Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on December 08, 2022 15:09   Verified By: MD on December 08, 2022 15:09   Encounter Info: Hospital, Inpatient, 12/08/22 -     * Final Report *          History of Present Illness/Subjective     This is a 66-year-old female with past medical history of COPD, bipolar disorder, coronary artery disease presented to the ED with altered mental status.  Patient's son visited her today in the morning and found her to be confused and hence brought her to the hospital.  She was recently admitted on June 25 for sepsis due to uti and colitis.  Previous admission was for for pneumonia in June as well  This time she was not able to contribute much to the history due to being drowsy,  On examination she was wheezing and had pinpoint pupils.  Woke up during the middle of the examination and was able to answer 2 out of 3 orientation questions   Lab values are significant for leukocytosis of 13.3 chronic stable anemia, mild hyponatremia of 129, hyperglycemia of 266, troponin elevation from 74-102, respiratory acidosis, UA shows protein ketones and glucose urea, negative for nitrate and leuk esterase.  X-ray shows shows airspace opacities, and  hilar lymphadenopathy  Review of Systems     13 point review of system was not obtained due to patient's condition  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  None reported this timeframe     Patient Weight    Patient Height  None Reported     Constitutional:  drowsy,  Eyes: pin point pupils. ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  b/l expiratroy wheezing 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 x2 Psychiatric:  Cooperative but drowsy    Assessment/Plan       1. Encephalopathy   G93.40  The patient has been encephalopathy, metabolic versus toxic  Likely due to hypertensive urgency,  Follow drug screen  Ammonia levels are 35 normal,  CO2 level of 56, unlikely the cause  No urinary tract infection  Follow-up thyroid levels   2. Hypertensive urgency   I16.0  Blood pressure 213/86 in the ED,  last BP : 158/68.  resolving   3. COPD exacerbation   J44.1  methylprednisone q8  DUONEBS Q6,  RT to assess and treat as per protocol   4. PNA (pneumonia)   J18.9  - Ceftriaxone and doxy  - pneumonia workup  - Deescalate as necessary   5. Hyponatremia   E87.1  new onset,  serum osmolality, urine sodium , urine osmolality,  unlikley the cause of AMS   6. Anemia   D64.9  Chronic stable anemia  monitor   7. Bipolar affective   F31.9  - resume home medication   8. Hyperlipidemia   E78.5  - resume home medication   10. Hypertension   I10  resume home meds   11. Elevated troponin   R77.8  trend, likley demand ischemia due to hypertensive urgency  - monitor for chest pain   12. Diabetes   E11.9  iss  poct,  insulin sliding scale    Code Status   None Recorded   Chronic Problem List    ADD (attention deficit disorder)  Affective disorder  Anemia  Back pain with sciatica  Bipolar affective  CAD  Chronic ankle pain  Chronic pain  Chronic pain of right hip  Chronic ulcer of buttock  CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min  Closed fracture of right proximal humerus  Diastolic dysfunction  Encounter for medication management  GERD  Hyperlipidemia  Hypertension  Ileus  Inflammatory arthritis  Insulin long-term use  Insulin long-term use  Medication management  Neurologic complication of diabetes mellitus  Onychomycosis  Pneumonia  Preventive measure  Tobacco use  Type 2 diabetes mellitus with complications  Urinary frequency  Urinary incontinence in female  Vertebral compression fracture  Procedure/Surgical History  ?Cholecystectomy ?Hysterectomy ?Left ankle ?left ankle surgery ?left shoulder surgery ?Lumpectomy ?pelvic ?right hip surgery   Surgical History Internal  03/08/2017    Central Line Insertion.    MD  06/16/2015    Lower Extremity Hardware Rem Deep  (Left, Lower)   MD  11/23/2012    Upper Extremity Open Reduction  (Left)   MD  Medications   Home Medications (28) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q6  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, QAM  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  busPIRone 10 mg oral tablet , TAKE 1 TABLET BY MOUTH 3 TIMES DAILY  busPIRone 15 mg oral tablet , 21 Each, TAKE 1 TABLET BY MOUTH 3 TIMES DAILY  calcium carbonate 750 mg chewable tablet 750 mg = 1 Tablet, PRN, Orally, TID  carvedilol 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, BID  carvedilol 12.5 mg oral tablet 25 mg = 2 Tablet, Orally, BID  carvedilol 25 mg oral tablet , 14 Each, TAKE 1 TABLET BY MOUTH TWICE DAILY  dapagliflozin 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  DME (Vendor) Miscellaneous See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  docusate-senna tablet 50 mg-8.6 mg 1 Tablet, Orally, At Bedtime  DULOXetine 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  DULOXetine 30 mg oral delayed release capsule 90 mg = 3 Capsule, Orally, Daily, do not crush or chew  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  gabapentin 600 mg oral tablet 900 mg = 1.5 Tablet, Orally, TID  GaviLyte-G oral powder for reconstitution See Instructions, as directed  HumaLOG (insulin lispro) KwikPen 100 units/mL subcutaneous injection 18 Units, Subcutaneous, With Meals  insulin glargine 100 units/mL subcutaneous solution 30 Units, Subcutaneous, BID  lactobacillus acidophilus and bulgaricus oral tablet, chewable , Orally, BID  methocarbamol 500 mg oral tablet 1,500 mg = 3 Tablet, Orally, TID  Nicorette 4 mg oral transmucosal gum 4 mg = 1 Each, PRN, Orally, Q2H  ondansetron 4 mg oral tablet 4 mg = 1 Tablet, Orally, Q8H  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  simethicone 80 mg oral tablet, chewable 160 mg = 2 Tablet, PRN, Orally, 4 Times Daily  sucralfate 1 g oral tablet 1,000 mg = 1 Tablet, Orally, BID Before Meals  valsartan 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily  Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 12/07/22 00:00:00 TO 12/08/22 15:08:52  None Reported  PRN Medications (0600 - 0559) from 12/07 - 12/08  None Reported  Allergies   Spiriva  Lyrica (swelling, Anxiety)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Applied for disability   Home/Environment   Lives with Children.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   Diabetes mellitus type 2: Mother, Father and Sister.  Disease: Mother and Father.  Heart disease..: Sister and Brother.  Hyperlipidemia..: Mother and Father.  Hypertension..: Mother and Father.  Lung cancer..: Sister.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 13.3 k/cumm High (12/08/22 08:38:00)  RBC: 4.03 million/cumm (12/08/22 08:38:00)  Hgb: 10.5 GM/dL Low (12/08/22 08:38:00)  Hct: 34.8 % Low (12/08/22 08:38:00)  MCV: 86 fL (12/08/22 08:38:00)  MCH: 26 pg Low (12/08/22 08:38:00)  MCHC: 30.1 GM/dL Low (12/08/22 08:38:00)  RDW: 15.3 % High (12/08/22 08:38:00)  Platelet: 403 k/cumm (12/08/22 08:38:00)  MPV: 7.6 fL (12/08/22 08:38:00)  Neutrophils %: 91 % (12/08/22 08:38:00)  Lymphocytes %: 6 % (12/08/22 08:38:00)  Monocytes %: 3 % (12/08/22 08:38:00)  Eosinophils %: 0 % (12/08/22 08:38:00)  Basophils %: 0 % (12/08/22 08:38:00)  Absolute Neutrophil: 12 k/cumm High (12/08/22 08:38:00)  Absolute Lymphocyte: 0.8 k/cumm Low (12/08/22 08:38:00)  Absolute Monocyte: 0.4 k/cumm (12/08/22 08:38:00)  Absolute Eosinophil: 0 k/cumm (12/08/22 08:38:00)  Absolute Basophil: 0 k/cumm (12/08/22 08:38:00)  Chemistry:  Sodium SerPl QN: 129 mmol/L Low (12/08/22 08:38:00)  Potassium SerPl QN: 4.3 mmol/L (12/08/22 08:38:00)  Chloride SerPl QN: 94 mmol/L Low (12/08/22 08:38:00)  Carbon Dioxide SerPl QN: 32 mmol/L High (12/08/22 08:38:00)  Anion Gap: 3 mmol/L (12/08/22 08:38:00)  BUN SerPl QN: 28 mg/dL High (12/08/22 08:38:00)  Creatinine SerPl QN: 0.97 mg/dL (12/08/22 08:38:00)  Estimated GFR (CKD-EPI, no race): 64 mL/min/1.73m2 (12/08/22 08:38:00)  Estimated CRCL (CG): 67 mL/min (12/08/22 08:38:00)  Glucose SerPl QN: 266 mg/dL High (12/08/22 08:38:00)  Calcium Total SerPl QN: 9.1 mg/dL (12/08/22 08:38:00)  Alkaline Phos SerPl QN: 109 Units/L (12/08/22 08:38:00)  ALT SerPl QN: 10 Units/L (12/08/22 08:38:00)  AST SerPl QN: 9 Units/L Low (12/08/22 08:38:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (12/08/22 08:38:00)  Total Protein SerPl QN: 7.3 GM/dL (12/08/22 08:38:00)  Albumin SerPl QN: 4 GM/dL (12/08/22 08:38:00)  Troponin-I High Sensitivity: 102 ng/L High (12/08/22 09:59:00)  BNP Pl QN: 558 pg/mL High (12/08/22 08:38:00)  Ammonia Pl QN: 35 mCmol/L (12/08/22 08:38:00)  Lactate Venous Pl QN: 1.2 mmol/L (12/08/22 08:38:00)  Blood Gas Comment: O2 3L (12/08/22 07:58:00)  pH Bld Arterial QN: 7.31 Low (12/08/22 07:58:00)  PCO2 Bld Arterial QN: 56 mmHg High (12/08/22 07:58:00)  PO2 Bld Arterial QN: 61 mmHg Low (12/08/22 07:58:00)  Base Excess Bld Arterial: 1 mmol/L (12/08/22 07:58:00)  Bicarb Bld Arterial Calc: 28 mmol/L (12/08/22 07:58:00)  O2 Sat Bld Arterial Calc: 88 % Low (12/08/22 07:58:00)  Patient Temperature: 37 DegC (12/08/22 07:58:00)  Sample Type: Arterial (12/08/22 08:21:00)  Urine Studies:  Color: Yellow (12/08/22 09:26:00)  Clarity: SL CLOUDY. (12/08/22 09:26:00)  Specific Gravity: 1.020 (12/08/22 09:26:00)  pH: 5.0 (12/08/22 09:26:00)  Protein: 100 Abnormal (12/08/22 09:26:00)  Glucose: >=1000 Abnormal (12/08/22 09:26:00)  Ketones: TRACE. Abnormal (12/08/22 09:26:00)  Bilirubin: NEGATIVE (12/08/22 09:26:00)  Hgb Ur: TRACE. Abnormal (12/08/22 09:26:00)  Nitrite: NEGATIVE (12/08/22 09:26:00)  Urobilinogen: NormalUro (12/08/22 09:26:00)  Leukocyte Esterase Ur: NEGATIVE (12/08/22 09:26:00)  WBC: 0-5 (12/08/22 09:26:00)  RBC: 0-2 (12/08/22 09:26:00)  Bacteria: Moderate Abnormal (12/08/22 09:26:00)  Squamous Epithelial: Few (12/08/22 09:26:00)  Transitional Epithelial: Few (12/08/22 09:26:00)  Mucous: PRESENT. (12/08/22 09:26:00)  Amorphous Crys Ur: PRESENT. (12/08/22 09:26:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (12/08/22 07:58:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (12/08/22 07:58:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/08/22 07:58:00)  Rapid Influenza A PCR: Not Detected (12/08/22 07:58:00)  Rapid Influenza B PCR: Not Detected (12/08/22 07:58:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/08/2022 09:05 - XR Chest PA or AP Portable  IMPRESSION:1.  Limited study due to hypoinflation with prominent interstitialand patchy airspace opacities, nonspecific and could be related toedema and/or infection.2.  Prominent hila bilaterally, not appreciated previously. This isaccentuated by low lung volumes, and could be further evaluated withimproved inspiratory radiographs and/or CT of the chest if warranted.Lymphadenopathy or other etiologies not excluded.Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Cardiothoracic Reading Room. For after-hours or emergency department cases, pleasecall.    12/08/2022 09:12 - CT Head W/o IV Contrast  IMPRESSION:  1.  No acute CT abnormality of the head. No acute intracranialhemorrhage, hydrocephalus, or large mass.Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Neuroradiology Reading Room. For after-hours or emergency department cases, pleasecall.I, have personally reviewed the image(s) and theprepared and signed interpretation. Based on myreview, I agree with the findings.                Signature Line Electronically Signed on 12/08/22 15:09  ________________________________________________________ MD