Received Mar 21, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 3 | — | SYR |
Document Type: Internal Medicine IP Progress Note Document Subject: Progress Note Comprehensive Performed By: DO on March 17, 2025 09:15 EDT Verified By: DO on March 17, 2025 09:15 EDT Encounter Info: Hospital, Inpatient, 03/16/25 - * Final Report * Subjective Patient seen and examined, relatively unchanged in PCU this morning. She is admitted yesterday for neck pain, this is SIRS, possible meningitis, she had an LP that showed colorless clear CSF with no elevated neutrophils. Glucose was elevated as was protein. Patient was started on meningitis protocol with acyclovir, full studies are pending. She has no new complaints. No other night events per nursing, she has not had repeat episodes of her nonepileptic activity. A.m. labs are pending. Objective Vitals and Measurements Vitals & Measurements most recent past 24 hours T: 36.6 °C (Oral) TMIN: 36.6 °C (Oral) TMAX: 36.7 °C (Oral) BP: 123/75 HR: 120 (Monitored) RR: 19 SpO2: 96% Oxygen Therapy: Room air Oxygen Flow Rate: 2 (L/min) WT: 96.2 kg Hemodynamics Neurologic Glasgow Coma Score: 15 Patient Weight Current Daily Weight: 96.2 kg 03/17/25 Previous Daily Weight: 94.5 kg 03/16/25 Difference from Previous: 1.700 kg BMI: 38.1 03/16/25 Obese (BMI 30-39.9) Patient Height Current Height: 157.5 cm 03/17/25 Nutritional Orders: NPO Advance as Tolerated, Start on: 03/17/25 3:15:00 EDT, Advance Diet to: 180 gm Carb per day Diet (1300-1600 Kcal, "No Fluid Restrictions" mL Nursing-NPO until after Dysphagia screening normal exam by RN (no diet or medication until completed). If dysphagia screening abnormal, change order to NPO and notify physician patient needs Speech Therapy for Dysphagia Eval and Treat ---------------------- Intake/Output I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 03/16 - 03/17 Total Intake 3789.55 mL Total Output 1050.00 mL Balance 2739.55 mL Physical Exam Constitutional: No acute distress Respiratory: Lungs CTAB Cardiovascular: Tachycardic Regular rhythm Gastrointestinal: Soft, non-tender, non-distended Skin: Intact, warm, dry no rashes Neurologic: Alert & oriented x 3, no cognitive impairment, no focal deficits Positive nuchal rigidity Lines, Tubes, and Drains External Dwelling Catheter Catheter IV cannula Forearm Left 20 gauge PIV Assessment/Plan Anxiety and depression F41.9 DM (diabetes mellitus), type 2 E11.9 H/O: CVA (cerebrovascular accident) Z86.73 History of psychogenic nonepileptic seizure Z87.898 Hyperlipidemia E78.5 Hypertension I10 Neck pain M54.2 SIRS (systemic inflammatory response syndrome) R65.10 1. Neck pain M54.2 (possible viral meningitis) given high wbc and negative imaging on CT head/neck and cspine, will start atbx until meningitis can be fully ruled out. Given high protein and glucose on CSF studies will also continue acyclovir. holding off on pain medications at this time given she is sleepy from Ativan. once she has become more awake and if she c/o pain, will add pain regimen at that time. 2. SIRS (systemic inflammatory response syndrome) R65.10 Meets sirs criteria with tachycardia and elevated wbc e/o unknown given neck pain, there is suspicion of meningitis. blood cx pending LP attempted in ED and was unsuccessful will need to consult IR in the am will start meningitis and sepsis protocol. will need to deescalate atbx and if meningitis is ruled out. UA pending 3. History of psychogenic nonepileptic seizure Z87.898 seizures like activity noted in ED. Ativan given seizure precaution 4. Anxiety and depression F41.9 holding home Xanax for now given that she is somnolent from the ativan given in ED 5. DM (diabetes mellitus), type 2 E11.9 CDA protocol resume home Lantus 6. H/O: CVA (cerebrovascular accident) Z86.73 noted 7. Hyperlipidemia E78.5 resume home statin 8. Hypertension I10 resume home BB Admission Disposition Fluids: Normal Saline Lines: PIV Diet: NPO Code Status/Goals of Care Discussion: Full Code VTE ppx: Heparin Sub Q Dispo: Observation Anticipated Length of stay on admission: Less than 2 midnights Discharge Disposition: _Expect the patient to be medically ready for discharge in 2-3 days, pending patient vital signs (HR/BP/RR/T) are within stable discharge parameters, symptomatic improvement, adequate pain control, improvement of mentation back to baseline, culture result(s) and discharge antibiotic regimens are finalized, Improvement in labs Location: Plan for discharge to be determined after therapy evaluations Discharge Needs: None Case Management Engaged I spent greater than 50 minutes in the evaluation and management of this patient with more than 50% of the time spent counseling and/or coordinating care. I counseled the patient and/or family about the findings, differential diagnoses, my assessment, recommendations, and plan. I coordinated care with the multidisciplinary healthcare team. Code Status Resuscitation Status - Ordered -- 03/17/25 3:15:00 EDT, Full Code Medications Active Scheduled Inpatient Medications acyclovir, Injection, 680 mg, IVPB, Q8H, Indication: Other (MUST specify in Comments), Start: 03/17/25 04:00:00 aztreonam, Injection, 2 GM, IVPB, Q6H, Indication: PCN/Cephalosporin Severe Allergy, Start: 03/17/25 04:00:00 heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 03/17/25 04:00:00 insulin glargine (insulin glargine (Core Diabetes App)), Injection, 28 Units, Subcutaneous, QPM, Start: 03/17/25 21:00:00 vancomycin, Injection, 750 mg, IVPB, Q12H, Indication: Meningitis/CNS Infection, Start: 03/17/25 19:00:00 Vancomycin - Pharmacy Dosing Consult, Miscellaneous, 1 Each, N/A, Daily, Indication: Meningitis/CNS Infection, Start: 03/17/25 03:15:00 Sodium Chloride 0.9% 1,000 mL IV Continuous 100 mL/hr 0 03/17/25 Dextrose 10% in Water 500 mL IV Continuous PRN interruption in TF/TPN at 80 mL/hr, per CDA One-Time Medications Given 03/16/25 00:00:00 TO 03/17/25 09:15:01 ceftRIAXone, Injection, 2 GM, IV Push, ONCE, (1 DOSE 03/17/25 00:53:00) dexamethasone, Injection, 10 mg, IV Push, ONCE, (1 DOSE 03/16/25 21:36:00) fentaNYL, Injection, 50 mCg, IV Push, ONCE, (1 DOSE 03/16/25 09:03:00) HYDROmorphone (HYDROmorphone Inj ED (1 mg/mL)), Injection, 0.5 mg, IV Push, ONCE, (1 DOSE 03/16/25 21:36:00) Lactated Ringers (LR Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 03/16/25 08:55:00) Lactated Ringers (LR Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 03/16/25 09:36:00) Lactated Ringers (LR Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 03/16/25 13:41:00) lidocaine topical (lidocaine 5% topical film), Patch, 1 Patch, Topical, ONCE, (1 DOSE 03/16/25 09:03:00) LORazePAM, Injection, 2 mg, IV Push, Ad Hoc ONCE, (1 DOSE 03/16/25 09:14:00) methocarbamol, Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 03/16/25 10:27:00) MIDazoLAM, Injection, 2.5 mg, IV Push, ONCE, (1 DOSE 03/16/25 13:49:00) MIDazoLAM, Injection, 2.5 mg, IV Push, ONCE, prn, Anxiety, (1 DOSE 03/16/25 21:41:00) ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 03/16/25 21:36:00) piperacillin-tazobactam, Injection, 4.5 GM, IV Push, ONCE, (1 DOSE 03/16/25 09:45:00) piperacillin-tazobactam, Injection, 3.375 GM, IVPB, ONCE, (1 DOSE 03/16/25 15:00:00) Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 03/16/25 21:36:00) vancomycin, Injection, 2 GM, IVPB, ONCE, (1 DOSE 03/16/25 09:43:00) vancomycin, Injection, 2 GM, IVPB, ONCE, (1 DOSE 03/17/25 06:49:00) PRN Medications (0600 - 0559) from 03/16 - 03/17 acetaminophen, 650 mg, Orally, Q4H, 0 Dose(s) glucagon, 1 mg, IM, Unscheduled, 0 Dose(s) glucose, Per Core Diabetes App , IV Push, Unscheduled, 0 Dose(s) insulin lispro, Per Core Diabetes App , Subcutaneous, Unscheduled, 0 Dose(s) ondansetron, 4 mg, IV Push, Q6H, 0 Dose(s) polyethylene glycol 3350, 17 GM, Orally, Daily, 0 Dose(s) Lab Results All Labs Last 24 hours (No Micro or Pathology) Chemistry: Lactate Venous Pl QN: 1.7 mmol/L (03/16/25 09:36:00) Gluc-Strip, POC: 197 mg/dL High (03/17/25 07:33:00) pH Bld Venous QN: 7.46 High (03/16/25 09:36:00) PCO2 Bld Venous QN: 33 mmHg Low (03/16/25 09:36:00) PO2 Bld Venous QN: 52 mmHg High (03/16/25 09:36:00) Base Excess Bld Venous: 0 mmol/L (03/16/25 09:36:00) Bicarb Bld Venous Calc: 24 mmol/L (03/16/25 09:36:00) O2 Sat Bld Venous Calc: 88 % (03/16/25 09:36:00) FIO2: Venous (03/16/25 09:36:00) Patient Temperature: 37 DegC (03/16/25 09:36:00) TSH 3rd Gen SerPl QN: 1.047 mcU/mL (03/17/25 04:20:00) Urine Studies: Color: Light-Yellow (03/17/25 04:20:00) Clarity: Clear (03/17/25 04:20:00) Specific Gravity: 1.02 (03/17/25 04:20:00) pH: 5.5 (03/17/25 04:20:00) Protein: NEGATIVE (03/17/25 04:20:00) Glucose: 500 Abnormal (03/17/25 04:20:00) Ketones: 40 Abnormal (03/17/25 04:20:00) Bilirubin: NEGATIVE (03/17/25 04:20:00) Hgb Ur: NEGATIVE (03/17/25 04:20:00) Nitrite: NEGATIVE (03/17/25 04:20:00) Urobilinogen: Normal (03/17/25 04:20:00) Leukocyte Esterase Ur: NEGATIVE (03/17/25 04:20:00) All Other Labs: Tube Number CSF: 3 (03/16/25 22:22:00) Color CSF: COLORLESS (03/16/25 22:22:00) Clarity CSF: Clear (03/16/25 22:22:00) Xanthochromia CSFld: COLORLESS (03/16/25 22:22:00) TNC CSF: 1 /cumm (03/16/25 22:22:00) TNC CSF Uncorrected: 1 /cumm (03/16/25 22:22:00) RBC CSF: 1 /cumm (03/16/25 22:22:00) Glucose CSF QN: 79 mg/dL High (03/16/25 22:22:00) Protein CSF QN: 54 mg/dL High (03/16/25 22:22:00) Micro - Last 7 days Rapid Influenza Method: PCR - Liat (03/16/25 08:50:00) Rapid Influenza A PCR: Not Detected (03/16/25 08:50:00) Rapid Influenza B PCR: Not Detected (03/16/25 08:50:00) Diagnostics Radiology Results - Last 24 hours Across Visits 03/16/2025 09:24 - XR Chest PA or AP Portable IMPRESSION:1. No evidence of acute process or significant interval change. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at (redacted) with any questions. 03/16/2025 11:47 - CT Head W/o IV Contrast IMPRESSION: No evidence of acute intracranial hemorrhage, parenchymal edema, significant intracranial mass effect or calvarial fracture. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at (redacted) with any questions. 03/16/2025 12:17 - CTA Head/Neck W/IV Contrast IMPRESSION:CTA HEAD:1. Normal CT angiogram of the intracranial arteries. 2. Specifically, no occlusion, stenosis or aneurysm. CTA NECK:1. Normal CT angiogram of the neck. 2. Specifically, no calcified plaques, occlusion, stenosis or dissection. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at (redacted) with any questions. 03/16/2025 12:17 - CT Cervical Spine W/o IV Contrast IMPRESSION: 1. Study limited due to streak artifact.2. No acute osseous abnormality.3. Scattered degenerative changes. No significant spinal canal or neural foraminal stenosis. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at (redacted) with any questions. Signature Line Electronically Signed on 03/17/25 09:15 EDT ________________________________________________________ DO