Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on November 19, 2023 06:45  Verified By: DO on November 19, 2023 06:45  Encounter Info: Hospital, Inpatient, 11/19/23 -     * Final Report *        Chief Complaint   Shortness of breath  History of Present Illness/Subjective     Patient is a 59-year-old male past medical history of Alzheimer's disease, schizophrenia, cognitive impairment, hypothyroidism, hypertension, hyperlipidemia, chronic anemia, anxiety disorder, type 2 diabetes, seizure disorder and cirrhosis (MELD  who presented from a group home due to shortness of breath.   Patient is present with his caregiver at bedside.  She reports that about 2 days ago he began getting progressively more short of breath.  Denies any fevers or chills, chest pain, nausea, vomiting, diarrhea or constipation.  Patient does report a nonproductive cough.  His caregiver says that the patient has been short of breath since his prior discharge on the 16th.  She says his abdomen has stayed tense but he never complains of any pain.  His bilateral lower extremities have been very edematous and they have been trying to elevate them.  He takes all his medications as prescribed including his lactulose and Lasix.  She reports he is a little more confused and sometimes does not respond appropriately to questions.  She reports that he has been having at least 3 nonbloody bowel movements per day.  Earlier today he did have a fall she is not sure if he hit his head but he is complaining of some although pain.  Patient is a full code and does not have any advanced directives at this time.   Of note: Patient was recently admitted from 11/11 until 11/16 for episode of hepatic encephalopathy.   On arrival to the ED initial blood pressure 101/45 patient afebrile heart rate 77 respiratory rate 18 saturating 96% on room air.  EKG rate 100 sinus no ST or T wave changes.  Lab results remarkable for a white count 12.8 with left shift.  Stable hemoglobin at 11.7, D-dimer 2000 sodium 131 glucose 175 alk phos 254 ALT 75 AST 173 bilirubin 1.1 initial high-sensitivity troponin 42 up trended to 55, BNP 117 and ammonia level 50 lactate 2.2 -> 1.5.  pH of 7.44 on VBG.  UA unremarkable.  COVID and flu negative. Chest x-ray with low lung volumes findings of possible atelectasis or pneumonia bibasilar.  CT chest PE protocol with no PE but a right layering pleural effusion and ascites noted in addition to right basilar compressive atelectasis and findings for possible pneumonia in addition to an ill-defined nodular infiltrate in the left upper lobe concerning for pneumonia.  X-ray left elbow negative for any acute fractures. CT head w/o contrast negative for any acute hemorrhage or mass. Patient given cefepime and azithromycin. Admitted to hospital for further management.  Review of Systems     Constitutional:  No fevers,  no chills,  no sweats Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No ear pain,  no nasal congestion,  no sore throat Respiratory:  + Shortness of breath,  + cough,  no wheeze Cardiovascular:  No chest pain,  no palpitations,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea,  no constipation, +abdominal distention Genitourinary:  No frequency,  no urgency,  no dysuria,  no hematuria Hematologic/Lymphatic:  No bruising,  no enlarged lymph nodes Allergic/Immunologic:  No hives Endocrine:  No cold intolerance,  no heat intolerance,  no polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash,  no pruritus Neurological:  No headache,  no focal weakness,  no numbness, +slight confusion Psychiatric:  + Anxiety,  + depression  Physical Exam/Objective Vitals & Measurements most recent past 24 hours    Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported      Constitutional:  + Mild distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Poor air movement bilaterally  Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, normoactive bowel sounds, distended, tense abdomen Musculoskeletal:  No joint swelling, no deformity, intact ROM, Bilateral 2 + pitting edema LE Integumentary:  Ecchymosis present on left elbow Neurologic: Moderate cognitive impairment,  no focal deficits, mild asterixis present Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Sepsis   A41.9   Patient meets sepsis criteria most likely due to pneumonia found on CT chest.  Could possibly also be abdominal source but patient is without any abdominal pain concerning for SBP.  Patient will need a diagnostic paracentesis.    - C/w Cefepime + Doxycycline   - Legionella, Strep urine antigen   - Sepsis protocol   - Blood cultures collected and pending    2. HAP (hospital-acquired pneumonia)   J18.9  As above, patient with left upper lobe pneumonia.  We will continue with antibiotic treatment as mentioned above and follow Legionella and strep urine antigens. Will treat for HAP as patient is within 3 days of recent hospital admission.    3. Dyspnea   R06.00   Dyspnea is most likely multifactorial.  Patient has above pneumonia in addition to a moderate pleural effusion on the right and large tense abdomen due to ascites causing decreased lung volumes.  Patient is not currently requiring oxygen.  We will continue with diuresis but suspect patient will need a therapeutic paracentesis and possibly thoracentesis.    - Possible IR paracentesis, thoracentesis Monday    4. Decompensated hepatic cirrhosis   K72.90   MELD 19, Childs-Pugh Class C. Follows with Dr., biopsy proven. Possibly drug induced versus NASH. Patient was recently admitted with HE and had last therapeutic paracentesis on 11/9 removing 3.2L of ascitic fluid. Patient has tense ascites and will most likely need a repeat paracentesis (both diagnostic and therapeutic), but will attempt diuresis first. Liver enzymes slightly elevated from baseline (ALT 75 from 54 & AST 173 from 125 with ALK-P 254 from 155), will get RUQ for further evaluation.    - Increase home diuretic regimen to Lasix 40 mg + Aldactone 100 mg   - Low salt diet    - Strict I/O's   - RUQ US with doppler    5. Pleural effusion on right   J90   Patient with right pleural effusion most likely due to hepatic hydrothorax.  We will continue with diuresis as mentioned above but patient may need a thoracentesis with IR.   6. Hepatic encephalopathy   K76.82   HE grade 1. Mild confusion compared to baseline, mild asterixis. Continue with lactulose.    - C/w Lactulose 45 ml TID; titrate 3-4 BM/day  - C/w home Rifaximin     7. Elevated troponin   R79.89   Troponin uptrending 42-55.  Most likely secondary to demand.  Will place patient on telemetry and continue to trend troponin.  No acute ST or T wave changes on initial EKG in the ED.   - Trend troponin to peak   - Telemetry monitoring  - Check Mg, TSH    8. Elevated d-dimer   R79.89   CT PE was negative for any pulmonary embolism.   9. Elevated brain natriuretic peptide (BNP) level   R79.89   No known history of heart failure.  No echo on file.  BNP very slightly elevated at 117.  Will order echo.   - TTE    10. Fall at home   W19.XXXA   Patient presenting after fall at his group home.  CT head without contrast unremarkable for any acute findings and also left elbow with ecchymoses present on exam was without any fracture on x-ray.   11. Chronic anemia   D64.9   chronic and stable, normocytic, no active signs of bleeding, continue to trend   12. Alzheimer disease   G30.9   Continue with home medications.  Patient is currently in a group home.  Caregiver that is present with patient feels that he would benefit from facility placement but reports this has been difficult to achieve in the past.  Could consider care management involvement for possible placement in a skilled nursing facility.    13. Anxiety disorder   F41.9   Continue with home medications.   14. Depression   F32.9   Continue with home medications.   15. Diabetes   E11.9  protocol in place   16. Hyperlipemia   E78.5   Continue with home statin therapy    17. Hypertension   I10   Hold home antihypertensive at this time, as we are pushing aggressive diuresis.  Consider restarting as appropriate.   18. Hypothyroid   E03.9   Continue home levothyroxine   19. Schizophrenia   F20.9   Continue with home antipsychotics   20. Seizure disorder   G40.909   Discussed with caregiver patient does not have a seizure disorder and was put on Depakote in the past for mood disorder, which she is now off of since he had a allergic reaction to this medication.   Orders:   furosemide, 40 mg, Orally, Tablet, Daily, 11/19/23 9:00:00   lactulose, 30 GM = 45 mL, Orally, Syrup, 4 Times Daily, 11/19/23 9:00:00  rifaXIMin, 550 mg, Orally, Tablet, BID, 11/19/23 9:00:00  spironolactone, 100 mg, Orally, Tablet, Daily, 11/19/23 9:00:00  Basic Metabolic Panel  Echocardiogram with Cardiac Doppler PW/CW/Color  Magnesium SerPl QN  Troponin-I High Sensitivity  US RUQ/Liver/GB/Pancreas   Code Status   FULL   Chronic Problem List    Alzheimer disease  Anemia  Anxiety disorder  Change in mental status  Closed nondisplaced fracture of greater tuberosity of right humerus with routine healing  Cognitive impairment  Depression  Diabetes  Diabetic neuropathy  Elevated LFTs  Encounter for removal of staples  Examination, physical, employee  Hallux abductovalgus  Hearing deficit  Hyperammonemia  Hyperlipemia  Hypertension  Hypotension  Hypothyroid  Long term use of drug  Onychogryphosis  Onychomycosis due to dermatophyte  Positive PPD  Pre-ulcerative calluses  Proximal humerus fracture  Scalp laceration  Schizophrenia  Seizure disorder  Subclinical hypothyroidism  Tachycardia  Unstable gait  Procedure/Surgical History  ?Diabetic retinal eye exam (09/14/2021) ?Colonoscopy (08/24/2014)     Medications   Home Medications (29) Active  Abreva 10% topical cream 1 App, PRN, Topical, 5 Times Daily  Aldactone 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  Aspirin Low Dose 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, Daily  Biotene Mouthwash oral solution 15 mL, Orally, TID, 2 bottles  busPIRone 30 mg oral tablet 30 mg = 1 Tablet, Orally, BID  ciclopirox 0.77% topical cream 1 App, Topical, BID  cloZAPine 50 mg, Orally, Daily  cloZAPine 100 mg oral tablet 100 mg = 1 Tablet, Orally, At Bedtime  cloZAPine 50 mg oral tablet See Instructions, 1 Tablet Orally  in am2 tablet in pm  DiazePAM 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  DiazePAM 5 mg oral tablet 5 mg = 1 Tablet, PRN, Orally, BID  divalproex sodium 250 mg oral delayed release tablet 250 mg = 1 Tablet, Orally, BID  fenofibrate 145 mg oral tablet 145 mg = 1 Tablet, Orally, Daily, with food  FeroSul 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, Daily  FLUoxetine 40 mg oral capsule 80 mg = 2 Capsule, Orally, Daily  lactulose 10 GM/15 mL oral syrup 20 GM = 30 mL, Orally, BID, 30 mL = 2 tablespoonfuls  Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  latanoprost 0.005% ophthalmic solution 1 Drop, Eyes, Both, At Bedtime  lisinopril 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily, for blood pressure  Milk of Magnesia 8% oral suspension 2.4 GM = 30 mL, PRN, Orally, At Bedtime  Mintox Maximum Strength oral suspension 5 mL, PRN, Orally, 4 Times Daily  multivitamin Multiple Vitamins oral tablet, chewable 1 Tablet, Orally, Daily  Namzaric 10 mg-28 mg oral capsule, extended release 1 Capsule, Orally, QHS  oxyBUTYnin 15 mg/24 hr oral tablet, extended release 15 mg = 1 Tablet, Orally, BID  rifaXIMin 550 mg oral tablet 550 mg = 1 Tablet, Orally, BID  Silvadene 1% cream 1 App, PRN, Topical, Daily  simvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, QHS  Synthroid 100 mCg (0.1 mg) oral tablet 100 mCg = 1 Tablet, Orally, Daily  Tylenol 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, 4 Times Daily  Active Scheduled Inpatient Medications  furosemide (Lasix), Tablet, 40 mg, Orally, Daily, Start: 11/19/23 09:00:00  lactulose (lactulose 10 GM/15 mL oral syrup), Syrup, 30 GM, Orally, 4 Times Daily, Start: 11/19/23 09:00:00  rifaXIMin, Tablet, 550 mg, Orally, BID, Start: 11/19/23 09:00:00  spironolactone (Aldactone), Tablet, 100 mg, Orally, Daily, Start: 11/19/23 09:00:00    One-Time Medications Given 11/18/23 00:00:00 TO 11/19/23 06:44:29  None Reported  PRN Medications (0600 - 0559) from 11/18 - 11/19  None Reported  Allergies   Depakote (Liver issues, weaning off, .)  RisperDAL (critical)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   lives at group ome ,   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: 12.8 k/cumm High (11/19/23 01:10:00)  RBC: 3.78 million/cumm Low (11/19/23 01:10:00)  Hgb: 11.7 GM/dL Low (11/19/23 01:10:00)  Hct: 35.1 % Low (11/19/23 01:10:00)  MCV: 93 fL (11/19/23 01:10:00)  MCH: 31 pg (11/19/23 01:10:00)  MCHC: 33.3 GM/dL (11/19/23 01:10:00)  RDW: 15.3 % High (11/19/23 01:10:00)  Platelet: 175 k/cumm (11/19/23 01:10:00)  MPV: 9.1 fL (11/19/23 01:10:00)  Neutrophils %: 89 % (11/19/23 01:10:00)  Lymphocytes %: 5 % (11/19/23 01:10:00)  Monocytes %: 5 % (11/19/23 01:10:00)  Eosinophils %: 1 % (11/19/23 01:10:00)  Basophils %: 0 % (11/19/23 01:10:00)  Absolute Neutrophil: 11.4 k/cumm High (11/19/23 01:10:00)  Absolute Lymphocyte: 0.6 k/cumm Low (11/19/23 01:10:00)  Absolute Monocyte: 0.7 k/cumm (11/19/23 01:10:00)  Absolute Eosinophil: 0.1 k/cumm (11/19/23 01:10:00)  Absolute Basophil: 0.1 k/cumm (11/19/23 01:10:00)  Chemistry:  Sodium SerPl QN: 131 mmol/L Low (11/19/23 01:10:00)  Potassium SerPl QN: 3.8 mmol/L (11/19/23 01:10:00)  Chloride SerPl QN: 100 mmol/L (11/19/23 01:10:00)  Carbon Dioxide SerPl QN: 26 mmol/L (11/19/23 01:10:00)  Anion Gap: 5 mmol/L (11/19/23 01:10:00)  BUN SerPl QN: 18 mg/dL (11/19/23 01:10:00)  Creatinine SerPl QN: 0.75 mg/dL Low (11/19/23 01:10:00)  Estimated GFR (CKD-EPI, no race): >90 (11/19/23 01:10:00)  Estimated CRCL (CG): 107 mL/min (11/19/23 01:10:00)  Glucose SerPl QN: 175 mg/dL High (11/19/23 01:10:00)  Calcium Total SerPl QN: 8.8 mg/dL (11/19/23 01:10:00)  Alkaline Phos SerPl QN: 254 Units/L High (11/19/23 01:10:00)  ALT SerPl QN: 75 Units/L High (11/19/23 01:10:00)  AST SerPl QN: 173 Units/L High (11/19/23 01:10:00)  Bilirubin Total SerPl QN: 1.1 mg/dL High (11/19/23 01:10:00)  Total Protein SerPl QN: 6.9 GM/dL (11/19/23 01:10:00)  Albumin SerPl QN: 2.8 GM/dL Low (11/19/23 01:10:00)  Troponin-I High Sensitivity: 55 ng/L High (11/19/23 02:24:00)  BNP Pl QN: 117 pg/mL High (11/19/23 01:10:00)  Ammonia Pl QN: 50 mCmol/L High (11/19/23 01:10:00)  Lactate Venous Pl QN: 1.5 mmol/L (11/19/23 05:41:00)  pH Bld Venous QN: 7.44 (11/19/23 01:10:00)  PCO2 Bld Venous QN: 41 mmHg (11/19/23 01:10:00)  PO2 Bld Venous QN: <34 Low (11/19/23 01:10:00)  Base Excess Bld Venous: 3 mmol/L High (11/19/23 01:10:00)  Bicarb Bld Venous Calc: 28 mmol/L (11/19/23 01:10:00)  O2 Sat Bld Venous Calc: 66 % (11/19/23 01:10:00)  Patient Temperature: 37 DegC (11/19/23 01:10:00)  Coagulation:  PT: 19 seconds High (11/19/23 01:10:00)  INR: 1.7 High (11/19/23 01:10:00)  D-Dimer Pl QN: 2018 ng/mL DDU High (11/19/23 01:10:00)  Urine Studies:  Color: Yellow (11/19/23 01:56:00)  Clarity: Slightly Cloudy (11/19/23 01:56:00)  Specific Gravity: 1.031 High (11/19/23 01:56:00)  pH: 6 (11/19/23 01:56:00)  Protein: 50 Abnormal (11/19/23 01:56:00)  Glucose: Normal (11/19/23 01:56:00)  Ketones: NEGATIVE (11/19/23 01:56:00)  Bilirubin: NEGATIVE (11/19/23 01:56:00)  Hgb Ur: NEGATIVE (11/19/23 01:56:00)  Nitrite: NEGATIVE (11/19/23 01:56:00)  Urobilinogen: Normal (11/19/23 01:56:00)  Leukocyte Esterase Ur: NEGATIVE (11/19/23 01:56:00)  WBC: None Seen (11/19/23 01:56:00)  RBC: None Seen (11/19/23 01:56:00)  Bacteria: NONE (11/19/23 01:56:00)  Squamous Epithelial: NONE (11/19/23 01:56:00)  Mucous: PRESENT. (11/19/23 01:56:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/19/23 01:19:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/19/23 01:19:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (11/19/23 01:19:00)  Rapid Influenza A PCR: Not Detected (11/19/23 01:19:00)  Rapid Influenza B PCR: Not Detected (11/19/23 01:19:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/19/2023 01:55 - XR Chest PA or AP Portable  IMPRESSION:1.  Low lung volumes. Subtle bibasilar airspace opacities, likelyrelated to atelectasis or pneumonia in the right clinical setting. Nopleural effusion or pneumothorax.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    11/19/2023 03:31 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  No obvious pulmonary embolism.2.  Moderate right layering pleural effusion with an estimated volumeof 200-300 mL.3.  Ascites4.  Right basilar compressive atelectasis, parenchymal scarringand/or early pneumonia in the correct clinical setting.5.  Ill-defined nodular infiltrate in the left upper lobe. Considerearly pneumonia in the correct clinical setting.Template Version: Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    11/19/2023 05:02 - XR Elbow 3 View Left  IMPRESSION:1.  No acute bony findings.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    11/19/2023 05:06 - CT Head W/o IV Contrast  IMPRESSION: 1.  No acute intracranial abnormality.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    11/19/2023 05:08 - CT Cervical Spine W/o IV Contrast  IMPRESSION: 1.  Mild to moderate degenerative changes of cervical spine; no acutefindings.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 11/19/23 06:45  ________________________________________________________ DO