Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on May 29, 2023 22:39 EDT   Verified By: MD on May 29, 2023 22:39 EDT   Encounter Info: Emergency, 05/29/23 - 05/30/23    * Final Report *        Chief Complaint   hyperglycemia  History of Present Illness/Subjective     73-year-old female with schizophrenia, epilepsy, prior CVA, bedbound hyperlipidemia TSH diabetes hypertension presenting from facility for evaluation of hyperglycemia.   Reportedly patient had glucose of 500s and was given 10 units of lispro. Per ED provider ECF notes that she has been more weak over the past several days. Patient nonverbal not able to provide much ancillary history. unclear what other symptoms she has had. Unable to obtain ROS.   Most recent blood pressure 148/72, afebrile, heart rate 103.   WBC 16.8, most recent glucose 480, bicarb low at 17, gap 18, troponin 9234, lactate 1.8, VBG with pH 7.38, PCO2 29, UA with ketones, RBCs, no bacteria no WBC   Was given cefepime, 500 cc LR, Flagyl, vank and lispro   CT head shows no acute process.  Chest x-ray shows no acute process.   Patient had recent admission in April for altered mental status.  Showed chronic stroke.  Found to have UTI discharged on Keflex.   Cardiology consulted in the ED secondary to elevated troponins.  Recommend holding off on heparin but stating trend troponins and obtain echo  Review of Systems     unable to obtain  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 37.5 °C (Axillary)  BP: 148/72  HR: 103 (Monitored)  RR: 20  SpO2: 92%  Oxygen Therapy: Room air  WT: 78.60 kg (WFC)   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    78.6 kg    05/29/23    Patient Height  Current Height:    157.5 cm    05/29/23        Constitutional:   No acute distress ,   well-nourished Eyes:  PERRLA,  EOMI,   normal conjunctiva ,   no scleral icterus ENMT:   Moist oral mucosa , atraumatic Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB, no rales, rhonci, crackles Cardiovascular:   Regular rate and rhythm , no murmur, rubs, gallops, no distant heart sounds Gastrointestinal:  Soft, non-tender,  non-distended Musculoskeletal:  Right sided weakness, left sided ROM intact, Integumentary:  Intact, warm, dry no rashes Neurologic:  Unable to obtain. aphasia, no obvious CN deficits Psychiatric:  Unable to obtain    Assessment/Plan     #DKA - E13.11  Patient presents with hyperglycemia, elevated urine ketones, elevated anion gap.  While her Ph was WNL on vbg she does have other clinical criteria for dka indicating a mild dka  No obvious trigger.  Patient does have an elevated white count and tachycardic on admission 2/2 possible sepsis however unable to get a good history given patient's nonverbal status.  Last discharge note states that she is on sliding scale insulin as well as Tradjenta.  DKA order set, hemoglobin A1C, BMP q4, insulin drip, IVF  When gap is closed will start pt on SC insulin regimen, npo until then. Unclear how patient eats at baseline. No feeding tube present. Goal: bicarb >20, glucose <200, gap < 12   #SIRS  SIRS 2/4, no obvious source  Lactate negative  UA negative  Started on broad-spectrum antibiotics in the ED with cefepime, Vanco and Flagyl. continue vanc, cefepime for now.  CT a/p pending   #Elevated Troponin - R77.8  Unclear etiology.  Sepsis, DKA?  Discussed with cardiology in the ED who recommends continue to trend troponins, holding off on heparin, obtain echo  EKG on admission showing sinus tachycardia, left axis deviation, no STEMI criteria  Trend troponins, telemetry, echo   #Hypertension  #Hypothyroidism  #Epilepsy  Not on AED per last discharge but was previously on oxcarbazepine.  Med rec pending  #History of ischemic left MCA stroke  #Chronic aphasia  #MCI  #Schizophrenia  On risperidone  #Depression    IP/ICU  Code Status: DNR per ECF paper  Home medications have not been reconciled unless explicitly stated above. Please resume pending reconciliation  Any mistakes/errors above are likely due to dictation issues with Medical Transcription software. Please contact me for any clarification   1. Aphasia   R47.01    2. Diabetes mellitus   E11.9    3. Chronic ischemic left MCA stroke   I69.30    4. Hypertension   I10    5. Schizophrenia   F20.9    6. Seizure disorder   G40.909    7. DKA (diabetic ketoacidosis)   E11.10    8. Hyperosmolar hyperglycemic state (HHS)   E11.00    9. SIRS (systemic inflammatory response syndrome)   R65.10    Elevated troponin   R77.8    Orders:   Pharmacy Medication History Consult   Code Status   None Recorded   Chronic Problem List    Aphasia  Chronic ischemic left MCA stroke  Diabetes mellitus  Epilepsy  Esophageal reflux  Fracture, humerus, proximal  Hypertension  Hypothyroid  Meningioma  Osteoarthritis  Schizophrenia  Seizure disorder  Procedure/Surgical History  ?Bone density scan (11/28/2005) ?Appendectomy ?Bypass of small intestine ?c-section ?Cesarean section ?Cholecystectomy ?Coronary artery bypass graft ?Intestinal gastric bypass surgery ?Intestinal surgeries following gastric bypass ?Ligation of fallopian tube ?Tonsillectomy and adenoidectomy     Medications   Home Medications (18) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  aspirin 81 mg oral capsule 81 mg = 1 Capsule, Orally, Daily  bisacodyl 10 mg rectal suppository 10 mg = 1 Suppository, PRN, Rectally, Daily  cloNIDine 0.1 mg/24 hr transdermal film, extended release 1 Patch, Topical, Every Sunday  Fleet Enema 7 g-19 g rectal enema 1 Each, PRN, Rectally, ONCE  Glucagon Emergency Kit for Low Blood Sugar 1 mg injection 1 mg, PRN, IM, Q4H  glucose 40% oral gel 15 GM, PRN, Orally  levothyroxine 75 mCg (0.075 mg) oral tablet 75 mCg = 1 Tablet, Orally, Daily  Lexapro 5 mg/5 mL oral solution 15 mg = 15 mL, Orally, Daily  loperamide 2 mg oral tablet 2 mg = 1 Tablet, PRN, Orally, Q4H, not to exceed 16 mg/day  Milk of Magnesia 8% oral suspension 2.4 GM = 30 mL, PRN, Orally, QHS  mirtazapine 7.5 mg oral tablet 7.5 mg = 1 Tablet, Orally, At Bedtime  Norco 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q6H  NovoLOG sliding scale, Subcutaneous, Before Meals, scale 150-200= 2u, 201-250=4u, 251-300=6u, 301-350=8u, 351-400=10u, >400=call MD  pregabalin 75 mg oral capsule 75 mg = 1 Capsule, Orally, BID  Risperdal 1 mg/ml oral solution 0.5 mg = 0.5 mL, Orally, BID  Senna-Time S 50 mg-8.6 mg oral tablet See Instructions, 1 Tablet Orally QAM and 2 Tablet Orally QHS  Tradjenta 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  cefePIME, Injection, 1 GM, IVPB, ONCE, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 05/30/23 01:00:00  Lactated Ringers (Lactated Ringers Bolus), Infusion, 1,000 mL, IVPB, ONCE, Start: 05/29/23 22:00:00  Sodium Chloride 0.45% + Potassium Chloride IV 150 mL/hr     Dextrose 5% Sod Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV 175 mL/hr     Insulin Regular + Sodium Chloride 0.9% IV 7.86 mL/hr [0.1 Units/kg/hr]       One-Time Medications Given 05/28/23 00:00:00 TO 05/29/23 22:39:40  cefePIME, Injection, 2 GM, IV Push, ONCE, (1 DOSE 05/29/23 21:57:00)  Lactated Ringers (LR - ED Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 05/29/23 19:53:00)  Lactated Ringers (LR - ED Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 05/29/23 21:45:00)  metroNIDAZOLE, Infusion, 500 mg, IVPB, ONCE, (1 DOSE 05/29/23 21:50:00)  vancomycin, Injection, 1.75 GM, IVPB, ONCE, (1 DOSE 05/29/23 21:47:00)  PRN Medications (0600 - 0559) from 05/28 - 05/29  glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   Allergies   LaMICtal (Rash)  Talwin (unknown)  penicillins (Hives)  sulfa drugs (Hives)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Exercise   Home/Environment   Facility, Lives with Facility. Home equipment: Glucose monitoring, Wheelchair.   Nutrition/Health   Type of diet: Difficulty swallowin s/p CVA. Aspiration precautions.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Alzheimer's disease: Mother.  Myocardial infarction: Father.  Thyroid disorder: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 16.8 k/cumm High (05/29/23 19:50:00)  RBC: 5.44 million/cumm High (05/29/23 19:50:00)  Hgb: 15.2 GM/dL High (05/29/23 19:50:00)  Hct: 46.1 % (05/29/23 19:50:00)  MCV: 85 fL (05/29/23 19:50:00)  MCH: 28 pg (05/29/23 19:50:00)  MCHC: 33 GM/dL (05/29/23 19:50:00)  RDW: 14.4 % (05/29/23 19:50:00)  Platelet: 392 k/cumm (05/29/23 19:50:00)  MPV: 7.6 fL (05/29/23 19:50:00)  MDW: 17.33 Units (05/29/23 19:50:00)  Neutrophils %: 88 % (05/29/23 19:50:00)  Lymphocytes %: 8 % (05/29/23 19:50:00)  Monocytes %: 4 % (05/29/23 19:50:00)  Eosinophils %: 0 % (05/29/23 19:50:00)  Basophils %: 0 % (05/29/23 19:50:00)  Absolute Neutrophil: 14.8 k/cumm High (05/29/23 19:50:00)  Absolute Lymphocyte: 1.3 k/cumm (05/29/23 19:50:00)  Absolute Monocyte: 0.7 k/cumm (05/29/23 19:50:00)  Absolute Eosinophil: 0 k/cumm (05/29/23 19:50:00)  Absolute Basophil: 0 k/cumm (05/29/23 19:50:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (05/29/23 19:50:00)  Potassium SerPl QN: 3.9 mmol/L (05/29/23 19:50:00)  Chloride SerPl QN: 104 mmol/L (05/29/23 19:50:00)  Carbon Dioxide SerPl QN: 17 mmol/L Low (05/29/23 19:50:00)  Anion Gap: 18 mmol/L High (05/29/23 19:50:00)  BUN SerPl QN: 28 mg/dL High (05/29/23 19:50:00)  Creatinine SerPl QN: 0.92 mg/dL (05/29/23 19:50:00)  Estimated GFR (CKD-EPI, no race): 66 mL/min/1.73m2 (05/29/23 19:50:00)  Estimated CRCL (CG): 53 mL/min Low (05/29/23 19:50:00)  Glucose SerPl QN: 571 mg/dL Critical (05/29/23 19:50:00)  Calcium Total SerPl QN: 9.6 mg/dL (05/29/23 19:50:00)  Alkaline Phos SerPl QN: 158 Units/L High (05/29/23 19:50:00)  ALT SerPl QN: 9 Units/L (05/29/23 19:50:00)  AST SerPl QN: 32 Units/L (05/29/23 19:50:00)  Bilirubin Total SerPl QN: 0.7 mg/dL (05/29/23 19:50:00)  Total Protein SerPl QN: 7.2 GM/dL (05/29/23 19:50:00)  Albumin SerPl QN: 3.9 GM/dL (05/29/23 19:50:00)  Troponin-I High Sensitivity: 8866 ng/L High (05/29/23 19:50:00)  Troponin-I High Sensitivity: 9234 ng/L High (05/29/23 19:50:00)  Lactate Venous Pl QN: 1.8 mmol/L (05/29/23 19:50:00)  Gluc-Strip, POC: 454 mg/dL High (05/29/23 22:36:00)  pH Bld Venous QN: 7.38 (05/29/23 19:50:00)  PCO2 Bld Venous QN: 29 mmHg Low (05/29/23 19:50:00)  PO2 Bld Venous QN: 59 mmHg High (05/29/23 19:50:00)  Base Excess Bld Venous: -6 mmol/L Low (05/29/23 19:50:00)  Bicarb Bld Venous Calc: 17 mmol/L Low (05/29/23 19:50:00)  O2 Sat Bld Venous Calc: 90 % (05/29/23 19:50:00)  Patient Temperature: 37 DegC (05/29/23 19:50:00)  Urine Studies:  Color: Yellow (05/29/23 20:25:00)  Clarity: Clear (05/29/23 20:25:00)  Specific Gravity: 1.036 High (05/29/23 20:25:00)  pH: 5.5 (05/29/23 20:25:00)  Protein: 300 Abnormal (05/29/23 20:25:00)  Glucose: >1000 Abnormal (05/29/23 20:25:00)  Ketones: 100 Abnormal (05/29/23 20:25:00)  Bilirubin: NEGATIVE (05/29/23 20:25:00)  Hgb Ur: Mod 2+ Abnormal (05/29/23 20:25:00)  Nitrite: Negat (05/29/23 20:25:00)  Urobilinogen: Normal (05/29/23 20:25:00)  Leukocyte Esterase Ur: NEGATIVE (05/29/23 20:25:00)  WBC: 0-5 (05/29/23 20:25:00)  RBC: 21-50 Abnormal (05/29/23 20:25:00)  Bacteria: NONE (05/29/23 20:25:00)  Yeast Ur: PRESENT. Abnormal (05/29/23 20:25:00)  Squamous Epithelial: Few (05/29/23 20:25:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 05/29/2023 19:43 - CT Head W/o IV Contrast  IMPRESSION: No acute intracranial process. Chronic intracranial abnormalities arestable.    05/29/2023 20:03 - XR Chest PA or AP Portable  IMPRESSION:  No acute cardiopulmonary process.    05/29/2023 22:23 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  No acute infectious or inflammatory process in the abdomen orpelvis.2.  Large stool burden in the rectum which may suggest constipation.3.  Equivocal urinary bladder wall thickening. This may reflectcystitis in the appropriate clinical setting. Correlate withurinalysis.4.  Additional nonacute findings as above.Thank you for consulting our team of subspecialty radiologists at  Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 05/29/23 22:39 EDT ________________________________________________________ MD