IDENTIFICATION: February 12, 2019

VC, M, white, American, 93 years old, married, 1234 Wilmington Rd, Great Neck, NY 11234, Jewish.

INFORMANT: The patient himself is an unreliable historian. Patient accompanied by his sons, both reliable historians.

REFERRAL SOURCE: Sons & Home Health Aide

CHIEF COMPLAINT: ‘Altered Mental Status’

PRESENT ILLNESS: VC is a 93-year-old male, with a PMH significant for AFib on Coumadin, DM2, HTN, HLD, s/p TAVR 11/2018 and dementia accompanied by his son noted to have increasing lethargy and altered mental status. Patient has had 3 hospitalizations in 2 months. On last admission, patient was admitted for pulmonary edema requiring MICU stay and a 9-day intubation with complications at extubation. Patient was discharged three weeks ago. Sons were told to return to hospital if patient became more lethargic, prompting their visit today, noting their father is increasingly lethargic and appears altered. Sons deny fevers, chills, hematuria, dysuria, cough or difficulty breathing.

Of note, patient’s sons report baseline hypothermia and note an extensive infectious etiological work up completed at Winthrop hospital earlier this month. 

PAST MEDICAL HISTORY

• Atrial Fibrillation
• Diabetes Mellitus 2
• Hypertension
• Hyperlipidemia
• TAVR 11/2018
• Dementia

PAST SURGICAL HISTORY

• Tonsillectomy

MEDICATIONS

• Warfarin – 3mg PO qd
• Metformin – 500 mg PO, extended release
• Potassium Chloride – 10 mEq PO qd
• Nystatin Powder – 1 application topical tid
• Humalog sliding scale subq q6h
• Pantoprazole – 40 mg IV push
• Pyridoxine – 100mg PO qd
• Albuterol/Ipratropium – 3mL q6h
• Hydralazine – 50mg PO qid
• Irbesartan – 300mg PO qd

ALLERGIES

• Penicillin: Hives
• No food/environmental allergies

FAMILY HISTORY

• Mother, deceased, arthritis, renal failure.
• Father, deceased, DM, HTN, AFib.
• Wife, 90, alive, HTN.
• Two sons, 64 & 68, alive and well.

SOCIAL HISTORY

• EtOH occasionally, former smoker, 30 pack years, quit 15 years ago. Denies any illicit drug use. Patient lives at home his wife and a full time home health aide. Patient is retired, former real estate broker.

REVIEW OF SYSTEMS

Unable to obtain secondary to altered mental status.

GENERAL SURVEY: 93-year-old altered male, sedated, catheterized (foley). Patient appears to be of stated age and well nourished, appearing lethargic.

VITALS

BP: 160/62 mmHg, supine, right arm

R: 20 breaths / min, unlabored

P: 70 beats / min

SpO2: 100%

Temperature: 98 F (oral)

Height: 5’11”                            Weight: 220 lbs                                                            BMI: 30.68

PHYSICAL EXAM

SKIN: Warm & dry, good turgor. Nonicteric, no lesions noted, no tattoos.

HAIR: Bald.

NAILS: No clubbing, capillary refill <2 seconds throughout.

HEAD: NC/AT nontender to palpation throughout.

EYES: No conjunctival injection, bilaterally. Symmetrical OU; no evidence of strabismus, exophthalmos or ptsosis; sclera white; cornea clear. Visual acuity: unable to obtain. Pupils equal bilaterally and reactive to light 2mm. Unable to obtain EOM. Fundoscopy: unable to obtain.

EARS: Symmetrical & normal size. No evidence of lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TMs pearly white, intact with light reflex in normal position AU. Unable to obtain auditory acuity, Weber and Rinne evaluation.

NOSE: Symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No evidence of foreign body.

SINUSES: Nontender to palpitation and percussion over bilateral frontal, ethmoid & maxillary sinuses.

LIPS: pink, dry & cracked, no evidence of cyanosis.

MUCOSA: pink, well hydrated. No masses; lesions noted, No evidence of leukoplakia.

PALATE: Unable to obtain due to sedation.

TEETH: Good dentition, with no discoloration of teeth.

GINGIVAE: Pink, moist. No evidence of hyperplasia, masses, lesions, erythema or discharge.

TONGUE: Pink, well papillated, no masses, lesions or deviations noted. Oropharynx well hydrated, no evidence of injection, exudates, masses, lesions, foreign bodies.  Unable to assess uvula due to sedation.

NECK: Trachea midline, no masses, lesions, scars, pulsations noted. Supple, nontender to palpation. Full ROM, no stridor noted, 2+ carotid pulses bilaterally, no thrills bilaterally, no bruits noted bilaterally, no palpable adenopathy noted. No JVD.

THYROID: Unable to obtain due to sedation.

CHEST: Symmetrical, no deformities, no evidence of trauma. LAT to AP diameter 2:1. Nontender to palpation.

LUNGS: Bibasilar crackles and rales. No wheezing and rhonci noted. Noted use of accessory muscles of breathing.

HEART: Cardiac monitor sinus rhythm without ectomy, S1 & S2 normal. Digits warm to tough. PMI is in 5^th ICS in midclavicular line. Carotid pulses 2+ bilaterally without bruit.

ABDOMEN: Soft nontender without distention. Hypoactive bowel sounds. Foley patent to BSD bladder nondistended, nonpalpable. Noevidence of striae, caput medusa or abnormal pulsations. No bruits hear over aortic/ renal/ iliac / femoral artiers. Tympany to percussion throughout. No evidence of organomegally. No masses noted. No evidence of guarding or rebound tenderness.

GENITALIA: Penile lesion noted at the tip of the urethral meatus.

RECTAL: Family declined.

VASCULAR: Peripheral pulses palpable with radial pulse 2+ bilaterally, DP/PT pulses 2+/2+ bilaterally.

NEURO: AO x0. Nonresponsive to verbal or noxious stimuli.

MUSCULOSKELETAL: 2+ bilateral lower and upper extremity edema. No soft tissue erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout.

DIAGNOSTICS:

1. LABS:
   • WBC: 23.0 (high)
   • Hgb: 8.8 (low)
   • Hct: 28.1% (low)
   • Creat: 1.85 (high)
   • BUN: 99 (high)
   • SODIUM: 153 (high)
   • POTASSIUM: 3.7 (normal)
   • CHLORIDE: 112 (high)
   • CO2: 25 (normal)
   • CALCIUM: 8.0 (low)
   • Mg2+: 2.2 (normal)
   • PHOSPHORUS: 3.5 (normal)
   • AlkPhos: 137 (high)
   • Total Bilirubin: 0.3 (normal)
   • AST: 21 (normal)
   • ALT: 15 (normal)
   • ALBUMIN: 2.5 (low)
   • PT: 32.5 seconds
   • INR: 2.15
   • ABG:
     pH: 7.11
     pCO2: 103
     pO2: 58
     HCO3: 31

2. IMAGING
   • Chest X-Ray: Bilateral pleural effusions. LLL PNA and/or atelectasis. Pulmonary vascular congestion.

ASSESSMENT: 93 year old male, with PMH significant for AFib on Coumadin, DM2, HTN, HLD, s/p TAVR 11/2018 and dementia presents with altered mental status most likely due to hypoxic respiratory failure secondary to sepsis from unknown organism.

PLAN:

1. Acute Hypoxemic Respiratory Failure
   1. MICU consult requested and obtained.
   2. Transfer to MICU for further care
   3. Pt is full code / requires intubation – ICU Fellow will intubate in unit.
2. Hypernatremia
   1. Continue with free water through NG Tube.
   2. Collect BMP q8h to evaluate electrolytes
3. Acute Kidney Injury
   1. Continue with IV Fluids
   2. Nephrology consult requested. Will evaluate patient once intubated in MICU.
4. Sepsis (of unknown etiology)
   1. Patient received 7-day course of Vancomycin and Aztreonam.
   2. Repeat blood cultures.
5. GI Consult Requested
   1. Concern for GI bleed with downtrending Hgb & Hct
   2. Continue with Protonix 40mg IV push qd
6. Atrial Fibrillation
   1. Hold anticoagulation
7. Advanced Care Planning / Counseling Discussion
   1. Patient is full code
   2. Discuss goals of care with family and educate family on palliative options and end of life care
8. Diabetes Mellitus
   1. Continue with sliding scale while hospitalized
9. Hypertension
   1. Continue with hydralazine as prescribed. 50mg PO qid.
10. Hyperlipidemia
    1. Continue with Irbesartan as prescribed. 300mg PO qd.

Differential Diagnosis

1. Sepsis
2. Acute Hypoxic Respiratory Failure
3. CHF exacerbation
4. Bacteremia
5. Stroke

 

Preceptor collected hard copy of H&P for review.