21:00:00  topiramate, 200 mg, G Tube, Tablet, At Bedtime, 02/15/23 21:00:00  topiramate, 100 mg, G Tube, Tablet, Daily, 02/16/23 9:00:00  Admit to Inpatient  Airway Assessment  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Oxygen Need Greater Than  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  CBC w/Differential  CK SerPl QN  Comp Metabolic Panel  CRP SerPl QN  D-Dimer Pl QN  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Ferritin SerPl QN  Fibrinogen  Heated Humidified Nasal Cannula  Heating Pad  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  L pneumophila Ag Ur QL  LDH SerPl QN  Level of Care  NPO Except Medications  Nutrition Consult  OT Evaluation and Treatment  Peripheral IV Insertion  PT Evaluation and Treatment  RCP Pt in Isolation  Resuscitation Status  Speech for Dysphagia Evaluation and Treatment  Strep pneumoniae Ag Urine  Telemetry Class II 48hr Recommendation  Titrate FiO2 to Keep O2 Sat  Vital Signs  Vital Signs  Weight   Code Status   Resuscitation Status - Ordered    -- 02/15/23 16:32:00, Full Code   Chronic Problem List    Abnormal ECG  Abnormality of Gait  Acute respiratory failure  Aspiration pneumonia  Chromosomal anomaly  Chronic incomplete spastic tetraplegia  Chronic respiratory failure with hypercapnia  Chronic respiratory failure with hypoxia and hypercapnia  CO2 retention  Cognitive and behavioral changes  Colostomy present  Compartment syndrome of right hand  Contracture of right hand  CP (cerebral palsy), spastic, quadriplegic  Developmental delay  Flexion contracture of right wrist joint  G tube feedings  Generalized Convulsive Epilepsy, with Intractable Epilepsy  GERD (gastroesophageal reflux disease)  History of restrictive pulmonary disease  Kyphoscoliosis  Lennox-Gastaut syndrome, intractable, without status epilepticus  Moderate mental retardation  Needs flu shot  OSA treated with BiPAP  Other Kyphoscoliosis and Scoliosis  PEG (percutaneous endoscopic gastrostomy) status  Protein calorie malnutrition  Restrictive lung disease due to kyphoscoliosis  Seizure disorder  Sepsis  Toxic Encephalopathy  Procedure/Surgical History  ?VNS replacement (02/26/2021) ?ileostomy (08/13/2014) ?Colonoscopy (07/08/2014) ?Conversion of GJ to gtube (09/01/2013) ?Spinal fusion (07/26/2013) ?conversion of gastrostomy tube to GJ tube (02/14/2013) ?conversion of gastrostomy to gastrojejunostomy (01/21/2013) ?Vagal Nerve Stimulator Insertion (02/15/2012) ?Endoscopy (09/08/2011) ?radical resection of temporal soft tissue mass; ATR (05/04/2010) ?aborted procedure due to hypertensive/bradycardic episode (01/19/2010) ?Endoscopy (01/06/2010) ?replacement of Baclofen pump (09/11/2008) ?G-Tube Insertion (07/22/2008) ?hardware removal (06/01/2004) ?femoral derotational osteotomy tendon lengthenings (07/24/2003) ?Baclofen pump placement (08/12/2002) ?Botox injection to leg contractures (04/17/2001) ?Orchiopexy (07/18/2000) ?Baclophen pump ?Ileostomy ?Vagal Nerve Stimulator   Surgical History Internal  11/08/2022    Upper Extremity Hardware Rem Deep  (Right)    12/13/2021    Spinal Drug Pump Revise Remove      02/26/2021    Brain Stimulator Generator Change/Remove     07/01/2018    Colostomy Opening    05/06/2015    Spinal Drug Pump Revise Remove     08/13/2014    Colostomy Opening      07/08/2014    Colonscpy Diagnostic/Screen      07/26/2013    Spine Fusion Posterior Thoracolumbar      02/15/2012    Vagal Nerve Stimulator Implant      09/08/2011    EGD Bx      05/04/2010    Orchiopexy  (Right)     01/19/2010    Scalp Reconstruction w  Flap      01/06/2010    EGD Bx      09/11/2008    Spinal Drug Pump Revise Remove      07/02/2008    EGD Diagnostic      01/24/2007    RADIOLOGY MRI.      06/01/2004    zzHardware Removal  (Lt)                    Medications   Home Medications (22) Active  acetaminophen 500 mg oral tablet 750 mg = 1.5 Tablet, PRN, G Tube, Q6H  albuterol 2.5 mg/0.5mL (0.5%) inhalation solution 2.5 mg = 0.5 mL, PRN, Neb Inhal, Q4H  Augmentin 875 mg-125 mg oral tablet 1 Tablet, Orally, BID  baclofen 10 mg oral tablet 10 mg = 1 Tablet, PRN, G Tube, TID  baclofen 2,000 mCg/mL intrathecal solution 606.6 mCg, INTRATHECAL by MD/Designee, Daily  Diastat AcuDial 10 mg rectal kit 7.5 mg, PRN, Rectally, Unscheduled  Humidification See Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  Suction Equipment See Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  Tracheostomy Supplies See Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  Emla 2.5%-2.5% cream 1 App, PRN, Topical, ONCE  ibuprofen 200 mg oral tablet 200 mg = 1 Tablet, PRN, G Tube, Q6H  lacosamide 10 mg/mL oral solution 125 mg = 12.5 mL, Orally, BID  leveTIRACetam 100 mg/ml oral solution 1,600 mg = 16 mL, G Tube, BID  Melatonin 10 mg oral capsule 10 mg = 1 Capsule, G Tube, At Bedtime  Misc Supplies See Instructions, O2 sensor for toe or fingerpatient has a trachJ96.00  multivitamin with minerals oral tablet 1 Tablet, G Tube, QHS, Nature's Made Brand  Nexium 40 mg oral powder for reconstitution, delayed release 40 mg = 1 Each, G Tube, QHS, Dissolve one pakcet in water prior to taking.  potassium chloride 20 mEq/15 mL oral liquid 20 mEq = 15 mL, Orally, BID  Probiotic Formula (Bacillus Coagulans) oral capsule 1 Capsule, G Tube, Daily  simethicone 80 mg oral tablet, chewable 160 mg = 2 Tablet, G Tube, BID  topiramate 200 mg oral tablet See Instructions, 1/2 Tablet via G-tube in the morning1 Tablet via G-tube at night  traZODONE 50 mg oral tablet 25 mg = 0.5 Tablet, PRN, Orally, At Bedtime  Active Scheduled Inpatient Medications  baclofen, Tablet, 10 mg, G Tube, TID, Start: 02/15/23 06:00:00  cefePIME, Injection, 1 GM, IVPB, Q8H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), Start: 02/15/23 17:00:00  dexamethasone, Injection, 6 mg, IV Push, Daily, Start: 02/15/23 17:00:00  doxycycline, Capsule, 100 mg, Orally, Q12, Indication: Pneumonia - CAP, Start: 02/15/23 17:00:00  enoxaparin, Injection, 30 mg, Subcutaneous, Daily, Start: 02/16/23 09:00:00  lacosamide (Vimpat), Injection, 100 mg, IV Push, BID, Start: 02/15/23 06:00:00  leveTIRACetam, Injection, 1,600 mg, IV Push, BID, Start: 02/15/23 07:25:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 02/16/23 09:00:00  potassium chloride (potassium chloride 20 mEq/15 mL oral liquid), Oral SOLN, 20 mEq, G Tube, BID, Start: 02/15/23 06:00:00  remdesivir, Injection, 100 mg, IVPB, At Bedtime, Start: 02/15/23 17:19:00  simethicone, Tab, Chewable, 160 mg, G Tube, BID, Start: 02/15/23 21:00:00  topiramate, Tablet, 200 mg, G Tube, At Bedtime, Start: 02/15/23 21:00:00  topiramate, Tablet, 100 mg, G Tube, Daily, Start: 02/16/23 09:00:00  Lactated Ringers  1,000 mL IV  75 mL/hr       One-Time Medications Given 02/14/23 00:00:00 TO 02/15/23 17:28:11  acetaminophen (Tylenol), Suppository, 650 mg, Rectally, ONCE, (1 DOSE 02/14/23 22:47:00)  azithromycin, Injection, 500 mg, IVPB, ONCE, (1 DOSE 02/14/23 22:47:00)  cefePIME, Injection, 2 GM, IV Push, ONCE, (1 DOSE 02/14/23 22:47:00)  cefePIME, Injection, 1 GM, IVPB, ONCE, (1 DOSE 02/14/23 23:02:00)  dexamethasone, Injection, 6 mg, IV Push, ONCE, (1 DOSE 02/15/23 00:31:00)  fentaNYL, Injection, 50 mCg, IV Push, ONCE, (1 DOSE 02/15/23 14:21:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 02/15/23 14:21:00)  pantoprazole (Protonix), Injection, 40 mg, IV Push, ONCE, (1 DOSE 02/15/23 03:59:00)  remdesivir, Injection, 200 mg, IVPB, ONCE, (1 DOSE 02/15/23 08:04:00)  topiramate, Tablet, 100 mg, G Tube, ONCE, (1 DOSE 02/15/23 05:36:00)  vancomycin, Injection, 1 GM, IVPB, ONCE, (1 DOSE 02/15/23 00:31:00)  PRN Medications (0600 - 0559) from 02/14 - 02/15  Lactated Ringers, 1,000 mL, IVPB, Unscheduled, 0  Dose(s)   acetaminophen, 750 mg, G Tube, Q6H, 0  Dose(s)   albuterol, 2.5 mg, Neb Inhal, Q4H, 0  Dose(s)   baclofen, 10 mg, G Tube, TID, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q6H, 0  Dose(s)   labetalol, 10 mg, IV Push, Q6H, 0  Dose(s)   ocular lubricant, 1 App, Eyes, Both, Q4H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   Unlisted Material/Environmental Allergy  Adhesive  Tape (welts)  codeine (Agitation)  sulfa drugs (tongue swells)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Parents.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Diabetes insipidus..: Mother.Negative: Father.  Diabetes mellitus type 2: Mother and Grandmother.Negative: Father.  Heart disease..: Negative: Mother and Father.  Heart failure: Negative: Mother and Father.  Hyperlipemia...: Mother and Father.  Hypertension..: Negative: Mother and Father.  Insomnia disorder: Negative: Mother and Father.  Narcolepsy...: Negative: Mother and Father.  Restless leg syndrome...: Mother.Negative: Father.  Sleep apnea...: Negative: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 17.2 k/cumm High (02/14/23 22:04:00)  RBC: 5.35 million/cumm (02/14/23 22:04:00)  Hgb: 16.1 GM/dL (02/14/23 22:04:00)  Hct: 48.1 % (02/14/23 22:04:00)  MCV: 90 fL (02/14/23 22:04:00)  MCH: 30.1 pg (02/14/23 22:04:00)  MCHC: 33.5 GM/dL (02/14/23 22:04:00)  RDW: 15.8 % High (02/14/23 22:04:00)  Platelet: 271 k/cumm (02/14/23 22:04:00)  MPV: 8.1 fL (02/14/23 22:04:00)  Neutrophils %: 92 % (02/14/23 22:04:00)  Lymphocytes %: 2 % (02/14/23 22:04:00)  Monocytes %: 6 % (02/14/23 22:04:00)  Eosinophils %: 0 % (02/14/23 22:04:00)  Basophils %: 0 % (02/14/23 22:04:00)  Absolute Neutrophil: 15.8 k/cumm High (02/14/23 22:04:00)  Absolute Lymphocyte: 0.4 k/cumm Low (02/14/23 22:04:00)  Absolute Monocyte: 1 k/cumm (02/14/23 22:04:00)  Absolute Eosinophil: 0 k/cumm (02/14/23 22:04:00)  Absolute Basophil: 0 k/cumm (02/14/23 22:04:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (02/14/23 22:04:00)  Potassium SerPl QN: 3.2 mmol/L Low (02/14/23 22:04:00)  Chloride SerPl QN: 100 mmol/L (02/14/23 22:04:00)  Carbon Dioxide SerPl QN: 24 mmol/L (02/14/23 22:04:00)  Anion Gap: 11 mmol/L (02/14/23 22:04:00)  BUN SerPl QN: 16 mg/dL (02/14/23 22:04:00)  Creatinine SerPl QN: 0.54 mg/dL Low (02/14/23 22:04:00)  Estimated GFR (CKD-EPI, no race): >90 (02/14/23 22:04:00)  Estimated CRCL (CG): >120 (02/14/23 22:04:00)  Glucose SerPl QN: 108 mg/dL High (02/14/23 22:04:00)  Calcium Total SerPl QN: 9.7 mg/dL (02/14/23 22:04:00)  Alkaline Phos SerPl QN: 127 Units/L High (02/14/23 22:04:00)  ALT SerPl QN: 19 Units/L (02/14/23 22:04:00)  AST SerPl QN: 33 Units/L (02/14/23 22:04:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (02/14/23 22:04:00)  Total Protein SerPl QN: 8.1 GM/dL High (02/14/23 22:04:00)  Albumin SerPl QN: 4.8 GM/dL (02/14/23 22:04:00)  Lactate Venous Pl QN: 1.5 mmol/L (02/14/23 22:04:00)  pH Bld Venous QN: 7.34 Low (02/14/23 22:04:00)  PCO2 Bld Venous QN: 40 mmHg (02/14/23 22:04:00)  PO2 Bld Venous QN: 80 mmHg High (02/14/23 22:04:00)  Base Excess Bld Venous: -4 mmol/L Low (02/14/23 22:04:00)  Bicarb Bld Venous Calc: 22 mmol/L (02/14/23 22:04:00)  O2 Sat Bld Venous Calc: 95 % (02/14/23 22:04:00)  Patient Temperature: 37 DegC (02/14/23 22:04:00)  All Other Labs:  Procalcitonin: 0.38 ng/mL (02/14/23 22:41:00)  COVID 19 Specimen Source: Nasopharyngeal (02/14/23 22:04:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (02/14/23 22:04:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/14/2023 22:32 - XR Chest PA or AP Portable  IMPRESSION:1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    02/15/2023 02:08 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Limited assessment of the pulmonary arteries due to metalartifact and motion artifact. Allowing for this limitation, there areno filling defects to the main pulmonary arteries bilaterally.Segmental and subsegmental pulmonary arteries are poorly assessed.2.  Limited assessment of the lungs. Mild retrocardiac consolidationminimal dependent right upper lobe consolidation. This favorsatelectasis. Component of pneumonia cannot be entirely excluded inthe setting of infection.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 02/15/23 17:29  ________________________________________________________ NP     Addendum by MD on February 15, 2023 21:34:49 (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.  General: Somnolent and disoriented, No acute distress.  Baseline neurologic status Eyes:   Extraocular movements are intact, no scleral icterus HEENT: Underlying cerebral palsy, Normal hearing, Moist oral mucosa Respiratory: Bibasilar crackles with scattered wheezes, trach congestion, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness. Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, nontender, nondistended, normal bowel sounds Musculoskeletal: Baseline range of motion restrictions Integumentary:  no rashes Neurologic: Sedate with baseline deficits Psychiatric: Uncooperative, blunted mood and affect     Signature Line Electronically Signed on 02/15/23 21:36  ________________________________________________________ MD