Age: 57.0
Sex: F
Vaccine: FLU4
Symptoms: Acinetobacter test, Acute respiratory failure, Anion gap, Anticoagulant therapy, Auscultation
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on December 15, 2022 17:24  Verified By: MD on December 15, 2022 17:24  Encounter Info: Inpatient, 12/15/22 -     * Final Report *          History of Present Illness/Subjective     57 year old female with Hx of COPD, OSA on CPAP and GERD presents to the ED via EMS c/o increased SOB and fevers onset 4 days ago.  Patient reports to be apparently well until 4 days ago when she started noticing shortness of breath associated with cough productive of greenish sputum.  1 week prior to onset of shortness of breath patient had flu respiratory disease which is managed symptomatically and did not require to be in the hospital.  Shortness of breath is associated with fever, cough, low urine volume, on and off chest pain and nausea.  No vomiting, diarrhea, headache, constipation   no recent travel history EMS gave breathing treatment, Solu-Medrol, en route.    Pt denies tobacco or EtOH use. She states she has been around people with a cough.   CODE STATUS-full code   In the ER  Vital signs In ED, pt's initial temperature was 40.2 C.   Blood pressure 137/71, heart rate 95, respiratory rate 18, on 4 L of nasal cannula.  She was noted to be in acute respiratory failure with increased work of breathing and has been on and off BiPAP throughout her hospital course in the ER.   Labs WBC 19.1, hemoglobin 9.5, hematocrit 29.3, platelet 150, sodium 136, potassium 4.1, chloride 102, bicarb 23, BUN/creatinine 34/1.71, glucose 126  Troponin 4, lactate 0.7  Venous blood gas pH 7.36, PCO2 44, PO2 58, oxygen saturation 88  Urinalysis-WBC 11-20, moderate to high squamous epithelial cell  Flu negative  COVID-negative   Imaging CT chest Multifocal airspace disease involving all lobes, including regions of frank consolidation involving both lower lobes, the lateral segment of the right middle lobe, and posterior left upper lobe as described above. Numerous smaller patchy foci of airspace disease as well. The appearance is nonspecific, with differential diagnosis including atypical infection and multifocal inflammatory lung disease.  Borderline/mild mediastinal and supra clavicular adenopathy.  No overt malignant findings.  CXR Right hilar prominence with multiple bilateral nodular opacities may represent multifocal pneumonia but raises the possibility of metastatic malignancy   Patient is admitted for acute respiratory failure secondary to multifocal pneumonia     Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.9 (36.9-36.9)  Temp (FAHR) 98.4 (98.4-98.4), BP 149/77 (149-149)/(77-77), HR 95 (95-95), RR 18 (18-18), O2Sat 92 (92-92)     Patient Weight    Patient Height  None Reported     General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: Lungs are clear to auscultation, Respirations are non-labored.  On 4 L of nasal cannula Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling,     Assessment/Plan     57 year old female with Hx of COPD, OSA on CPAP and GERD presents to the ED via EMS c/o increased SOB and fevers onset 4 days ago   1. Pneumonia   J18.9  Evidenced on chest imaging.  Pneumonia is multifocal and given history of recent influenza infection, pneumonia is likely to be post influenza pneumonia which is usually caused by MRSA.  We will give broad coverage antibiotics to include MRSA infection-cefepime and vancomycin  -Send pneumonia labs  -Continue oxygen supplementation to maintain SPO2 above 92%  -Other respiratory protocol to continue  -Get MRSA swab  -Pharmacy to dose vancomycin   2. Sepsis   A41.9  Meets SIRS criteria on admission with high-grade fever tachycardia, and leukocytosis.  Lactate is normal so no severe sepsis. , imaging for multifocal infiltrate.  Blood cultures pending, urinalysis appears weakly positive at this time URINE sample is dirty evidenced by squamous epithelium, procalcitonin pending, lactate repeat WNL.  Continue empiric coverage with cefepime and vancomycin de-escalate therapy as appropriate. SARS CoV 2 negative.  Continue IVF at 100cc/hr   3. Acute respiratory failure   J96.00  Secondary to pneumonia  Management as outlined in #1   4. Chronic kidney disease   N18.9  Creatinine at baseline.  Patient reports reduced urinary output, will monitor urinary output closely with IV hydration for response.  Avoid nephrotoxic medications   5. Dependence on CPAP ventilation   Z99.89  Due to OSA.  Patient needs nightly CPAP for OSA  To ensure continuation during hospitalization.   6. HTN (hypertension)   I10  Chronic  Continue home meds as blood pressure tolerates   7. Hyperlipidemia   E78.5  Chronic  Continue home meds   8. OSA on CPAP   G47.33  Nocturnal CPAP to continue   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 12/15/22 15:42:00  albuterol-ipratropium, 3 mL, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, 12/15/22 19:00:00  cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 12/15/22 20:00:00, for 14 Doses, 12/20/22 4:00:00, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  heparin, 7,500 Units, Subcutaneous, Injection, Q8, Routine, 12/15/22 22:00:00  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 12/15/22 15:42:00  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 12/15/22 15:42:00  Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 12/15/22 15:42:00, 100 mL/hr, Clinical Weight  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV, 12/15/22 16:40:00, Other - See Comments, Clinical Weight  vancomycin, 1.5 GM = 15 mL, IVPB, Injection, Q18H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 12/15/22 21:00:00  180 gm Carb per day Diet  Admit to Inpatient  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  CBC w/Differential  Comp Metabolic Panel  CPAP Intermittent  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Hgb A1C HPLC Bld QN  Incentive Spirometry  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  L pneumophila Ag Ur QL  Level of Care  Lipid Panel SerPl QN  Medical Service  MRSA PCR  Mucous Clearance Device  Nasal Cannula  OT Evaluation and Treatment  Peripheral IV Insertion  Procalcitonin  Procalcitonin  PT Evaluation and Treatment  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  RVP2 PCR  Strep pneumoniae Ag Urine  Titrate FiO2 to Keep O2 Sat  TSH w FreeT4 reflex  Vancomycin Pharmacy Dosing Consult  Vital Signs  Vital Signs  Weight  Greater than 60 minutes total with greater than 50% of time face-to-face with patient reviewing course, plan of care, and in care coordination  Code Status   Resuscitation Status - Ordered    -- 12/15/22 15:42:00, Full Code   Chronic Problem List    Addison's disease  Anxiety  Anxiety and depression  Breast cancer screening  Chronic UTI  Constipation  COPD (chronic obstructive pulmonary disease)  Depression  GERD (gastroesophageal reflux disease)  History of bariatric surgical procedure.  History of kidney stones  HTN (hypertension)  Hydronephrosis  Hyperlipidemia  Hypothyroidism  Knee pain  Leg cramps  Lesion of bladder  Medicare annual wellness visit, subsequent  Morbid obesity  Nausea  OA (osteoarthritis)  OA (osteoarthritis) of knee  OSA on CPAP  RA (rheumatoid arthritis)  Super obesity  Tachycardia  Procedure/Surgical History  ?cystoscopy with stent placement (10/20/2022) ?cystoscopy (08/2022) ?cysto, bladder biopsy, fulguration, bilat retrograde pyelogram (01/17/2022) ?Colonoscopy (10/17/2018) ?History of laparoscopic adjustable gastric banding ?Hysterectomy ?Left knee surgery ?Surgery ?Tonsillectomy and adenoidectomy   Surgical History Internal  11/11/2022    Ureteroscopy.     10/20/2022    Cystoscopy Insert Ureteral Stent or Cath  (Right)    01/17/2022    Cystoscopy Bladder Biopsy      10/17/2018    Colonscpy Diagnostic/Screen      Medications   Home Medications (29) Active  acetaminophen 650 mg oral tablet, extended release 1,300 mg = 2 Tablet, PRN, Orally  Aldactone 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  amitriptyline 25 mg oral tablet 25 mg = 1 Tablet, Orally, At Bedtime  amLODIPine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  carvedilol 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  Centrum Silver Ultra Women's 1 Tablet, Orally, QAM  Colace 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  Combivent Respimat CFC free 100 mCg-20 mCg/inh inhalation aerosol 1 Puff, Inhalation, 4 Times Daily Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  Dulera 200 mCg-5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  estradiol topical 0.1 mg/gm cream See Instructions, Apply pea sized amt to vaginal opening nightly x 2 weeks, then 2x/week thereafter.  Fasenra 30 mg, Subcutaneous, Every 8 Weeks  fluticasone 50 mCg/inh nasal spray 100 mCg = 2 Spray, intraNASAL, BID  hydrALAZINE 50 mg oral tablet 100 mg = 2 Tablet, Orally, TID  hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q6H  hydrOXYzine hydrochloride 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, Q6H  leflunomide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  levothyroxine 100 mCg (0.1 mg) oral tablet 100 mCg = 1 Tablet, Orally, QAM  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Mucinex DM 30 mg-600 mg oral tablet, extended release 1 Tablet, Orally, Q12H  Myrbetriq 50 mg oral tablet, extended release 50 mg = 1 Tablet, Orally, Daily  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  sertraline 100 mg oral tablet 150 mg = 1.5 Tablet, Orally, Daily  solifenacin 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  Spiriva Respimat 1.25 mCg/inh inhalation aerosol 2.5 mCg = 2 Puff, Inhalation, Daily  theophylline 400 mg/24 hours oral tablet, extended release 400 mg = 1 Tablet, Orally, BID  torsemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Unscheduled, as needed for shortness of breath  zafirlukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, BID  Zofran 4 mg oral tablet 4 mg = 1 Tablet, PRN, Orally, Q6H  Active Scheduled Inpatient Medications  albuterol-ipratropium (albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL), Inhalation SOLN, 3 mL, Neb Inhal, Q6H, Start: 12/15/22 19:00:00  cefePIME, Injection, 1 GM, IVPB, Q8H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), Start: 12/15/22 20:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 7,500 Units, Subcutaneous, Q8, Start: 12/15/22 22:00:00  Vancocin, Injection, 1.5 GM, IVPB, Q18H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), Start: 12/15/22 21:00:00  Lactated Ringers  1,000 mL IV  125 mL/hr     Sodium Chloride 0.9%  1,000 mL IV  100 mL/hr     Sodium Chloride 0.9%  500 mL IV  Other - See Comments       One-Time Medications Given 12/14/22 00:00:00 TO 12/15/22 17:24:12  None Reported  PRN Medications (0600 - 0559) from 12/14 - 12/15  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   Plaquenil (Difficulty Breathing)  sulfa drugs (Difficulty Breathing)  Augmentin (Hives)  Ceclor (Hives)  codeine (Itching)  Social History    Alcohol   Past, 1-2 times per month   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Unemployed   Home/Environment   Lives with Spouse. Home equipment: CPAP/BiPAP.   Other   2 children   Substance Abuse   Past, Marijuana   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. Started age 13.0 Years. Stopped age 20 Years.  Family History   COPD - Chronic obstructive pulmonary disease: Mother, Father, Sister, Brother and Brother.  Diabetes mellitus: Mother, Father, Brother and Grandmother (M).  Diabetes mellitus type 1: Brother.  Diabetes mellitus type 2: Sister and Child.  ESRD - End stage renal disease: Brother.  Heart attack: Father.  Heart disease: Mother.  Hypertension: Father.  Kidney disease: Father.  Kidney stone: Mother.  Rheumatoid arthritis: Sister and Brother.  Stroke: Father.  Transplant of kidney: Brother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 19.1 k/cumm High (12/15/22 05:27:00)  RBC: 3.3 million/cumm Low (12/15/22 05:27:00)  Hgb: 9.5 GM/dL Low (12/15/22 05:27:00)  Hct: 29.3 % Low (12/15/22 05:27:00)  MCV: 89 fL (12/15/22 05:27:00)  MCH: 28.9 pg (12/15/22 05:27:00)  MCHC: 32.6 GM/dL (12/15/22 05:27:00)  RDW: 15.6 % High (12/15/22 05:27:00)  Platelet: 150 k/cumm (12/15/22 05:27:00)  MPV: 9.9 fL (12/15/22 05:27:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (12/15/22 05:27:00)  Potassium SerPl QN: 4.1 mmol/L (12/15/22 05:27:00)  Chloride SerPl QN: 102 mmol/L (12/15/22 05:27:00)  Carbon Dioxide SerPl QN: 23 mmol/L (12/15/22 05:27:00)  Anion Gap: 11 mmol/L (12/15/22 05:27:00)  BUN SerPl QN: 34 mg/dL High (12/15/22 05:27:00)  Creatinine SerPl QN: 1.71 mg/dL High (12/15/22 05:27:00)  Estimated GFR (CKD-EPI, no race): 35 mL/min/1.73m2 Low (12/15/22 05:27:00)  Estimated CRCL (CG): 55 mL/min Low (12/15/22 05:27:00)  Glucose SerPl QN: 126 mg/dL High (12/15/22 05:27:00)  Calcium Total SerPl QN: 9.2 mg/dL (12/15/22 05:27:00)  Troponin-I High Sensitivity: 4 ng/L (12/15/22 05:27:00)  Lactate Venous Pl QN: 0.7 mmol/L (12/15/22 05:27:00)  pH Bld Venous QN: 7.36 (12/15/22 09:28:00)  PCO2 Bld Venous QN: 44 mmHg (12/15/22 09:28:00)  PO2 Bld Venous QN: 58 mmHg High (12/15/22 09:28:00)  Base Excess Bld Venous: -1 mmol/L (12/15/22 09:28:00)  Bicarb Bld Venous Calc: 25 mmol/L (12/15/22 09:28:00)  O2 Sat Bld Venous Calc: 88 % (12/15/22 09:28:00)  FIO2: Venous (12/15/22 09:28:00)  Patient Temperature: 37 DegC (12/15/22 09:28:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/14/22 09:08:00)  Rapid Influenza A PCR: Not Detected (12/14/22 09:08:00)  Rapid Influenza B PCR: Not Detected (12/14/22 09:08:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/15/2022 08:20 - CT Chest W/O IV Contrast  IMPRESSION:  Limited exam in the absence of intravenous contrast.Multifocal airspace disease involving all lobes, including regions offrank consolidation involving both lower lobes, the lateral segmentof the right middle lobe, and posterior left upper lobe as describedabove. Numerous smaller patchy foci of airspace disease as well. Theappearance is nonspecific, with differential diagnosis includingatypical infection and multifocal inflammatory lung disease.Borderline/mild mediastinal and supra clavicular adenopathy.No overt malignant findings.Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact.                Signature Line Electronically Signed on 12/15/22 17:24  ________________________________________________________