Comprehensive H&P: Admission Note

CC: Right hip pain s/p Right THA 10 days ago

HPI: 68 y/o Greek M with PMHx DM2, HTN, HLD, CKD, PAD, COPD current smoker (1 ppd x 50 yrs), s/p Right Hip Arthroplasty (7/20/20) on DVT ppx Eliquis 2.5mg BID x 30 days presented to ED last night (7/29) c/o weakness and right hip pain x 1 wk. Pt is poor historian, slow to respond, A/O x 2. Limited PMHx and ROS obtained from chart review and nephew.

Pt reports he came to ED for right hip pain, persistent, 5/10 pain radiating from right hip down lateral side of upper leg. Denies any alleviating factors. Reports aggravation with movement or positional change. Denies having taken any medications. Ambulatory with cane or walker.

Per nephew, pt lives with his brother who noted yesterday evening pt became acutely confused. Pt baseline is A&Ox3. He is independent, normal ADLs, and works in a restaurant. Patient reports using 2-3 pillows to sleep at night and can only walk 2 blocks before SOB. Patient denies fall, LOC, fever, chills, generalized pain, fatigue, neck pain/back pain, headache, changes in vision, dizziness, chest pain, palpitations, LE edema, cough/congestion, shortness of breath, abdominal pain, N/V/D, constipation, blood in stool or urine, changes in urine such as frequency/retention/pain upon urination, muscle weakness, joint pain, numbness/tingling or any new rashes/wounds/ulcers. Nephew states patient was COVID-19 negative prior to surgery, had outpatient Pulm/Renal/Cardio/PMD clearance prior to surgery, denies recent travel or known sick contacts.

PMHx

• HTN
• HLD
• DM2
• CKD Stage 3 (baseline 2.5-2.7 per renal Dr.)
• COPD current smoker (1 ppd >50 years)
• s/p Right Hip Arthroplasty (7/20/20) on DVT ppx Eliquis 2.5mg BID x 30 days

PSHx:

• s/p Right Hip Arthroplasty x (7/20/20)
• s/p hernia repair x many years ago

FamHx:

• Mother: Alive Age: 90s.
• Father: Deceased Age: Cancer lung CA 2/2 smoking.
• 1 Brother: Alive and well
• 1 Sister: Deceased from breast cancer.
• Denies familial HTN, HLD, DM, MI, TIA/CVA.

SocHx: Single, not sexually active. Lives with brother. Works in restaurant. Current smoker, 1ppd x 50 years. Denies alcohol or illicit drug use.

ROS:

• Constitutional – Admits to weakness. Denies fall, LOC, fever, chills, generalized pain, or fatigue.
• Eyes – denies vision change
• ENT – unremarkable
• CV – denies HA, vision change, dizziness, CP, palpitations, or LE edema.
• Resp – denies cough, congestion, SOB.
• GI – denies abd pain, N/V/D, constipation, or blood in stool.
• GU – Denies lower abd/pelvic pain, blood in urine, changes in urine frequency, retention, or pain.
• MS – Reports right hip pain and difficulty with ambulation and positional changes.
• Integumentary – denies any new rashes, wounds, or ulcers.
• Neuro – Denies fall, LOC, generalized pain, fatigue, neck/back pain, HA, changes in vision, dizziness, muscle weakness, numbness, or tingling.
• Psych – Unremarkable.
• Endo – Unremarkable.
• Heme/Lymph – Unremarkable.

Allergy/Immune – Unremarkable.

Allergies: NKDA.

Meds:

• Crestor 20 mg PO once daily (HLD)
• Norvasc 10 mg PO once daily (HTN)
• Hyzaar 100 mg-25 mg PO once daily (HTN)
• metoprolol succinate XR 100 mg PO daily (HTN)
• Cardura 8 mg PO once daily (BPH)
• GlipiZIDE XL 10 mg PO once daily (DM2)
• enalapril 2.5 mg PO once daily (HTN)
• oxyCODONE 5 mg PO Q 6 hrs PRN (analgesia s/p RIGHT HIP REPLACMENT)
• Senna 8.6 mg PO QHS (constipation)
• Protonix 40 mg PO once daily (GI PPX x 30 days s/p right hip replacement)
• apixaban 2.5 mg PO BID (DVT PPX x 30 days s/p right hip replacement)

Flowsheet Data:
VITALS (last 24h):
Tc: 36.7 Tmax: 39.1 @ 29 Jul  22:45
HR: 116 (88 – 122)
BP: 136/73 (102/61 – 161/87)
Device: Nasal Cannula, , O2 Flow: 6L, SpO2: 92% (88 – 96), RR(pt): 28 (14 – 28).

Physical Exam:
GENERAL: Pt awake, seated comfortably, NAD. A/O x 2, to self and place. Slow to respond, difficulty answering open-ended questions, inappropriate responses. Shaking noted likely febrile

HEENT: Head normocephalic, atraumatic. PEERLA B/L 5mm pupils. EOM intact. Mouth without lesions or thrush.

NECK: Neck is supple, full range of motion. Trachea midline. No JVD. No LAD of cervical lymph nodes. Thyroid not palpable. Spine nontender to palpable

LUNGS: Regular RR, Normal rise and fall of chest. Diminished breath sounds in bases b/l with scattered rhonchi. No wheezing. Congestive cough noted on deep inspiration.

CARDIAC:  S1,S2 heard with tachycardia No S3, S4, murmurs, or gallops heard on ascultation

ABDOMEN: Obses, nondistended soft. BS x 4. Nontender to palpation, no rebound or guarding. No CVA tenderness. Odorous moisture, exudate, and skin changes in inguinal b/l.

Rectal exam – No lesions, hemorrhoids, bleeding or discharge noted. Residual light brown feces on external rectum. Good sphincter tone. Light brown feces in rectal vault. FOBT negative.

Right Hip: limited ROM due to recent arthroplasty, Right scar well approximate, c/d/i. Indurated, but no erythema, warmth, fluctuance, or discharge. No ecchymosis. Mild right LE swelling throughout 1+ edema. Sensation intact.
Right knee and ankle: strength 5/5. Sensation intact.
Left leg: normal strength and sensation.

NEURO: A&Ox2. Motor sensation grossly intact. Grip strength intact. Sensation grossly intact.

EXTREMITIES: 2+ Radial, dorsalis pedis, and posterior tibialis pulses. Bilateral Ankles positive petechiae, pallor, and hair loss b/l. Feet cold, clammy, with medial hyperpigmentation.

SKIN: Warm, dry skin noted. Otherwise, without obvious wounds/lacerations/ulcers

Lab Results:
LABS (last 48h):

WBC: 9.23 / Hb: 9.0 (MCV: 96.4) / Hct: 29.4 / Plt: 190    [07/30 @ 12:48]

ABG — pH: 7.469, pCO2: 43.4, pO2: 79.5, HCO3: 31.1, SaO2 (calc): 95.0    [07/30 @ 12:13]

143 | 100 | 28.3
——————–< 123   Ca: 8.6   P: 3.1   Mg: 2.0   Anion Gap: 16    [07/30 @ 11:43]
3.6 |  27 | 2.41

Troponin: 0.061    [07/30 @ 11:18]

Troponin: 0.119    [07/30 @ 01:32]

UA — Appearance: Yellow / Cloudy. SG:1.017. pH: 5.0. Glucose: Negative. Protein: 300. Ketones: Negative. Blood: Moderate. Glucose: Negative. Nitrite: Negative. Leuk Est: Negative
UA (micro) — RBC: 7, WBC: 10, Bacteria: Negative    [07/29 @ 22:14]

144 |  99 | 36.6
——————–< 150   Ca: 8.9   P: 3.2   Mg: 1.8   Anion Gap: 14    [07/29 @ 21:33]
3.9 |  31 | 2.72

WBC: 11.27 / Hb: 9.5 (MCV: 95.6) / Hct: 30.1 / Plt: 203    [07/29 @ 21:33]
—  Diff: N:79.9%  L:7.50%  Mo:10.1%

PT: 16.3 / PTT: 49.3 / INR: 1.41    [07/29 @ 21:33]

Prot: 5.9 / Alb: 3.7 / Bili: 0.8 / AST: 11 / AlkPhos: 46    [07/29 @ 21:33]

Troponin: 0.111    [07/29 @ 21:32].

Radiology/Other Results:
RADIOLOGY:

(7/30/20) EKG: Heart Rate: 121 bpm/ PRInterval: 200 ms/ QRSDuration: 152 ms/ QTInterval: 352 ms/ QTc: 458 ms/ PAxis: 57/ QrsAxis: -99/ TAxis: 65/ POSSIBLE ATRIAL FIBRILLATION/ VENTRICULAR COUPLETS/ MARKED LEFT AXIS DEVIATION/ Broad R or R’ in V1 or V2/ QRS axis superior to -30 degrees/ RIGHT BUNDLE BRANCH BLOCK WITH LEFT ANTERIOR FASCICULAR BLOCK/ Low R waves + extensive Q waves/ ST elevation also present/ POSSIBLE EXTENSIVE INFARCTION – AGE UNDETERMINED/ Comparison Summary: NO SERIAL COMPARISON MADE/ Summary: ABNORMAL ECG

(7/30/20) TTE LIMITED:  Summary
Technically difficult study. Endocardial definition enhanced with IV contrast. Patient is markedly tachycardic during the study, precluding accurate assessment of wall motion and LV function. There appears to be grossly preserved LV function. RV not well seen. Likely preserved systolic function.  Aortic valve not well seen. No obvious aortic stenosis based on available  Doppler.  No significant aortic regurgitation.  Mitral valve leaflets appear normal with normal opening. Tricuspid valve not well seen. No significant tricuspid regurgitation. Pulmonary artery pressures could not be adequately assessed. No significant pericardial effusion.

(7/30/20) CT pelvis w/o contrast: IMPRESSION:
Small collection with surrounding fat stranding just deep to the right
tensor fascia lata, which may represent evolving hematoma given the
patient’s history of recent right total hip arthroplasty. Superimposed
infection cannot be excluded. No displaced fracture.

(7/29/20) CXR: FINDINGS/IMPRESSION:
Devices / Lines and Tubes: Telemetry leads project over the chest.
Lungs/Pleura: No pneumothorax is seen. Mild left greater than right perihilar opacities are suggested, which can reflect vascular congestion with mild interstitial edema and/or atypical infection/pneumonia. Mild blunting of the left costophrenic sulcus which can suggest a small effusion.
Cardiomediastinal Silhouette: There is mild prominence of the cardiac
silhouette, which can be projectional related to low lung volumes, or
reflect cardiomegaly and/or pericardial effusion. Aortic arch calcifications.
Other: Spinal degenerative changes.

ASSESSMENT/PLAN:
68 y/o male with PMHx HTN, HLD, DM presents with right hip pain, Afib RVR, AMS, and acute hypoxemic respiratory failure. Admit to inpatient for w/u and tx PNA and Afib.

# COVID-19 Negative, High Risk
– recent hospitalization, prior COVID-19 PCR negative as per ortho at HSS
– Patient 88% O2 sat on RA, febrile, WBC 11.27 with decrease lymph, esr/crp elevatd
– patient with productive cough. Unreliable ROS. Family denies recent travel outside of NYS, recent known sick contacts or hx of symptoms / positive swab.
– CXR with possible atypical/viral pnuemonia, COVID-19 swab negative x 1
– High supision for COVID-19 until cause of sepsis/hypoxia known, patient will be transferred to ETAP for further evaluation.
Admitting made aware.

# Sepsis with Metabolic Encephalopathy rule out Post-op Bacterial Pneumonia vs Infected Right Hip s/p Replacement (7/20/20)
# Acute on Chronic Hypoxic Respiratory Failure due to COPD/ Bronchitis
# Rule out COVID-19 Viral Pneumonia
– On admission febrile, tachycardic Hr 122 improved to HR 88, hypotensive BP 102/61 improved to 149/80, hypoxic on RA O2 sat 88% placed on 4L NC O2 sat 95%, RR 24
– Leukocytosis WBC 11.27 with decreased lymph, elevated ESR/CRP
– Lactate 1.75
– ABG on 4L NC: pH 7.469, pCO2 43.4, HCO3 31.1
– COVID-19 nasal PCR negative x1
– CXR: Mild left greater than right perihilar opacities are suggested, which can reflect vascular congestion with mild interstitial edema and/or atypical
infection/pneumonia. Mild blunting of the left costophrenic sulcus which can suggest a small effusion.
– s/p Vancomycin, Cefepime, NS 1000cc Bolus, Tylenol in ED
– SIRS/qSOFA mets criteria for sepsis with GCS 14
– maintain O2 sat >94%, supplemental O2 with NC as needed
– maintain COVID-19 precautions
– fall/aspiration precautions
– neurochecks & supportive care due to confusion
– Atrovent neb prn for SOB/wheezing
– Tylenol for fever control, gentle IVF hydration
– Incentive Spirometer , encourage cough/deep breath
– Empiric Antibiotic: Cefepime IV and Vanco IV dosed per trough
– consider Prednisone if wheezing occurs
– Smoking cessation and Nicotine Patch Initiated
– f/u procal, pancultures: BCx, UCx, Sputum Cx
– r/o atypical PNA: mycoplasma, Strep/Legionella
– Repeat COVID-19 PCR swab in 24hrs
– f/u chest CT to evaluate for PNA
– monitor CBC, inflammatory markers
– ID consulted

– Pulmonary consulted

# s/p Right Hip Arthroplasty (7/20/20) r/o Infection
– Right Hip:  Clean, dry, and intact, no signs of infection at this time; Right LE swelling likely secondary to recent surgery
– CT Pelvis: Small collection with surrounding fat stranding just deep to the right tensor fascia lata, which may represent evolving hematoma. Superimposed infection cannot be excluded.
– s/p Hydromorphone 0.4mg and Fentanyl 50mg given in ED
– Ortho consulted in ED, low suspicion for R PJI given recent time course, controlled R hip pain and unconcern exam. Signed off
– Pain control as needed, bowel regimen
– Maintain hip precautions, f/u PT evaluation
– On Eliquis 2.5mg BID for DVT ppx s/p arthroplasty
– f/u UE B/L LE
– Outpatient Orthopedic PA made aware
– Monitor right hip scar for signs of infection.

Plan:
# Possible New Onset Afib
# Elevated Troponins likely due to Demand Ischemia r/o ACS
# Prolonged QTc
– On admission Troponin 0.111, 0.119 , f/u 3rd troponin. TSH 1.21
– EKG: sinus tachycardia vs afib HR 123, PVCs noted with RBBB, QTc 498
– s/p ASA 325mg given in ED
– CHADS-Vasc = 2 (HTN, DM) Intermediate risk of thromboembolic event. 4.0% risk of event per year if no coumadin.
– Monitor on tele, trend troponin x 3, f/u AM EKG
– Avoid QTc prolongating medications
– Started Metoprolol 12.5mg BID with holding parameters for rate control
lowered from home dose Metoprolol XL 100mg qd as patient is septic/hypotensive on admission
– FOB negative, H/H stable, on Eliquis 2.5mg BID for DVT ppx s/p arthroplasty
– Cardiology & EP consulted

# Elevated ProBNP with Small Left Pleural Effusion r/o CHF
– On admission proBNP 2322, CXR possible vascular congestion
– No diuresis at this time, f/u Cardio recommendations
– Monitor I&O, daily weight, f/u echo

# CKD Stage 3
– Baseline serum Cr ~ 2.5-5.7 per o/p nephrologist
– On admission serum Cr 2.72, BUN 36.6
– Avoid nephrotoxic agents/NSAIDS/contrast, renal dose medications, monitor BMP daily, f/u US renal/bladder

# HTN
– D/C home BP meds: Norvasc, Hyzaar, Enalapril due to current sepsis

– Resume as patient clinically improves

# HLD
– Continue Crestor 20 mg QHS, LFTs stable, f/u Lipid Panel

# DM2

– D/c home med Glipizide ER 10mg daily.

– Start inpatient ISS, monitor FS & adjust as appropriate, f/u A1c

# BPH – continue Cardura, monitor VS

# Incidental (+) Cocaine in Urine
– Family denies drug use. Patient counseling when less confused.
– Supportive Care for now, monitor for withdrawals

# Ethics
– Nephew is surrogate will find paperwork or refill if needed

# DVT/ GI ppx
– Protonix PO
– Maintain Eliquis 2.5mg BID for DVT ppx s/p arthroplasty

Article for Site Eval:

Reflection on Rotation:

Internal medicine felt like a whiplash from my previous rotation in emergency medicine. Whereas before, I was seeing patients as quickly and efficiently  as possible in the context of emergency outpatient care, internal medicine is like slowing from a brisk jog to a steady orderly walk through cases. There is more time spent going through each patients chronic illnesses and co-morbidities as well as their primary complaint that brought them to the hospital in the first place. Sometimes it was difficult for me to discern which background medical issues warranted the most scrutiny. On this rotation I did my first set of compressions on a cardiac arrest patent in almost 5 years since I was an EMT. I also evaluated stroke patients, and witnessed my first declaration of death in an inpatient setting.

Similar to emergency medicine, there will be instances where rapid assessment and treatment for stroke, sepsis, or ACS may suddenly take precedent over whatever I may be doing with other cases. The day-to-day pace of internal medicine can be punctuated by emergent situations that makes for potentially very dynamic workflow.

Another aspect of spending multiple 12-hr days in a row in the same department is that you get to know the patients, the arc of their illness and recovery, and their families with more familiarity than I’ve experienced in other specialties. This creates a heightened sense of responsibility an investment in patient outcomes.

My knowledge of pharmacology was put to the test daily on this rotation. The typical patient admitted to medicine at NYPQ is usually elderly and with some combination of HTN, HLD, DM2, CKD, and/or CAD with PAD or CVA in their history. I would often have to adjust dosages for renal impairment. IN some case choose alternative forms of antibiotics or analgesia for renal and hepatic function or QT prolongation.

I was also challenged to remember some specific criteria when determining the appropriate level of care for some patients: the NIH Stroke Scale for neuro patients, Light’s criteria for pleural effusions, and HEART Score and CHA2DS2-VASc for cardio patients.

Moving forward, I will try to retain some of the habits I developed regarding prescribing new medication to patients with co-morbidities, medication reconciliation, and knowing which clinical scoring criteria to call upon for appropriate patients.