Age: 58.0
Sex: F
Vaccine: FLU3
Symptoms: Coma scale normal, Condition aggravated, Cough, Creatinine renal clearance decreased, Dehydration
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Performed By: NP on February 16, 2025 12:10   Verified By: NP on February 16, 2025 12:10   Encounter Info: Hospital, Inpatient, 02/12/25 -     * Final Report *  Document Contains Addenda        Subjective     Admission Date: 02/12/2025 09:02  LOS: 4 Days  Patient is a 58-year-old female past history significant for COPD, hypertension, peripheral artery disease present emergency room increase embolus shortness of breath cough and congestion.  Patient states that she has had several members in her household ill over the course of the weekend.  2 days ago she began noticing increased symptoms of cough and congestion.  Over the last 24 to 48 hours she has noticed progressively worsening shortness of breath with progressive hypoxia initially she was saturating in the low 90 to 92% and then later in the low 84 to 85% range.  She placed herself on 2 L of oxygen but her shortness of breath persisted.  She tried using breathing treatments at home but they were only minimally relieving her with ongoing symptoms.  She felt clammy at times but did not check her temperature but was found to be febrile by EMS.  No symptoms of chest pain but she has had a productive cough that is been yellow in nature.  No symptoms of myalgias or arthralgias noted.  As her shortness of breath worsened and she progressively declined she present emergency room for further evaluation.  In the emergency room:  Blood pressure was 144/64 heart rate 106 respiratory rate 20 oxygen saturation was 85% on room air temperature 37.9  Serology: White count  18,900 with a left shift hemoglobin 12.2 hematocrit 36.7 and a platelet count of 402,000.  INR 2.25 with a pro time of 25.3.  Sodium 137 potassium 3.7 chloride 93 bicarb 32 BUN 18 creatinine 1.3 and a blood sugar of 135.  Troponin 7 BNP 20 serum lactate 1.5 venous blood gas pH 7.41 pCO2 54 pO2 less than 35.  COVID PCR negative.  Influenza A PCR positive.  Influenza B PCR negative.  Chest x-ray showed no acute findings.  Past medical history: Peripheral artery disease including celiac artery stenosis and mesenteric artery stenosis, hypertension, GERD status post Nissen fundoplication, history of CVA, iron deficiency anemia, ongoing tobacco use.???????   2/13: Pts blood sugars elevated, borderline diabetic at baseline, added CDA protocol, Pt feels better but still not well. Bld cx pending, tapering steroids. Still on 4l nc   2/14: wbc went up again today , tapered her steroids again today. Still wheezy and coarse, RA is baseline and she is on 2l nc today down from 4l yesterday, She feels a little better but not ready to go home.   2/15:  Feels fair.  Oxygen intermittently.  She has home oxygen, but "hasn't needed it for months".  Occasional prod cough, sinus congestion.  Feels weak after being up.  IV came out.  Multiple attempts to restart unsuccessful.???????   2/16:  Feels fair.  Breathing a little better.  Room air.  Increased productive cough.  No fever or chills.  Worried about returning home and smoking again.  WBC remains significantly elevated.    Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI???????  Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 36.4 °C (Oral)  TMIN: 36.4 °C (Oral)  TMAX: 36.7 °C (Oral)  BP: 128/48  HR: 88 (Monitored)  RR: 18  SpO2: 100%  Oxygen Therapy: Room air  Oxygen Flow Rate: 0 (L/min)    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    91.8 kg    02/13/25  Previous Daily Weight:    82.7 kg    02/12/25  Difference from Previous:    9.100 kg  BMI:    30.3    02/12/25    Obese (BMI 30-39.9) Patient Height  Current Height:    165.1 cm    02/13/25        Nutritional Orders:  2000 mg Sodium Diet, Start on: 02/13/25 15:28:00, 225 gm Carb per day, "No Fluid Restrictions" mL Nursing  ----------------------     Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 02/15 - 02/16  Total Intake 410.00 mL    Total Output 0.00 mL     Balance 410.00 mL     Physical Exam     Constitutional:  No acute distress Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs dim bases, coarse with faint exp??????? wheezes Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect      Lines, Tubes, and Drains  There are no active lines present.  Assessment/Plan        Orders (Last 12 Hours): ?XR Chest PA and Lateral, Routine, For: leukocytosis, influenza, 02/16/25 11:51:00   1. Influenza A   J10.1   Patient presents with influenza A with acute respiratory failure.  tamiflu started 2/12  Rt protocol  -on 2l, wean as tolerated-- room air 2. Sepsis   A41.9   Patient for feel sepsis physiology.  Blood cultures x 2 no growth  -Negative Urine for Legionella and strep antigens  -Procal 0.16, 0.15  Repeat procal due to sig leukocytosis-- >0.07 3. Hyperglycemia   R73.9  recheck a1c, 7/24 7.4%  -started CDA protocol  [1] 4. Acute respiratory failure   J96.00  Secondary to COPD exacerbation due to influenza A and underlying potential pneumonia.  Continue RT protocol.  Frequent nebulizer treatments and treatment of underlying infection.  [2] 5. COPD exacerbation   J44.1   Noted.  Secondary to influenza A.  Frequent nebulizer treatments.  RT protocol with IV Solu-Medrol.  Expectorant therapy.  Oxygen therapy to maintain saturations above 90% with close follow-up. [3] 6. GERD (gastroesophageal reflux disease)   K21.9   Continue reflux precautions and PPI therapy. 7. Hypertension   I10   Noted.  Blood pressure mains stable this time.  Titrating patient's home medical regimen accordingly. [5] 8. Acute kidney injury superimposed on chronic kidney disease   N17.9   Patient has acute on chronic kidney injury secondary to most likely prerenal azotemia from dehydration.  She was started on judicious IV fluid rehydration and monitor renal function closely.  Should correct fairly quickly. ??????? [6] ???????  Improving 9. Leukocytosis   D72.829  continue abx and wean steroids, monitor for improvement daily  -Bld cx negative.  Only slight improvement, afebrile, neg procal  Will repeat CXR  Iron deficiency anemia   D50.9   Stable at this time.  Will continue to trend hemoglobin levels and transfuse if hemoglobin drops below 7. [7] PAD (peripheral artery disease)   I73.9   Noted.  Continue patient's baseline anticoagulation and ongoing risk factor modification. [8] Tobacco use   Z72.0   Patient needs to stop smoking.  Options and prescription medications were discussed and offered to the patient at this time  Discussed strategies to quit   Admission Disposition   Fluids: saline locked  Lines:  PIV  Diet:  Diabetic Carb Controlled  Code Status/Goals of Care Discussion: Full Code  VTE ppx:  Lovenox Sub Q  Dispo:  Home No Needs  Anticipated Length of stay on admission: Greater than 2 midnights???????     Discharge Disposition: _Expect the patient to be medically ready for discharge in tomorrow???????, pending patient vital signs (HR/BP/RR/T) are within stable discharge parameters   Location: Plan for discharge to be determined after therapy evaluations  Discharge Needs: None, Discharge therapy (PT/OT/ST) recommendations  Case Management Engaged  Code Status  Resuscitation Status - Ordered    -- 02/12/25 13:09:00, Full Code   Medications   Active Scheduled Inpatient Medications  albuterol-ipratropium (albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL), Inhalation SOLN, 3 mL, Neb Inhale, Q6H, Start: 02/14/25 13:00:00  apixaban, Tablet, 5 mg, Orally, BID, Start: 02/12/25 21:00:00  cefPODOXime, Tablet, 400 mg, Orally, BID, Indication: COPD Exacerbation, Start: 02/15/25 21:00:00  doxycycline, Capsule, 100 mg, Orally, BID, Indication: Pneumonia - CAP, Start: 02/12/25 22:00:00  guaiFENesin (Mucinex 600 mg oral tablet, extended release), Tab, Extended Rel, 600 mg, Orally, BID, Start: 02/12/25 21:00:00  hydroCHLOROthiazide (hydroCHLOROthiazide (HCTZ) 12.5 mg oral capsule), Tablet, 12.5 mg, Orally, Daily, Start: 02/14/25 09:00:00  lisinopril, Tablet, 10 mg, Orally, Daily, Start: 02/14/25 09:00:00  oseltamivir (Tamiflu), Capsule, 30 mg, Orally, BID, Indication: Influenza Treatment, Start: 02/12/25 21:00:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 02/13/25 09:00:00  predniSONE, Tablet, 20 mg, Orally, Daily, Start: 02/16/25 09:00:00  Dextrose 10% in Water  500 mL IV Continuous  PRN interruption in TF/TPN at 80 mL/hr, per CDA       One-Time Medications Given 02/15/25 00:00:00 TO 02/16/25 12:10:38  None Reported  PRN Medications (0600 - 0559) from 02/15 - 02/16  OXYcodone-acetaminophen, 1 Tablet, Orally, Q8H, 0  Dose(s)   acetaminophen, 1,000 mg, Orally, Q8H, 0  Dose(s)   acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2.5 mg, Neb Inhale, Q2H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Core Diabetes App , IV Push, Unscheduled, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q8H, 2  Dose(s)   insulin lispro, Per Core Diabetes App , Subcutaneous, Unscheduled, 4  Dose(s)   magnesium sulfate, 2 GM, IVPB, Q12H, 0  Dose(s)   magnesium sulfate, 4 GM, IVPB, Q12H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 1  Dose(s)   potassium chloride, 20 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 30 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 40 mEq, Orally, Unscheduled, 0  Dose(s)   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 29.6 k/cumm High (02/16/25 02:09:00)  RBC: 4.1 million/cumm (02/16/25 02:09:00)  Hgb: 11.5 GM/dL Low (02/16/25 02:09:00)  Hct: 35.1 % (02/16/25 02:09:00)  MCV: 86 fL (02/16/25 02:09:00)  MCH: 28 pg (02/16/25 02:09:00)  MCHC: 32.7 GM/dL (02/16/25 02:09:00)  RDW: 14.8 % High (02/16/25 02:09:00)  Platelet: 621 k/cumm High (02/16/25 02:09:00)  MPV: 7.5 fL (02/16/25 02:09:00)  Neutrophils %: 76 % (02/16/25 02:09:00)  Lymphocytes %: 14 % (02/16/25 02:09:00)  Monocytes %: 8 % (02/16/25 02:09:00)  Eosinophils %: 1 % (02/16/25 02:09:00)  Basophils %: 1 % (02/16/25 02:09:00)  Absolute Neutrophil: 22.4 k/cumm High (02/16/25 02:09:00)  Absolute Lymphocyte: 4.1 k/cumm High (02/16/25 02:09:00)  Absolute Monocyte: 2.4 k/cumm High (02/16/25 02:09:00)  Absolute Eosinophil: 0.4 k/cumm High (02/16/25 02:09:00)  Absolute Basophil: 0.2 k/cumm (02/16/25 02:09:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (02/16/25 02:09:00)  Potassium SerPl QN: 5 mmol/L (02/16/25 02:09:00)  Chloride SerPl QN: 99 mmol/L (02/16/25 02:09:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (02/16/25 02:09:00)  Anion Gap: 7 mmol/L (02/16/25 02:09:00)  BUN SerPl QN: 33 mg/dL High (02/16/25 02:09:00)  Creatinine SerPl QN: 1.29 mg/dL High (02/16/25 02:09:00)  Estimated GFR (CKD-EPI, no race): 48 mL/min/1.73m2 Low (02/16/25 02:09:00)  Estimated CRCL (CG): 54 mL/min Low (02/16/25 02:09:00)  Glucose SerPl QN: 202 mg/dL High (02/16/25 02:09:00)  Calcium Total SerPl QN: 9.6 mg/dL (02/16/25 02:09:00)  Alkaline Phos SerPl QN: 61 Units/L (02/16/25 02:09:00)  ALT SerPl QN: 8 Units/L (02/16/25 02:09:00)  AST SerPl QN: 13 Units/L (02/16/25 02:09:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (02/16/25 02:09:00)  Total Protein SerPl QN: 6.6 GM/dL (02/16/25 02:09:00)  Albumin SerPl QN: 3.9 GM/dL (02/16/25 02:09:00)  Magnesium SerPl QN: 2.1 mg/dL (02/16/25 02:09:00)  Gluc-Strip, POC: 176 mg/dL High (02/16/25 11:31:00)  All Other Labs:  Procalcitonin: 0.07 ng/mL (02/15/25 12:42:00)  Micro - Last 7 days  L pneumo Urine Ag QL: Not Detected (02/13/25 06:16:00)  L pneumo Urine Ag QL Interp: L pneumo Urine Ag QL Interp (02/13/25 06:16:00)  Strep pneumo Ag Ur: GeneXpert NOT DETECTED (02/13/25 06:16:00)  Strep pneumo Ag Ur Interp: Strep pneumo Ag Ur Interp (02/13/25 06:16:00)  Rapid Influenza Method: PCR - Liat (02/12/25 09:16:00)  Rapid Influenza A PCR: Detected Abnormal (02/12/25 09:16:00)  Rapid Influenza B PCR: Not Detected (02/12/25 09:16:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.             Signature Line Electronically Signed on 02/16/25 12:10 ________________________________________________________ NP     Addendum by MD on February 16, 2025 18:43:39 (Verified)    I saw and evaluated the patient in addition to NP.  I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care.  General:  Alert and oriented, No acute distress. Eyes:   Extraocular movements are intact, no scleral icterus HEENT:  Normocephalic, Normal hearing, Moist oral mucosa Respiratory:  Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness. Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, nontender, nondistended, normal bowel sounds Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: Alert, no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  MD   Signature Line Electronically Signed on 02/16/25 18:43 ________________________________________________________ MD