Age: 88.0
Sex: F
Vaccine: COVID19
Symptoms: Pneumonia, Procalcitonin, Protein total normal, Rales, Red blood cell count decreased
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on June 06, 2023 20:58 EDT   Verified By: MD on June 09, 2023 00:57 EDT   Encounter Info: Hospital, Observation, 06/06/23 -     * Final Report *        Basic Information  Time Seen:  MD / 06/06/2023 20:46  Chief Complaint  SOA  History of Present Illness     Patient Seen: 06/06/23 20:57:06  89 year old female presents to the ED via private vehicle complaining of hypotension. Pt lives at an assisted living facility and called her family friend earlier this evening regarding her shortness of breath, weakness, and low BP for the past several days. Her friend, who accompanies her in ED, states pt's O2 reading at the facility was 88. Endorses ankle swelling and cough x3 days. Denies fever, chills, or chest pain. She uses a walker to ambulate and reports increased difficulty over the past few days since onset of symptoms.  Review of Systems     Refer to HPI for pertinent positives and negatives noted on review of systems.   Physical Exam/Objective  Vitals & Measurements most recent  T: 37 °C (Oral)  BP: 93/58  HR: 104 (Monitored)  RR: 20  SpO2: 99%  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 2 (L/min)  WT: 49.67 kg (Ideal Body Weight Calculated)  WT: 68.2 kg  WT: 49.665 kg (Ideal Body Weight Calculated)  HT: 157 cm      General:  alert, no acute distress Skin: warm, dry , pink, no pallor, no rash Head:  normocephalic Eye: PERRLA, EOMI, normal conjunctiva ENT: oral mucosa moist , no pharyngeal erythema or exudate Neck:  supple Cardiovascular:  tachycardic rate and regular rhythm , no murmur, no edema Respiratory:  expiratory wheezes, bibasilar crackles Chest Wall: no deformity, no tenderness Back: normal ROM Gastrointestinal:  soft, non tender , non distended , normal BS,,  no organomegaly Extremities:  no tenderness , normal ROM, normal strength, no swelling Neurological:  no focal neuro deficits , A&O x4, CN II - XII intact, normal sensory, normal motor, normal speech Psych: cooperative , appropriate mood and affect  Medical Decision Making     DDx includes but is not limited to: pneumonia, sepsis, CHF exacerbation, hypovolemia, COPD exacerbation, other SOB, PE, other generalized weakness  Documentation Review: PCP note (2/20/23), Nursing Notes   I have ordered the following tests: basic labs, D dimer, lactate, urine, troponin, EKG, CXR  Symptomatic Management provided: IVF_ Pain Control_Antibiotics _Other: Breathing Tx   LabsReviewed ImagingReviewed EKGReviewed  EKG Interpretation: Date: 6/6/23 Time: 20:15 Rhythm: atrial-sensed ventricular-paced rhythm Rate: 106 bpm PR interval: 162 ms QRS duration: 118 ms QT/QTc: 398/528 ms P-R-T axes: 48  92  23 Comments: no significant changes compared to prior tracing on 12/6/22    Additional Orders: None   Results Discussion: CBC is mostly WNL, Creatinine is 1.5, which is improved from prior. CXR shows bilateral opacifications at bases, per my review.   Consults: Hospitalist   Social Determinants of Health: Polypharmacy; lives at ECF  06/07/23 00:20:10 Chose not to give patient IV fluids, given her history of heart failure. Her BP and HR have improved without medicine or fluids. Suspect polypharmacy has been contributing to her low BP. She has been asking for her home Norco and Xanax pills, but I have not given them, as she is hypotensive.   06/07/23 00:30:36 Pt's CXR shows new bilateral lower infiltrates. Her troponin and repeat troponin were both elevated at 15 and 17, respectively. Her D-dimer was elevated but CTA chest can not be obtained at this time as her creatine clearance is low. Will seek admission for the patient.   Disposition: Admit to Dr. here at hospital               Condition     Stable  Assessment/Plan       Chronic heart failure with preserved ejection fraction (HFpEF)   I50.32    Chronic, continuous use of opioids   F11.90    COPD with emphysema   J43.9    Hypotension   I95.9    Pneumonia   J18.9    Orders:   Blood CX  Blood CX     Follow Up  No qualifying data available   Chronic Problem List    Anxiety and depression  Aortic stenosis  Chronic heart failure with preserved ejection fraction (HFpEF)  Chronic kidney disease stage 3 (disorder)  Chronic kidney disease stage 4 (disorder)  Chronic pain syndrome  Chronic, continuous use of opioids  COPD with emphysema  Elevated troponin  Encounter for long-term current use of medication  Fatigue  History of colon polyps  HTN (hypertension)  Hyperlipidemia  Hypertension  Hypothyroidism  Hypoxia  Iron deficiency anemia  Long term use of drug  Low back pain  Lupus  Medication management  Nonrheumatic aortic valve stenosis with insufficiency  Obstructive hypertrophic cardiomyopathy  Pacemaker  Peripheral edema  Pulmonary emphysema (disorder)  S/P TAVR (transcatheter aortic valve replacement)  Systemic lupus erythematosus (disorder)  Tachycardia  Thoracic back pain  UTI (urinary tract infection)  Procedure/Surgical History  ?cardiac cath (04/15/2019) ?bunionectomy (11/13/2018) ?Colonoscopy (03/11/2016) ?Mammogram - screening (05/14/2012) ?bunionectomy (1960) ?Appendectomy ?LEEP ?Tonsillectomy ?Vocal cord nodule  Surgical History Internal  11/07/2019    Transcatheter Aortic Valve Replacement    MD  11/13/2018    Hammertoe Repair  (Left)   DPM  03/11/2016    Colonscpy Diagnostic/Screen    MD  Medications  Home Medications (15) Active atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily ferrous sulfate 325 mg (65 mg elemental iron) oral delayed release tablet 325 mg = 1 Tablet, Orally, Daily hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, TID hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, TID levothyroxine 88 mCg (0.088 mg) oral tablet 88 mCg = 1 Tablet, Orally, Daily metoPROLOL tartrate 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID MiraLax oral powder for reconstitution 17 GM, Orally, Daily, dissolve in water before taking Mirapex 0.5 mg oral tablet 0.5 mg = 1 Tablet, Orally, At Bedtime multivitamin with minerals oral tablet 1 Tablet, Orally, Daily olanzapine 5 mg oral tablet 5 mg = 1 Tablet, Orally, TID Plaquenil 200 mg oral tablet 200 mg = 1 Tablet, Orally, Daily potassium chloride 99 mg oral tablet 99 mg = 1 Tablet, Orally, Daily predniSONE 10 mg oral tablet See Instructions, 4 tab x 3 days, then 3 tab x 3 days, then 2 tab x 3 days, then 1 tab x 3 days Xanax 0.5 mg oral tablet 0.5 mg = 1 Tablet, PRN, Orally, TID  Medication Administration   Given  albuterol 2.5 mg/0.5mL (0.5%) inhalation solution, 5 mg, Neb Inhal  ipratropium 0.5 mg/2.5 mL (0.02%) inhalation solution, 0.5 mg, Neb Inhal  Allergies   sulfa drugs (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use 26-50 inhales/day.   Employment/School   Retired   Home/Environment   Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Heart attack..: Father.  Stroke: Mother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  06/08/23 03:41  9.5  02/09/23  11.3  High          RBC  06/08/23 03:41  4.05  02/09/23  4.39          Hgb  06/08/23 03:41  11.8  Low  02/09/23  12.6          Hct  06/08/23 03:41  35.0  02/09/23  39.0          MCV  06/08/23 03:41  87  02/09/23  89          MCH  06/08/23 03:41  29.3  02/09/23  28.7          MCHC  06/08/23 03:41  33.8  02/09/23  32.4          RDW  06/08/23 03:41  14.6  High  02/09/23  14.9  High          Platelet  06/08/23 03:41  200  02/09/23  262          MPV  06/08/23 03:41  10.2  02/09/23  9.1          Neutrophils %  06/08/23 03:41  76  02/09/23  74          Lymphocytes %  06/08/23 03:41  16  02/09/23  14          Monocytes %  06/08/23 03:41  8  02/09/23  10          Eosinophils %  06/08/23 03:41  0  02/09/23  2          Basophils %  06/08/23 03:41  0  02/09/23  1          Absolute Neutrophil  06/08/23 03:41  7.2  02/09/23  8.4  High          Absolute Lymphocyte  06/08/23 03:41  1.6  02/09/23  1.6          Absolute Monocyte  06/08/23 03:41  0.7  02/09/23  1.1          Absolute Eosinophil  06/08/23 03:41  0.0  02/09/23  0.2          Absolute Basophil  06/08/23 03:41  0.0  02/09/23  0.1           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  06/08/23 03:41  137  02/09/23  142          Potassium SerPl QN  06/08/23 03:41  4.5  02/09/23  3.4  Low          Chloride SerPl QN  06/08/23 03:41  100  02/09/23  97  Low          Carbon Dioxide SerPl QN  06/08/23 03:41  28  02/09/23  35  High          Anion Gap  06/08/23 03:41  9  02/09/23  10          BUN SerPl QN  06/08/23 03:41  30  High  02/09/23  43  High          Creatinine SerPl QN  06/08/23 03:41  1.50  High  02/09/23  1.87  High          Estimated GFR (CKD-EPI, no race)  06/08/23 03:41  33  Low  02/09/23  25  Low          Estimated CRCL (CG)  06/08/23 03:41  23  Low  12/06/22  13  Low          Glucose SerPl QN  06/08/23 03:41  104  High  02/09/23  83          Calcium Total SerPl QN  06/08/23 03:41  8.3  Low  02/09/23  9.6          Alkaline Phos SerPl QN  06/07/23 12:16  67  12/06/22  72          ALT SerPl QN  06/07/23 12:16  6  Low  12/06/22  35          AST SerPl QN  06/07/23 12:16  13  12/06/22  91  High          Bilirubin Total SerPl QN  06/07/23 12:16  0.7  12/06/22  0.8          Total Protein SerPl QN  06/07/23 12:16  6.6  12/06/22  7.8          Albumin SerPl QN  06/07/23 12:16  3.6  12/06/22  4.4           Serology Tests  LATEST RESULTS  HISTORICAL RESULTS          Procalcitonin  06/08/23 03:41  0.11  10/03/22  0.06          Molecular Diagnostic Tests  LATEST RESULTS        MRSA PCR  06/07/23 12:16  Negative        Staph aureus PCR  06/07/23 12:16  Negative      Diagnostic Results  XR Chest PA or AP Portable    06/06/23 23:36:12  IMPRESSION:  1. Shallow inspiration with new mild bibasilar atelectasis and/or  pneumonia.  2. Otherwise stable chronic changes, as described.    Thank you for consulting our team of subspecialty radiologists at Radiology.     Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 06/07/23 01:59 EDT ________________________________________________________    Electronically Signed on 06/09/23 00:57 EDT ________________________________________________________ MD