T2Q-0Q-015 ID: rvar6010190 PWD: nuance2011

PRIMARY CARE PHYSICIAN: None. PRESENTING COMPLAINT: Confusion since yesterday. HISTORY OF PRESENTING ILLNESS: The patient is a 77-year-old white male, who was brought to the hospital this early morning by the police. He was found in his ca r, which had stepped into a ditch, did not sustain any injuries. Apparently, he has been driving around the town for well over 12 hours and could not remember w here his house is. He says he has been confused the whole day. He has not eaten the whole day or drunk anything. When found by the police, he did not know where he was and then by the time we got him to the emergency room he could not tell where he was, and could not identify even the places. Currently, he knows that h e is in the hospital at Aiken and knows his name. He has a headache, but no feve r, no nausea or vomiting. He denies any chest pain. PAST MEDICAL HISTORY: Hypertension. MEDICATIONS: He does not take any medicine because he does not believe in taking medicine. ALLERGIES: No known drug allergies. FAMILY HISTORY: He does not recall any medical history in the family of signific ance. SOCIAL HISTORY: He lives alone, smokes about a pack of cigarettes a day, and occ asionally will drink some alcohol. _____ he does not recall which ones he has ha d before. REVIEW OF SYSTEMS: He denies any fever or chills. No cough or palpitation. No ch est pain. No abdominal pain or weight loss. No change in bowel habits. Appetite has been down. He denies any leg swelling or joint pains. No redness. No skin le sions. Mood has been depressed. His wife died about 25 years ago, and other syst ems are unremarkable. PHYSICAL EXAMINATION: GENERAL: The patient is quiet in bed. He looks just unwell. VITAL SIGNS: Shows temperature of 98, respiratory rate is 20 per minute, pulse i s 102, blood pressure systolic between 169-203 and diastolic of 106, oxygenation is normal at 98% on room air. HEAD AND NECK: Head is atraumatic. Neck is supple. No tenderness. Thyroid glands are enlarged. Mucous membranes are dry. Pupils are equal, reactive to light and accommodation. His looks like he has a cataract especially on the right eye. Hi s extraocular muscles are intact. CHEST: No chest wall tenderness. Chest moves with respiration. Air entry is good bilaterally. Breath sounds are normal. Chest sounds are clear to auscultation. CARDIOVASCULAR: Heart sounds 1 and 2 are heard, slightly loud, tachycardic. Ther e is no jugular venous distention or carotid bruit. No pedal edema. Peripheral p ulses are normal. ABDOMEN: Nondistended. Bowel sounds are present and normal. No tenderness and no organomegaly. NEUROLOGIC: He is currently awake and alert, and obeys all commands. Normal musc le tone and bulk. No focal neurological deficit.

SKIN: Intact. EXTREMITIES: No joint swelling. No redness, and no calf tenderness. LABORATORY EXAMINATION: Hematology: White count is 7.8, hemoglobin is 16.5, hema tocrit is 47.8, MCV is 91, and platelet is 242,000. Electrolytes: Sodium is 141, potassium is 3.9, chloride is 103, bicarbonate is 29, BUN is 39, creatinine is 1.64 with a glucose of 103. Urinalysis WBC of 5 to 10, leukocyte esterase is +2 and bacteria is 1+. His CT scan of the head is reported as no acute intracranial abnormality. EKG shows sinus tachycardia with atrial enlargement and left vent ricular hypertrophy by voltage criteria. ASSESSMENT: This is an elderly male, who was involved in an accident after being confused the whole day and presented with: 1. Altered mental status. This is most likely secondary to #1. 2. Dehydration. 3. Acute kidney injury secondary to dehydration. 4. Urinary tract infection. 5. Hypertension. PLAN: Plan is to admit the patient to the medical floor, give some gentle IV flu ids and his blood pressure will be treated with Norvasc and metoprolol, and hydr alazine as needed. Urinary tract infection will be treated with IV Levaquin once we _____??? the culture result. The patient after rehydration will repeat the e lectrolytes and monitor kidney function.

____________________________ Yaw Otchere-Boateng, MD DID 048850 CC: 48850/6010190 / D: 10/23/2012 05:50:39 DT: 10/23/2012 09:01:51 Job#: 80802 54 / Voice ID: 7403763 R: 10/23/2012 09:01:51