Progress Note
Subjective
NAE overnight. Patient states she feels well. No complaints.
Hospital Course
66-year-old female with a past medical history of COPD, HFrEF, CAD (no stents), HTN, HLD, CKD3 who presents for altered mental status. History obtained from patient’s husband. Husband states patient has not been herself past few days. She missed medications where she normally does not. Per her husband, patient was passenger in car and one moment she was speaking with her husband and the next she was “passing out” on his shoulder. He immediately drove her to SBUH for further evaluation. Her husband denied any overt symptoms other than lethargy and confusion.
In ED, vitals initially hypotensive to 90/50, HR 100, RR18, sat 96% room air. WBC elevated to 15, UA positive for nitrites and leukocyte esterase. Started on Vanc and Zosyn. Lasix and clonidine held due to relative hypotension.
Admitted 10 days ago, Finished course of antibiotics for UTI. Pt has remained hemodynamically stable. Awaiting placement to SAR
HOME MEDICATIONS
- Aspirin 325 mg Tab, 1 by mouth daily
- clonidine HCl 0.2 mg tablet, 1 by mouth daily
- Coreg 25 mg tablet, 1 by mouth three times daily
- Furosemide 20mg PO daily
- folic acid 1 mg tablet, 1 by mouth daily
- isosorbide mononitrate ER 60 mg tablet,extended release 24 hr, 1 by mouth four times daily
- Lantus 100 unit/mL subcutaneous solution, 14 units in theam and 14 units in pm
- Nitrostat 0.4 mg sublingual tablet, as needed, for chest pain x3 doses
- Novolog Mix 70-30 100 unit/mL subcutaneous solution, Take as Directed
- Protonix 40 mg tablet,delayed release (DR/EC), 1 by mouth daily
- Ranexa 500 mg tablet,extended release, 1 by mouth twice daily
- Symbicort 160mcg/4.5mcg 2 puff daily
- Reglan 10 mg tablet, 1 by mouth three times daily
- Vitamin C 500 mg tablet, 1 by mouth daily
- Vitamin D31,000 unit tablet, 2 by mouth daily
- zinc sulfate 220 (50) mg capsule, 1 by mouth daily
- Atorvastatin 40 mg capsule, 1 by mouth daily
HISTORIES
- Past Medical History: As above
- Family History: Mother: CAD w/stent Father: Cancer (nos)
- Procedure history: Procedure History: Ovary removal 2/2 torsion, Cholecystectomy
- Social History: Alcohol: Denies Tobacco: Former smoker, pack years unknown Illicits: Denies
- Travel: Not applicable
- Exposure: Not applicable
REVIEW OF SYSTEMS:
- Gen: Feeling well
- Resp: Slight difficulty breathing, no cough or sputum production
- Cardiac: Denies chst pain or palpitations
- GI: Denies Abd pain, nausea vomiting, constipation or diarrhea
- GU: Denies dysuria symptoms
PHYSICAL EXAMINATION
- Vitals Signs BP160/80, HR 90, RR22, O2 94% on room air
- General: A&Ox2 (name and place), appears tired,
- Eye: Pupils are equal, round and reactive to light, Normal conjunctiva.
- HENT: Normocephalic, Oral mucosa is moist.
- Respiratory: Symmetrical chest wall expansion, crackles in lower lung fields
- Cardiovascular: Normal rate, Regular rhythm, No murmur, Normal peripheral perfusion, 1+ Edema. Peripheral pulses: +1.
- Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.
- Integumentary: Warm, Dry, Pink.
- Neurologic: CNII-XII intact
IMPRESSION AND PLAN
Impression:
66-year-old female with a past medical history of COPD, HFrEF, HTN, HLD, CKD3 who presents for altered mental status. Found to have UTI now S/p completion of IV antibiotics. Awaiting placement to SAR.
Plan:
- UTI
- Initial UA with Large LE and Nitrites, >182 wbcs
- s/p 5 days ceftriaxone
- Urine culture contaminated
- Leukocytosis on admission since resolved
- HTN/HLD/HFrEF/CAD
- Initially hypotensive, however progressively becoming more hypertensive
- Restart home clonidine
- Hold Imdur
- Restart home Lasix
- Hold home Coreg
- C/w asa 325mg daily
- C/w Atorvastatin 40mg daily
- COPD
- currently on RA
- c/w Symbicort
- c/w prn nebs
- CKD3
- Baseline Cr: ~1.6
- Renally Dose Meds
- Avoid Nephrotoxins
- Strict I/O
- F/u w/ Social work regarding SAR
Dispo: pending SAR placement
DVT PPX: Heparin SubQ
FULL CODE