Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 03, 2023 16:33   Verified By: MD on February 03, 2023 16:33   Encounter Info: Hospital, Inpatient, 02/03/23 -     * Final Report *          History of Present Illness/Subjective      Chief complaint: Altered mental state  HPI: Patient is a 95-year-old male patient with history of atrial fibrillation not on anticoagulation, dementia, history of stroke in adulthood, hyperlipidemia, incomplete bladder emptying, chronic urinary tract infections, obstructive sleep apnea and bladder  Contracted presented to emergency department via EMS from extended-care facility for altered mental status.  History was obtained from daughter who was at bedside and this history is from emergency room chart due to patient's altered mental state which is quite altered from his baseline dementia.  Patient was apparently recently discharged from our facility on January 28 where he had been treated for flu.  At that time patient was septic septic from influenza a.  As per the reports from family patient has gotten progressively worse since and has been out of it for past 3 days.  Patient also complains of having cough which is blamed on influenza A infection recently.  Patient has never used oxygen at home and apparently was having low oxygen today when he presented to the emergency room as low as 87% on room air.  Upon evaluation in the emergency room laboratory data was fairly benign with normal white count normal kidney function glucose elevated at 120 normal liver enzymes troponin at 27 BNP 45 lactate 1.6 urinalysis showing large amount of hemoglobin positive nitrites many bacteria flu negative COVID-positive patient was not COVID-positive at his last hospitalization.  A chest x-ray was obtained that failed to show any pneumonia and CT abdomen pelvis was done that showed no acute findings in the abdomen or pelvis chronic findings which remain unchanged CT head without IV contrast shows advanced microvascular ischemic changes and generalized atrophy if clinical suspicion for acute ischemia persists consider further evaluation with brain MRI no CT evidence of acute intracranial hemorrhage.  Patient is full code which has been confirmed with the family by emergency room doctor.  Since patient was requiring oxygen it was decided to bring inpatient for treatment of 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)  None reported this timeframe     Patient Weight    Patient Height  None Reported     General: Alert but not oriented Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. Cardiovascular: Normal rate, Regular rhythm. Gastrointestinal: Soft, Non-tender. Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect       Assessment/Plan       1. COVID   U07.1   New diagnosis of COVID 19 likely acquired from nursing home.  -We will start patient on remdesivir since symptoms are fairly new and patient is requiring oxygen.  -Dexamethasone 6 mg IV daily  -Check procalcitonin levels and other appropriate labs as ordered in order set.  -Oxygen as needed.  -Keep patient isolated.   2. Hypoxia   R09.02   Oxygen as above  -Hypoxia resulting from COVID-19 infection.   3. Altered mental state   R41.82   Altered mental status likely due to current infection by COVID-19 and hypoxia.  -Oxygen as needed.  -Monitor for falls.   4. Dementia   F03.90   Noted.   5. Recurrent UTI   N39.0   Patient will be given ceftriaxone for his urinary tract infection and we will look for cultures and if cultures are negative we will discontinue antibiotics.  He may just be having colonization due to having recurrent urinary tract infections and incomplete bladder emptying.  Urine cultures from last visit were negative but 1 urine cultures from January 14 showed ESBL positive E. coli.  -We will treat with cefepime   6. Atrial fibrillation   I48.91   Patient is rate controlled on atenolol.  -I do not see any anticoagulation for this patient likely due to advanced age and risk of falls.  -Continue to monitor for now.   7. BPH with obstruction/lower urinary tract symptoms   N40.1   Noted resume home medications   8. GERD (gastroesophageal reflux disease)   K21.9   Patient will be on Protonix.   9. Hyperlipemia, mixed   E78.2   Resume home medications   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/03/23 15:59:00   albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q4H, PRN, Shortness of Breath/Wheezing, 02/03/23 15:59:00, RT Care Assessment and Protocol per Policy  labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 02/03/23 15:59:00   ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 02/03/23 15:59:00   polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, 02/04/23 9:00:00   promethazine, 12.5 mg, IVPB, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 02/03/23 15:59:00, 300 mL/hr, Infuse Over 10 minutes, Total Volume (mL) = 50  Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 02/03/23 15:59:00, 60 mL/hr, Clinical Weight  2000 mg Sodium, 20 gm Saturated Fat Diet  Admit to Inpatient   Basic Metabolic Panel  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  Ferritin SerPl QN  Fibrinogen  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  Magnesium SerPl QN  Medical Service  OT Evaluation and Treatment  Phosphorus SerPl QN  Procalcitonin  PT Evaluation and Treatment  Resuscitation Status  Strep pneumoniae Ag Urine  Troponin-I High Sensitivity  Vital Signs  Weight   Code Status   None Recorded   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  Malnutrition  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 (15) 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  miconazole 2% topical powder 1 App, Topical, BID, to affected area  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  Sodium Chloride 0.9%  1,000 mL IV  60 mL/hr       One-Time Medications Given 02/02/23 00:00:00 TO 02/03/23 16:33:54  None Reported  PRN Medications (0600 - 0559) from 02/02 - 02/03  None Reported  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: 7.8 k/cumm (02/03/23 10:23:00)  RBC: 4.87 million/cumm (02/03/23 10:23:00)  Hgb: 14.6 GM/dL (02/03/23 10:23:00)  Hct: 45 % (02/03/23 10:23:00)  MCV: 92 fL (02/03/23 10:23:00)  MCH: 29.9 pg (02/03/23 10:23:00)  MCHC: 32.4 GM/dL (02/03/23 10:23:00)  RDW: 14.4 % (02/03/23 10:23:00)  Platelet: 323 k/cumm (02/03/23 10:23:00)  MPV: 8.4 fL (02/03/23 10:23:00)  Neutrophils %: 66 % (02/03/23 10:23:00)  Lymphocytes %: 19 % (02/03/23 10:23:00)  Monocytes %: 15 % (02/03/23 10:23:00)  Eosinophils %: 0 % (02/03/23 10:23:00)  Basophils %: 0 % (02/03/23 10:23:00)  Absolute Neutrophil: 5.1 k/cumm (02/03/23 10:23:00)  Absolute Lymphocyte: 1.4 k/cumm (02/03/23 10:23:00)  Absolute Monocyte: 1.1 k/cumm (02/03/23 10:23:00)  Absolute Eosinophil: 0 k/cumm (02/03/23 10:23:00)  Absolute Basophil: 0 k/cumm (02/03/23 10:23:00)  Chemistry:  Sodium SerPl QN: 144 mmol/L (02/03/23 10:23:00)  Potassium SerPl QN: 4 mmol/L (02/03/23 10:23:00)  Chloride SerPl QN: 108 mmol/L (02/03/23 10:23:00)  Carbon Dioxide SerPl QN: 23 mmol/L (02/03/23 10:23:00)  Anion Gap: 13 mmol/L High (02/03/23 10:23:00)  BUN SerPl QN: 19 mg/dL (02/03/23 10:23:00)  Creatinine SerPl QN: 0.81 mg/dL (02/03/23 10:23:00)  Estimated GFR (CKD-EPI, no race): 81 mL/min/1.73m2 (02/03/23 10:23:00)  Estimated CRCL (CG): 58 mL/min Low (02/03/23 10:23:00)  Glucose SerPl QN: 120 mg/dL High (02/03/23 10:23:00)  Calcium Total SerPl QN: 9.6 mg/dL (02/03/23 10:23:00)  Alkaline Phos SerPl QN: 65 Units/L (02/03/23 10:23:00)  ALT SerPl QN: 24 Units/L (02/03/23 10:23:00)  AST SerPl QN: 49 Units/L High (02/03/23 10:23:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (02/03/23 10:23:00)  Total Protein SerPl QN: 7.7 GM/dL (02/03/23 10:23:00)  Albumin SerPl QN: 3.7 GM/dL (02/03/23 10:23:00)  Lipase SerPl QN: 39 Units/L (02/03/23 10:23:00)  Troponin-I High Sensitivity: 27 ng/L High (02/03/23 10:23:00)  BNP Pl QN: 45 pg/mL (02/03/23 10:23:00)  Lactate Venous Pl QN: 1.6 mmol/L (02/03/23 10:23:00)  pH Bld Venous QN: 7.37 (02/03/23 10:23:00)  PCO2 Bld Venous QN: 47 mmHg (02/03/23 10:23:00)  PO2 Bld Venous QN: 71 mmHg High (02/03/23 10:23:00)  Base Excess Bld Venous: 1 mmol/L (02/03/23 10:23:00)  Bicarb Bld Venous Calc: 27 mmol/L (02/03/23 10:23:00)  O2 Sat Bld Venous Calc: 94 % (02/03/23 10:23:00)  Patient Temperature: 37 DegC (02/03/23 10:23:00)  Urine Studies:  Color: Yellow (02/03/23 10:34:00)  Clarity: Clear (02/03/23 10:34:00)  Specific Gravity: >=1.030 (02/03/23 10:34:00)  pH: 6.0 (02/03/23 10:34:00)  Protein: 30 Abnormal (02/03/23 10:34:00)  Glucose: NEGATIVE (02/03/23 10:34:00)  Ketones: NEGATIVE (02/03/23 10:34:00)  Bilirubin: NEGATIVE (02/03/23 10:34:00)  Hgb Ur: LARGE. Abnormal (02/03/23 10:34:00)  Nitrite: POSITIVE Abnormal (02/03/23 10:34:00)  Urobilinogen: NormalUro (02/03/23 10:34:00)  Leukocyte Esterase Ur: NEGATIVE (02/03/23 10:34:00)  WBC: 6-10 Abnormal (02/03/23 10:34:00)  RBC: 11-20 Abnormal (02/03/23 10:34:00)  Bacteria: Many Abnormal (02/03/23 10:34:00)  Squamous Epithelial: Few (02/03/23 10:34:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/03/23 10:34:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (02/03/23 10:34:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/03/23 10:34:00)  Rapid Influenza A PCR: Not Detected (02/03/23 10:34:00)  Rapid Influenza B PCR: Not Detected (02/03/23 10:34:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/03/2023 10:54 - 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.    02/03/2023 11:32 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  No acute findings in the abdomen or pelvis.2.  Chronic findings as described.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    02/03/2023 11:32 - CT Head W/o IV Contrast  IMPRESSION:  1. Advanced microvascular ischemic changes and generalized atrophy.If clinical suspicion for acute ischemia persists, consider furtherevaluation with brain MR.2. No CT evidence of acute intracranial hemorrhage.Thank you for consulting our team of subspecialty neuroradiologists at Radiology. Health careproviders wishing to discuss this case further can contact the Neuroradiology Reading Room.                Signature Line Electronically Signed on 02/03/23 16:33  ________________________________________________________ MD