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Medical status patient was seen and examined on rounds in the patient’s room with his wife. He continues to make progress in all therapeutic areas. He is tolerating physical therapy and occupational therapy. Review of systems he complains of weakness and balance deficits. He voices

no other new complaints. Remainder of the 14-point review of systems is essentially negative. On exam, pleasant male in no acute distress. Vital signs are stable. Blood pressure 130/88, temperature 98.2, heart rate 90 heart rate 82. HEENT extraocular motions intact. Mucous membranes moist without lesions. Neck supple without lymphadenopathy. Lungs clear to auscultation without rhonchi, crepitus or wheezing. Heart regular rate and rhythm without murmurs or extra sounds. Abdomen

soft, nontender. No organomegaly. Extremities with trace edema in the lower extremities. Spine without paraspinal muscle tenderness. Neurologic patient moves all extremities without focal weakness. He has some give way weakness at the hips and shoulders with 4+/5 strength noted. Labs WBC 4.4, hemoglobin 12.3, hematocrit 35.7. Sodium 137, potassium 4.

chloride 106, CO2 24, BUN I mean glucose 70, BUN 14, creatinine 0.88. Assessment disuse d i s u s e disuse myopathy with progressive weakness and frequent falls. Number two Alzheimer’s dementia, managed with Exelon patch. Number three rheumatoid arthritis, managed with Prednisone. Number four spinal stenosis with chronic low back pain, managed with Tramadol. Number five gastroesophageal reflux disease, managed with Pepcid. Number six hypertension,

managed with multidrug regimen. Number seven depression and anxiety disorder, managed with Lexapro and anxiolytics as needed. Plan it is felt the patient will benefit from continued subacute rehabilitation with physical therapy to upgrade mobility and occupational therapy to upgrade activities of daily living.

Reason for consult is PEG malfunction. Date of consultation was 11, 2017. History of present illness, patient is a 71-year-old white male with history of encephalopathy, diabetes, and hypertension and coronary artery disease who presented to outside hospital with

hypotension and respiratory insufficiency. He was diagnosed with sepsis attributed to pneumonia, also found to have elevated troponins attributed to non-ST-elevated MI versus demand ischemia with IV antibiotic. Patient was was stabilized and subsequently transferred to for further management. Patient

was noted to have pulled out gastrostomy tube and is currently being fed via nasogastric tube, which he is tolerating well {period} Patient was unable to provide any history. All history is obtained from the chart of previous records {period} Past medical, surgical history includes encephalopathy, coronary artery disease, diabetes mellitus, hypertension

bipolar disorder, depression, peripheral vascular disease, status post right below-the-knee amputation, anemia, hypoxemic respiratory failure, status post lower extremity bypass surgery. Review of systems, unable to obtain. Patient with encephalopathy. Social history, patient is skilled nursing facility resident. No history of tobacco or alcohol. Allergies, lamotrigine. Medications, albuterol, prednisone, vitamin D, aspirin, pravastatin, neomycin, Lovenox 30

morphine, Zofran. On physical exam, patient has a blood pressure of 97/35, pulse is 101, temp is 97, respiratory rate is 20, O2 sat 92% on non-rebreather. Generally, patient is chronically ill-appearing white male, moderate respiratory distress. HEENT, head is normocephalic

accommodation. Extraocular motions intact {period} Extraocular motions are intact. Neck is supple. No masses. Lungs, coarse breath sounds bilaterally. Heart is tachy, regular rate. Abdomen is soft, nontender, nondistended. Foley catheter is in place of previous gastrostomy tube. Extremities, no cyanosis or clubbing. 1+ pulses. Skin, no rash or lesion appreciated. Neurologically, patient minimally responsive to pain.

Moves all extremities in response to pain. Laboratory, patient has a white count of 5.7, hemoglobin is 10.1, and platelet count is 395. INR is 1.4. PTT is 42. Patient has creatinine of .81, BUN is 23.

Chest x-ray done on 2/11 shows consolidation, left lung base. Impression, recommendations, patient is a 71-year-old male with history of multiple medical

including encephalopathy, diabetes, and hypertension with with associated dysphagia requiring gastrostomy tube for long period nutritional support. Agree, note that patient will benefit from EGD with replacement of gastrostomy tube. This is best

once patient is medically stable with improvement in his respiratory status and also ideally treatment of underlying scabies. Patient at, is at somewhat of an increased risk from a cardiac standpoint because of recent

elevated troponins and likely cardiac [skip] at least likely cardiac ischemia secondary to septicemia. Consequently, I will minimize sedation for the procedure

{period} For now, continue with prednisone and bronchodilators for respiratory insufficiency. Pulmonary Medicine is following {period} Continue with nutrition per NG tube, which patient has been tolerating well {period}

Regarding history of coronary artery disease, continue with aspirin. There has been no risk of gastrointestinal bleeding despite the fact the patient

has been anemic, continue to monitor. Consider starting the patient on proton pump inhibitor {period} Thank you for this consultation. Follow patient with you. End of dictation.