Another Critical Care Question
I have a note that I would like to post that is critical care...again, please help me clarify that this is a critical care visit. thank you.
Chief Complaint/HPI
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Patient is a 65 yr old M presents to MD office this am with c/o feeling dizzy. While at home he reached to turn the stove on felt dizzy and felll down with no true LOC and got him concerned and went to MD office. In MD office BP low so sent to ER. Initially on admit Bp was 70 systolic improved with fluuid challenge. feels less dizzy now. No chest pain, SOB, palpitation sweating through this episode. drinks regularly heavy and r/o withdrawal. Last drink 2 days ago and today had 2 loose BM watery to semi formed. No problems urinating and did urinate prior to going to MD office. No fevers,cough,phelgm. Chronic erythrema of umbilicus treated with out[pt antibiotics by MD in july
Past Medical History
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Alcoholic active and a member of AAA
Abdominal aorta anuerysm
H/o anginal s/s not recently with ABn stress test
HTN history
CKD baseline creatinine 1.7
h/o alcoholic pancreatitis
GERD
active tob user
Active tob user
History
Home Medication
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Home Reported Medications
Active
Allopurinol 300 Mg Tablet (Allopurinol) 300 Mg PO DAILY
Lotensin 10 Mg Tablet (Benazepril HCl) 10 Mg PO DAILY
Elavil 25 Mg Tablet (Amitriptyline HCl) 25 Mg PO DAILY
Ambien 10 Mg Tablet (Zolpidem Tartrate) 10 Mg PO HS PRN
Aldactone 50 Mg Tablet (Spironolactone) 50 Mg PO BID
Lasix 40 Mg Tablet (Furosemide) 1 Tab PO DAILY
Martinic (Vitamin B12-Intrinsic Factor) 1 Cap PO DAILY
Prilosec 20 Mg Capsule (Omeprazole) 20 Mg PO DAILY
Potassium-99 (Potassium) 99 Mg PO DAILY
Folic Acid 1 Mg PO DAILY
Reported
Cephalexin 500 Mg Capsule (Cephalexin Monohydrate) 500 Mg PO Q8H
Ecotrin 325 Mg Tablet (Aspirin) 325 Mg PO DAILY
Allergies
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Coded Allergies:
No Known Allergies (Verified , 7/2/08)
Social History
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active alcohol and an alcoholic at r/o withdrawal
active tob user 11/2 PPD
denies drug use
Family History
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non contributory
Review of Systems
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refer to hpi
Physical Examination
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vitals noted
S1,S2 + RRR
B/l AE decrterased but no adventitious sounds
Soft, NT BS + with erythrema umbilicus chronic does not seem like source of infection
AAO X3
no edema
Clinical Data
Vital Signs Temperature: 96.6, Heart Rate: 89, Respiratory Rate: 20, BP: 85/46, Pulse Oximetry: 99
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All data reviewed in the EMR.
Impression/Plan
Impression
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Hypotension of unclear etiolgy r/o sepsis r/o MI
ARF
Alcoholic at r/o withdrawal mild s/s now
Hepatitis ? acute vs chronic
H/o Abn stress test
H/o AAA
h/o HTN
Plan
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ivf, pan cultures and antibiotics
renal US and foley's with strict I/o
CE X3, echo and consult cards
alcohol withdrawal protocol and consult BHU
critical care time spent 45 min