History

Identifying Data:

Full Name: Mr Z

Address: Not Disclosed

Age: 71 years

Date & time:7/14/2021 9:30 AM

Location: NYPQ 

Religion: Not disclosed

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Self

Chief Complaint: “Nausea and vomiting” x1 day

History of Present Illness:

71 year old Mandarin speaking male with past medical history of HTN, DM, ESRD on HD (Tue, Thu, Sat at Trude) presented to the ED complaining of multiple episodes of nonbilious nonbloody vomiting and nausea x1 day. Associated with upper abdominal discomfort, chills, subjective fever, and feeling generally unwell. Symptoms began after eating breakfast, have been improving since he stopped eating. Has not missed dialysis or any daily medications. Urinates 1-2x per day.  In ED systolic BP was >200 and developed SOB with O2sat 92%, was started on BIPAP for concern of pulmonary edema and fluid overload.

Denies CP, diarrhea, constipation, LE edema, headache

Past medical history:

DM– controlled on current regimen

HTN – poorly controlled on current regimen, systolic BP >200 in ED

ESRD – on HD Tue, Thu, and Sat

Past surgical history:

AV fistula – L forearm

Medications:

Atorvastatin 40 mg PO daily

Lantus 24 units subcutaneous nightly

Admelog 9 units subcutaneous 3x daily before meals

Lisinopril 10 mg PO daily

Allergies:

NKDA
No known food or environmental allergies

Family History:

Mother- diabetes – deceased age 88

Father- hypertension – deceased age 86

Social History:

Mr Z is a married 71 year old male living in an apartment with his wife and is independent in ADLs and IADLs. Current everyday smoker, 1 cigarette per day x40 years. Does not drink alcohol, or use drugs. Retired delivery driver.  

Travel-No recent travel

Sleep-Sleeps 5 hours per night

Visual Impairment: None

Hearing impairment: None

Falls in the past year: None

Assistive devices used: None

Gait Impairment: None

Urinary incontinence: None

Fecal incontinence: None

Osteoporosis: None

Cognitive Impairment: None

Depression: None

Home safety issues: None

Health Care Proxy: Yes – son

Advance directives: DNR/DNI

Review of Systems:
General-See HPI

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies head trauma, LOC, fracture

Eyes – Denies lacrimation, erythema

Ears – Denies tinnitus, discharge, ear pain, hearing changes

Nose/sinuses – Denies discharge, epistaxis, obstruction

Mouth/throat – Denies bleeding gums, mouth ulcers, voice changes. Does not follow with dentist

Neck – Denies lumps, swelling, decreased ROM

Pulmonary system – Admits nonproductive cough. Denies SOB, dyspnea, wheezing, hemoptysis, orthopnea, PND

Cardiovascular system –Denies CP, palpitations, irregular heartbeat, edema of LE, syncope

Gastrointestinal system-  See HPI

Genitourinary – Denies frequency, dysuria, incontinence, nocturia, hematuria

Nervous –Denies seizures, loss of consciousness

Musculoskeletal– Denies joint pain, deformity, swelling

Hematological system –Denies bleeding, easy bruising, lymph node enlargement, blood transfusions

Vitals

Temp 38.2 C oral

BP 189/109

HR 99 RRR

RR 20

Sp02 100%

Wt 79.4 kgs

Ht 167.6 cm

BMI 28.3

Physical exam:

General: Uncomfortable appearing elderly male on BIPAP, well groomed, nontoxic appearing. Appears stated age.

Skin:   warm & moist, good turgor. capillary refill <2 seconds throughout. No jaundice or pallor. No petechiae or rash.

Hair:   average quantity and distribution

Head: normocephalic, atraumatic, no signs of injury

Eyes – symmetrical; sclera white; conjunctiva pink and moist, no discharge. PERRLA, EOMI

Nose –  Nasal mucosa moist. No rhinorrhea, congestion, masses, trauma, or deformities

Lips –  Pink, moist; no cyanosis or lesions.  

Neck – +JVD, FROM, supple, no rigidity. Trachea midline.   No masses; lesions; scars noted. no stridor noted. no palpable adenopathy noted.

Chest – Symmetrical, no deformities, no evidence trauma. No paradoxic respirations or use of accessory muscles noted. No nasal flaring or retractions

Lungs – On BIPAP. Crackles at bilateral bases. Apices clear to auscultation bilaterally, no wheezes

Heart:   RRR. S1 and S2 are distinct with no murmurs, S3 or S4. No friction rubs appreciated.

Abdomen: Flat and symmetrical without striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Soft, nondistended, nontender to palpation. Tympanic throughout, no guarding or rebound noted. Negative Murphy’s sign. No hepatosplenomegaly or CVA tenderness appreciated.

Extremities: No cyanosis or clubbing. Left upper extremity AV fistula with palpable thrill. Non-pitting edema bilateral LE. DP/PT pulses 2+

Neuro: Alert, no focal deficit noted. No asterixis

Chest xray – portable, 1 view: Impression: Bilateral predominantly perihilar consolidations may reflect multifocal pneumonia or pulmonary edema

Assessment:

71 year old male with past medical history of HTN, DM, ESRD on HD presents for nausea, nonbloody vomit, abdominal discomfort, chills, nonproductive cough x1 day. On BIPAP for concern of pulmonary edema and fluid overload. CXR with bilateral perihilar consolidations may reflect multifocal pna or pulmonary edema.

• Acute respiratory failure 2/2 pulmonary edema vs multifocal pneumonia
  • CXR showed perihilar consolidations
  • COVID negative
  • Cefepime 1 gram and vancomycin 1 gram
  • Follow up blood cultures
  • Discuss case with ID
  • Lactate 1.1, procalcitonin 0.35, continue to monitor
  • Inpatient hemodialysis
  • Continue BIPAP
• ESRD
  • Inpatient HD
  • Renal diet
  • Limit sodium and fluid intake
  • Monitor I&Os
  • Lasix 80 mg daily
• HTN
  • Losartan 50 mg, labetalol 200 mg q12 hours and amlodipine 10 mg daily
  • Monitor BP
• DM
  • Finger stick q6 hours
  • Continue current regimen
• Tobacco use
  • Smoking cessation counseling
• DVT PPx
  • IPCD
  • Lovenox 30 mg subcutaneous once daily