Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 02, 2023 04:22   Verified By: MD on February 02, 2023 04:22   Encounter Info: Hospital, Inpatient, 02/02/23 -     * Final Report *  Document Has Been Revised        Chief Complaint   AMS  History of Present Illness/Subjective     History of Present Illness/Subjective  This is an 83-year-old woman with past medical history of atrial fibrillation and DVT on anticoagulation, diabetes mellitus, fibromyalgia, hyperlipidemia, hypertension, hypothyroidism, osteoarthritis, dementia, anemia, stable chronic anemia, and chronic congestive heart failure with preserved ejection fraction.   The patient presents from nursing home this evening, initial work-up showing elevated BNP, peripheral edema, and chest radiograph suggestive of low-grade pulmonary edema in addition to findings consistent with urinary tract infection.  I called the patient emergency department, she is awake, pleasant, alert, not a great historian but in no distress.   Discharge back to nursing facility the emergency department, however, the nursing facility promptly return the patient back to his department.  Troponin 36, BNP 1383, creatinine 2.75, not too far from baseline.  She was hospitalized in July 2020 due to COVID and severe acute kidney injury superimposed on chronic kidney disease, at that time it appears at her baseline renal function has declined from creatinine now 2.5-2.75 range.    Echocardiogram 7/27/2022 showing normal LVEF and right atrial and pulmonary arterial pressures.  She is atrial fibrillation with a rate of 95, no acute ischemic change, no QRS.   The patient is negative for alert but has had problems with encephalopathy and hallucination on prior admission to the hospital.  Based on discussion with the ER provider and chart review, it appears that the patient was directed to the emergency department due to altered mentation.  At this point, I suspect she is not far from baseline.  He has lower extremity edema that was wrapped in gauze presentation of the knee.  Does not look like cellulitis.   Based on chart review, he does appear to be of 15 to 20 g from her prior baseline weight.     Review of Systems     Remaining 10 point review systems negative as noted above, however, limited reliability.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  None reported this timeframe     Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  MM are dry Neck:  Supple, non-tender, intact range of motion, no jugular venous distention noted Respiratory:  Lungs CTAB Cardiovascular: Normal rate, irregularly irregular rhythm.  Lower extremity peripheral edema Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Pleasantly mildly confused but cooperative and alert.  Moves all extremities. Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Acute lower UTI   N39.0  Ceftriaxone 1 g every 24 hours, follow culture results.  Monitor for urinary retention, history of   2. Severe sepsis without septic shock   R65.20  Present on admission, adequate capillary refill/perfusing pressure on repeat examination, imaging negative for infiltrate, at low risk for hemodynamic and respiratory instability, placing in med/surg status with low threshold to transfer to to ICU.  Blood cultures pending, urinalysis appears positive at this time, serum lactate within normal limits continue empiric coverage with roecphin.  De-escalate therapy as appropriate.  Meets SIRS criteria with leukocytosis and confusion/end-organ injury.  Febrile but only 100.2    1 g Rocephin, 40 milligrams Lasix in the emergency department   Chronic kidney disease exacerbates her volume issues and with urinary tract infection and possible impending sepsis physiology, would approach continued diuresis gingerly.   ADDENDUM: Initial blood cultures growing gram-positive cocci, appears to be 1 out of 2 bottles, clusters.  Could be contaminant, expand coverage, vancomycin and rocephin, follow cxs.      3. Acute encephalopathy   G93.40  UTI, most likely, nothing suggesting stroke and I'm not sure that she is far from baseline at this time.  Monitor clinicall.   4. Acute kidney injury superimposed on CKD   N17.9  Advanced progressively worsening kidney disease with superimposed CHF makes a complicated picture in regards to volume status.  Avoid nephrotoxins.  No IV contrast.  No NSAIDs.  Will diuresis x1 IV Lasix, monitor.  If we have issues with blood pressure or urine output, may need to replace volume.  She presently 97% on room air.  Chronic, uncontrolled disease.   Significant fluid retention, weight gain, diastolic chf with chronic kidney disease, however, some concern for developing sepsis physiology.  We will again attempt diuresis but need to monitor closely.   5. Chronic atrial fibrillation   I48.20  Continue beta-blocker and anticoagulation   6. Acute on chronic diastolic CHF (congestive heart failure)   I50.33  Significant limitation, daily, intake and output   7. Diabetes   E11.9  Basal insulin with sliding scale correction   8. Chronic anticoagulation   Z79.01  Home medication    Code Status  FULL CODE       ADDENDUM - MSSA bacteremia, prelim, 1/2, increase rocephin dosing, d/c vanc.   Chronic Problem List    Anemia, iron deficiency  Atrial fibrillation  B12 deficiency  Benign Neoplasm of Ear and External Auditory Canal  Benign Paroxysmal Positional Vertigo  Chronic kidney disease stage 4 (disorder)  Chronic renal disease  Diabetes  Dysfunction of Eustachian Tube  Fatigue  Fibromyalgia  Hypercholesterolemia  Hypertension  Hypothyroidism  Meniere's disease NOS  Moderate nonproliferative retinopathy due to diabetes mellitus (disorder)  OA (osteoarthritis)  Peripheral edema  Persistent proteinuria  Refractory anemia  Sensorineural Hearing Loss, Asymmetrical  Sensorineural Hearing Loss, Unilateral  Subjective Tinnitus  Urinary tract infection in female  Procedure/Surgical History  ?Small bowel capsule (03/01/2018) ?Colonoscopy (02/21/2018) ?EGD (02/21/2018) ?Bone density scan (08/10/2016) ?Mammogram (10/13/2014) ?Appendectomy ?Back ?Knee replacement ?Right Ear ?TAH BSO - Total abdominal hysterectomy and bilateral salpingo-oophorectomy ?Tonsillectomy   Surgical History Internal  02/21/2018    Colonscpy Snare Tmr Polyp Lsn    MD  Medications   Home Medications (21) Active  Accu-Chek Guide Test Strips Check up to 2 times daily, Other, Unscheduled, E11.9 check blood sugar twice daily  acetaminophen 500 mg oral tablet 1,000 mg = 2 Tablet, PRN, Orally, Q12H  aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  carvedilol 3.125 mg oral tablet 3.125 mg = 1 Tablet, Orally, BID  cholecalciferol (vitamin D3) 50 mCg (2,000 intl units) oral capsule 50 mCg = 1 Capsule, Orally, Daily  dimethicone 5% topical cream 5%, BID  docusate sodium 100 mg oral capsule 100 mg = 1 Capsule, PRN, Orally, BID  Eliquis 5 mg oral tablet 2.5 mg, Orally, BID  esomeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, PRN, Orally, Daily  famotidine 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  glucagon 3 mg nasal powder   insulin glargine 100 units/mL subcutaneous solution 8 Units, Subcutaneous, BID  Keflex 500 mg oral capsule 500 mg = 1 Capsule, Orally, TID  Lantus (insulin glargine) 100 units/mL subcutaneous solution 12 Units, Subcutaneous, Unscheduled, Use up to a total of 20 units daily, SEE INSTRUCTIONS FROM YOUR PROVIDER  meclizine 25 mg oral tablet 25 mg = 1 Tablet, Orally, 4 Times Daily  metoPROLOL succinate 25 mg oral tablet, extended release 25 mg = 1 Tablet, Orally, Daily  ondansetron 4 mg oral tablet 4 mg = 1 Tablet, PRN, Orally, Q8H  senna 8.6 mg oral tablet 8.6 mg = 1 Tablet, PRN, Orally, BID  torsemide 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Tradjenta 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/01/23 00:00:00 TO 02/02/23 04:22:05  None Reported  PRN Medications (0600 - 0559) from 02/01 - 02/02  None Reported  Allergies   sulfa drugs  Bactrim  Isoptin  Macrobid  Vibramycin  codeine  morphine  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   home from Rehab 3 weeks, 2 CHILDREN   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Breast cancer: Mother.  DM (diabetes mellitus)..: Mother and Grandmother.  Father: History is unknown  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 18 k/cumm High (02/01/23 23:37:00)  RBC: 3.5 million/cumm Low (02/01/23 23:37:00)  Hgb: 9.5 GM/dL Low (02/01/23 23:37:00)  Hct: 30.1 % Low (02/01/23 23:37:00)  MCV: 86 fL (02/01/23 23:37:00)  MCH: 27.1 pg (02/01/23 23:37:00)  MCHC: 31.5 GM/dL Low (02/01/23 23:37:00)  RDW: 16.6 % High (02/01/23 23:37:00)  Platelet: 258 k/cumm (02/01/23 23:37:00)  MPV: 7.2 fL (02/01/23 23:37:00)  Neutrophils %: 90 % (02/01/23 11:09:00)  Lymphocytes %: 2 % (02/01/23 11:09:00)  Monocytes %: 7 % (02/01/23 11:09:00)  Eosinophils %: 0 % (02/01/23 11:09:00)  Basophils %: 0 % (02/01/23 11:09:00)  Absolute Neutrophil: 14.7 k/cumm High (02/01/23 11:09:00)  Absolute Lymphocyte: 0.4 k/cumm Low (02/01/23 11:09:00)  Absolute Monocyte: 1.2 k/cumm (02/01/23 11:09:00)  Absolute Eosinophil: 0 k/cumm (02/01/23 11:09:00)  Absolute Basophil: 0 k/cumm (02/01/23 11:09:00)  Chemistry:  Sodium SerPl QN: 131 mmol/L Low (02/01/23 23:37:00)  Potassium SerPl QN: 4 mmol/L (02/01/23 23:37:00)  Chloride SerPl QN: 97 mmol/L Low (02/01/23 23:37:00)  Carbon Dioxide SerPl QN: 22 mmol/L (02/01/23 23:37:00)  Anion Gap: 12 mmol/L High (02/01/23 23:37:00)  BUN SerPl QN: 55 mg/dL High (02/01/23 23:37:00)  Creatinine SerPl QN: 2.75 mg/dL High (02/01/23 23:37:00)  Estimated GFR (CKD-EPI, no race): 17 mL/min/1.73m2 Low (02/01/23 23:37:00)  Estimated CRCL (CG): 15 mL/min Low (02/01/23 23:37:00)  Glucose SerPl QN: 251 mg/dL High (02/01/23 23:37:00)  Calcium Total SerPl QN: 8.6 mg/dL (02/01/23 23:37:00)  Alkaline Phos SerPl QN: 102 Units/L (02/01/23 23:37:00)  ALT SerPl QN: 19 Units/L (02/01/23 23:37:00)  AST SerPl QN: 28 Units/L (02/01/23 23:37:00)  Bilirubin Total SerPl QN: 1.8 mg/dL High (02/01/23 23:37:00)  Total Protein SerPl QN: 6.8 GM/dL (02/01/23 23:37:00)  Albumin SerPl QN: 3.3 GM/dL Low (02/01/23 23:37:00)  Lipase SerPl QN: 5 Units/L Low (02/01/23 23:37:00)  Troponin-I High Sensitivity: 36 ng/L High (02/02/23 01:19:00)  BNP Pl QN: 1383 pg/mL High (02/01/23 23:37:00)  Lactate Venous Pl QN: 1.1 mmol/L (02/01/23 11:09:00)  Gluc-Strip, POC: 137 mg/dL High (02/01/23 16:53:00)  pH Bld Venous QN: 7.3 Low (02/01/23 23:37:00)  PCO2 Bld Venous QN: 45 mmHg (02/01/23 23:37:00)  PO2 Bld Venous QN: <34 Low (02/01/23 23:37:00)  Base Excess Bld Venous: -4 mmol/L Low (02/01/23 23:37:00)  Bicarb Bld Venous Calc: 22 mmol/L (02/01/23 23:37:00)  O2 Sat Bld Venous Calc: 52 % (02/01/23 23:37:00)  Patient Temperature: 37 DegC (02/01/23 23:37:00)  Coagulation:  PT: 22.3 seconds High (02/01/23 11:09:00)  INR: 1.9 High (02/01/23 11:09:00)  Urine Studies:  Color: Yellow (02/01/23 14:15:00)  Clarity: Clear (02/01/23 14:15:00)  Specific Gravity: 1.020 (02/01/23 14:15:00)  pH: 5.5 (02/01/23 14:15:00)  Protein: 30 Abnormal (02/01/23 14:15:00)  Glucose: NEGATIVE (02/01/23 14:15:00)  Ketones: NEGATIVE (02/01/23 14:15:00)  Bilirubin: NEGATIVE (02/01/23 14:15:00)  Hgb Ur: SMALL. Abnormal (02/01/23 14:15:00)  Nitrite: POSITIVE Abnormal (02/01/23 14:15:00)  Urobilinogen: NormalUro (02/01/23 14:15:00)  Leukocyte Esterase Ur: SMALL. Abnormal (02/01/23 14:15:00)  WBC: 6-10 Abnormal (02/01/23 14:15:00)  RBC: None Seen (02/01/23 14:15:00)  Bacteria: Moderate Abnormal (02/01/23 14:15:00)  Squamous Epithelial: Few (02/01/23 14:15:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/01/23 11:16:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/01/23 11:16:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/01/23 11:16:00)  Rapid Influenza A PCR: Not Detected (02/01/23 11:16:00)  Rapid Influenza B PCR: Not Detected (02/01/23 11:16:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/01/2023 11:35 - XR Chest PA or AP Portable  IMPRESSION:Large hiatal hernia.Limited inspiratory effort with cardiomegaly and mild mild congestivechanges but no obvious focal infiltrates.    02/01/2023 23:56 - XR Chest PA or AP Portable  IMPRESSION:1.  Mildly increased mild pulmonary edema.2.  Large hiatal hernia.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 02/02/23 04:22  ________________________________________________________ MD  Electronically Signed on 02/02/23 04:25  ________________________________________________________ MD  Electronically Signed on 02/02/23 04:33  ________________________________________________________ MD  Electronically Signed on 02/02/23 04:55  ________________________________________________________ MD  Electronically Signed on 02/02/23 04:57  ________________________________________________________ MD  Electronically Signed on 02/02/23 04:59  ________________________________________________________ MD  Electronically Signed on 02/02/23 06:31  ________________________________________________________ MD