Age: 75.0
Sex: F
Vaccine: FLU3
Symptoms: Acute respiratory failure, Anaemia of chronic disease, Anion gap, Atelectasis, Atrial fibrillation
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on January 07, 2025 14:07 EST   Verified By: MD on January 07, 2025 14:26 EST   Encounter Info: Hospital, Emergency, 01/07/25 - 01/07/25    * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     75-year-old female with a history of A-fib on Eliquis, COPD, non-small cell lung cancer status postchemotherapy, anemia presents emerged department via EMS with complaint of chest pain and shortness of breath x 3 days  Patient was seen and evaluated while still in the ER. She states for the past 3 days she has been having intermittent chest pain and nonproductive cough.  Associated with fever and shortness of breath.   She notes that she has been taking her breathing treatments more frequently than usual.  Chest pain is mid chest in location and does not radiate.  She denies any palpitations, headache, blurry vision, excessive sweating, abdominal pain, or dysuria.  No leg swelling or pain  She has a history of non-small cell lung cancer and follows up with Dr. at the cancer center. Reports that she has recently finished her chemotherapy treatments for her lung cancer but is getting ready start immunotherapy.   No recent travel or sick contacts.  She is up-to-date with her pneumonia vaccines   In the ER  Vitals blood pressure 142/82, heart rate 107, respiratory rate 19, SpO2 94% on 4 L of nasal cannula   Labs  WBC 11.5, hemoglobin 8.8, platelet 4 1, D-dimer 422, sodium 135, potassium 3.9, chloride 96, bicarb 31, BUN/creatinine 16/0.85, glucose 166, BNP 292, lactic venous 1.3  COVID-negative  Flu AB-   Radiology  1.Central venous access port.  2.  Cardiomegaly with mild pulmonary vascular congestion.  3.  Increasing atelectasis and consolidation in the right middle and  lower lung fields.  4.  Small right pleural effusion.  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 Vitals & Measurements most recent past 24 hours  T: 37.2 °C (Route Not Specified)  BP: 142/82  HR: 107 (Monitored)  RR: 19  SpO2: 94%  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 4 (L/min)  WT: 70.30 kg (WFC)  BMI: 25    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    70.3 kg    01/07/25  BMI:    25    01/07/25    Overweight (BMI 25-29.9) Patient Height  Current Height:    167.6 cm    01/07/25         General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: Reduced air entry to auscultation, Respirations are non-labored. 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      1. Sepsis   A41.9   Inpatient Sepsis Bundle Care:  Sepsis Bundle was Started in the Emergency Department   Sepsis with End Organ dysfunction   NO, Criteria NOT met for Sepsis with End Organ Dysfunction (previously severe sepsis).  Patient met critiera for sepsis only (known or suspected infection +2 SIRS), NO acute organ dysfunction at this time.  Source Pneumonia Associated End Organ Dysfunction None  Associated Underlying Device  Other Central Line Drug Resistance Unknown at this time   Patient has chronic organ dysfunction as evidenced by None   Initial Lactate Done    IF Initial Lactate >2, Repeat Lactate Auto ordered if applicable  IF 2nd lactate greater than initial, continue to trend Lactate Levels, Auto Ordered if applicable   Antibiotics Started in the Emergency Department, YES   Blood Cultures Collected prior to Antibiotic start, YES   Target Volume=30mg/kg Crystalloid Fluids    30mg/kg Crystalloid Fluids were given in the Emergency Department YES.  IF NO, reason  _  ,  Instead _       Septic Shock is present on admission NO   Vasopressor(S) were initiated in the Emergency Department,N/A   Sepsis Reassessment/Review of Systems completed at   N/A    Follow-up blood culture and other sepsis workup ???????   2. Acute hypoxic on chronic hypercapnic respiratory failure   J96.01   From ongoing pneumonia. she requires 3 L nasal cannula however EMS reports she was satting in the mid 80s on her baseline O2 and is currently requiring 6 L to maintain sats above 90  We will treat pneumonia and wean oxygen back to baseline as needed.  RT evaluation   3. PNA (pneumonia)   J18.9   Seen on chest x-ray.  Will start broad-spectrum antibiotics and send pneumonia labs.  Given patient's immunocompromise status, will cover for MRSA  Follow-up pneumonia labs   4. Anemia due to multiple mechanisms   D64.89  Likely anemia of chronic disease.  Trend daily.  No signs of ongoing losses.   5. Atrial fibrillation with rapid ventricular response   I48.0  Likely exaggerated by ongoing sepsis and pneumonia.  Will monitor closely.  Telemetry monitoring  Will resume her home beta blocker and anticoagulation   6. Chronic obstruct airways disease   J44.9  Not in acute exacerbation.  Resume home inhaler.   7. NSCLC of right lung   C34.2  Reports that she has recently finished her chemotherapy treatments for her lung cancer but is getting ready start immunotherapy.   Will hold off on any cancer directed treatments until sepsis is resolved  -Outpatient follow-up with oncology   8. Port-A-Cath in place   Z95.828  Noted.    9. Elevated brain natriuretic peptide (BNP) level   R79.89  Noted.  Chest x-ray demonstrates mild pulmonary vascular congestion.  We will careful with fluid resuscitation.  If respiratory failure does not improve in the next few days, will consider Lasix   10. Elevated d-dimer   R79.89  Noted.  Likely from pneumonia.  Patient is on apixaban at home.  Will resume here.  If respiratory failure is not improving, will obtain CT PE to rule out PE   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   None Recorded   Chronic Problem List    Anemia due to multiple mechanisms  Atrial fibrillation with rapid ventricular response  Chronic obstruct airways disease  Former smoker  Low bone mass  NSCLC of right lung  Osteoporosis  Port-A-Cath in place  Port-A-Cath in place  Sepsis  Procedure/Surgical History  ?port placement (10/21/2024) ?Biopsy (07/02/2024) ?Tubal ligation   Surgical History Internal  10/21/2024    Portacath Insertion    MD  Medications   Home Medications (18) Active  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhale, Q6H  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, 4 Times Daily  amiodarone 200 mg oral tablet 200 mg = 1 Tablet, Orally, BID, BID for 30 days, then 1 daily  Calcium Plus Vitamin D3 600 mg-10 mCg (400 intl units) oral tablet 1 Tablet, Orally, BID  diltiaZEM 360 mg/24 hours oral tablet, extended release 360 mg = 1 Tablet, Orally, Daily  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  Eliquis 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  famotidine 20 mg oral tablet 20 mg = 1 Tablet, Orally, BID  ferrous sulfate 160 mg (50 mg elemental iron) oral tablet, extended release 160 mg = 1 Tablet, Orally, Daily  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  lidocaine-prilocaine 2.5%-2.5% topical cream See Instructions, Dab 1 App Topical 60 minutes prior to port access; cover with plastic wrap  metoPROLOL succinate 100 mg oral tablet, extended release 100 mg = 1 Tablet, Orally, Daily  ondansetron 8 mg oral tablet, disintegrating See Instructions, PRN, May use tablets if patient preference/less expensive first dose scheduled on night of chemotherapy.  8mg PO/sl q12h PRN chemo days 1,2,and 3 and as needed thereafter for nausea  Potassium Chloride (Eqv-K-Tab) 10 mEq oral tablet, extended release See Instructions, 2 in AM, 1 in evening.  prochlorperazine 10 mg oral tablet See Instructions, PRN, 0.5-1 Tablet Orally Q6H prn nausea  Trelegy Ellipta 200 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H  Vitamin B12 5000 mCg oral tablet, disintegrating 5,000 mCg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  ampicillin-sulbactam, Injection, 3 GM, IVPB, ONCE, Indication: Pneumonia - CAP, Start: 01/07/25 16:00:00  Sodium Chloride 0.9% 500 mL IV Continuous 42 mL/hr Days 1, 15       One-Time Medications Given 01/06/25 00:00:00 TO 01/07/25 14:07:08  albuterol (albuterol 2.5 mg/0.5 mL (0.5%) inhalation solution), Inhalation SOLN, 5 mg, Neb Inhale, ONCE, (1 DOSE 01/07/25 10:54:00)  ampicillin-sulbactam, Injection, 3 GM, IVPB, ONCE, (1 DOSE 01/07/25 12:20:00)  doxycycline, Injection, 100 mg, IVPB, ONCE, (1 DOSE 01/07/25 12:56:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 01/07/25 13:02:00)  PRN Medications (0600 - 0559) from 01/06 - 01/07  None Reported  Allergies   Contrast Dye (anaphylactic)  Social History    Alcohol   Current, 1-2 times per month   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Unemployed, Previous employment/school: Worked at a Dr Office.   Home/Environment   Lives with Alone.   Nutrition/Health   Diet: Regular.   Sexual   Sexually active: No. Sexually active at age 16 Years. Number of current partners 0. Number of lifetime partners 3. Sexual orientation: Heterosexual. Uses condoms: No. History of sexual abuse: No.   Sexual Orientation and Gender Identity   Which of the following do you identify most closely with? (check all that apply) Heterosexual (or straight). What is your current gender identity? (check all that apply) Female.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Arrhythmia..: Mother.  COPD: Mother and Father.  Cancer: Father and Aunt/Uncle.  Congestive heart failure..: Mother.  Heart failure..: Mother.  High blood pressure..: Mother.  Pulmonary edema..: Mother.   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 11.5 k/cumm High (01/07/25 10:49:00)  RBC: 2.53 million/cumm Low (01/07/25 10:49:00)  Hgb: 8.8 GM/dL Low (01/07/25 10:49:00)  Hct: 25.6 % Low (01/07/25 10:49:00)  MCV: 101 fL High (01/07/25 10:49:00)  MCH: 34.8 pg High (01/07/25 10:49:00)  MCHC: 34.4 GM/dL (01/07/25 10:49:00)  RDW: 16.4 % High (01/07/25 10:49:00)  Platelet: 401 k/cumm (01/07/25 10:49:00)  MPV: 7.2 fL (01/07/25 10:49:00)  Neutrophils %: 81 % (01/07/25 10:49:00)  Lymphocytes %: 8 % (01/07/25 10:49:00)  Monocytes %: 9 % (01/07/25 10:49:00)  Eosinophils %: 1 % (01/07/25 10:49:00)  Basophils %: 0 % (01/07/25 10:49:00)  Absolute Neutrophil: 9.3 k/cumm High (01/07/25 10:49:00)  Absolute Lymphocyte: 1 k/cumm (01/07/25 10:49:00)  Absolute Monocyte: 1.1 k/cumm (01/07/25 10:49:00)  Absolute Eosinophil: 0.1 k/cumm (01/07/25 10:49:00)  Absolute Basophil: 0 k/cumm (01/07/25 10:49:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (01/07/25 10:49:00)  Potassium SerPl QN: 3.9 mmol/L (01/07/25 10:49:00)  Chloride SerPl QN: 96 mmol/L Low (01/07/25 10:49:00)  Carbon Dioxide SerPl QN: 31 mmol/L High (01/07/25 10:49:00)  Anion Gap: 8 mmol/L (01/07/25 10:49:00)  BUN SerPl QN: 16 mg/dL (01/07/25 10:49:00)  Creatinine SerPl QN: 0.85 mg/dL (01/07/25 10:49:00)  Estimated GFR (CKD-EPI, no race): 71 mL/min/1.73m2 (01/07/25 10:49:00)  Estimated CRCL (CG): 57 mL/min Low (01/07/25 10:49:00)  Glucose SerPl QN: 166 mg/dL High (01/07/25 10:49:00)  Calcium Total SerPl QN: 9.2 mg/dL (01/07/25 10:49:00)  Troponin-I High Sensitivity: 10 ng/L (01/07/25 11:58:00)  BNP Pl QN: 292 pg/mL High (01/07/25 10:49:00)  Lactate Venous Pl QN: 1.3 mmol/L (01/07/25 11:56:00)  Coagulation:  D-Dimer Pl QN: 422 ng/mL DDU High (01/07/25 10:49:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (01/07/25 10:49:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (01/07/25 10:49:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (01/07/25 10:49:00)  Rapid Influenza A PCR: Not Detected (01/07/25 10:49:00)  Rapid Influenza B PCR: Not Detected (01/07/25 10:49:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 01/07/2025 11:27 - XR Chest PA or AP Portable  IMPRESSION:1.  Central venous access port.2.  Cardiomegaly with mild pulmonary vascular congestion.3.  Increasing atelectasis and consolidation in the right middle andlower lung fields.4.  Small right pleural effusion.                Signature Line Electronically Signed on 01/07/25 14:26 EST ________________________________________________________ MD  Electronically Signed on 01/07/25 14:38 EST ________________________________________________________ MD