Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: SARS-CoV-2 test, SARS-CoV-2 test negative, Tachypnoea, Tobacco user, Troponin
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By:  MD on May 22, 2023 23:45   Verified By: MD on May 23, 2023 02:55   Encounter Info: Hospital, Emergency, 05/22/23 - 05/23/23    * Final Report *        Basic Information  Time Seen:  05/22/2023 23:42  Chief Complaint  Shortness of breath (Complaint of)  History of Present Illness     67-year-old male, history significant for CHF, COPD, hyperlipidemia, hypertension, presenting for shortness of breath.  Notes he has been feeling short of breath since his last hospital visit.  Continues to smoke heavily.  Notes he does not have home oxygen or BiPAP at night.  Denies any chest pain, abdominal pain, recent fevers, vomiting or diarrhea.  Notes for a chronic cough that has not changed in nature.  Upon EMS arrival patient was noted to be 70% on room air and placed on CPAP.  Given DuoNebs as well as Solu-Medrol.  Review of Systems     Negative except as noted above  Physical Exam/Objective  Vitals & Measurements most recent  T: 36.1 °C (Axillary)  BP: 171/83  HR: 94 (Peripheral)  HR: 97 (Monitored)  RR: 24  SpO2: 97%  Oxygen Therapy: BIPAP  Oxygen Flow Rate: 6 (L/min)  FiO2: 0.28  WT: 66.12 kg (Ideal Body Weight Calculated)  WT: 63.1 kg  WT: 66.118 kg (Ideal Body Weight Calculated)  HT: 170.2 cm      Constitutional: no diaphoresis, no distress CV: Normal rate, Regular rhythm, Intact distal pulses Pulm: Moderate respiratory distress, diffuse wheezing bilaterally, diminished bilateral breath sounds GI: Soft, no distention, no tenderness MSK: ROM normal, no edema or tenderness Neuro: AOx3, no focal deficits, no abnormal coordination, no abnormal tone Skin: Warm, Dry, no erythema, no rash Psych: Behavior normal  Medical Decision Making     Six 7-year-old male, history of CHF, COPD, hypertension, hyperlipidemia, presenting for shortness of breath.  Vitals reviewed and patient is found to be tachypneic.  Exam shows diffuse bilateral wheezing with diminished breath sounds, moderate respiratory distress and accessory muscle use.    Chart reviewed.  Differentials considered include COPD exacerbation, hypercapnia, bronchitis, pneumonia, ACS, CHF, COVID  Transition to BiPAP here.  Started on nebulized treatments.  Lab work nonactionable.  EKG nonischemic.  Troponin 24, BNP 362 -both appear at baseline from prior values.  VBG showing PCO2 of 46.  COVID-negative.  Otherwise nonactionable labs.  Chest x-ray negative for acute pathology. Hospitalist, Dr. consulted for admission and they accepted pt to their service. Explained findings, interventions as well as plan for admission to pt_, who is understanding and agreeable. Pt remained hemodynamically stable the entire ED course and is suitable for transfer to floor at this time.             Condition     Stable  Assessment/Plan       1. Respiratory failure with hypoxia   J96.91    2. COPD exacerbation   J44.1    Orders:   **Coronavirus SARS-CoV2 Rapid  Basic Metabolic Panel  Bed Request (Decision to Admit)  BIPAP Intermittent  Blood Gas Venous QN  BNP Pl QN  CBC  COVID 19 PCR  Electrocardiogram  Troponin-I High Sensitivity  XR Chest PA or AP Portable     Follow Up  No qualifying data available   Chronic Problem List    Abnormal chest x-ray  Abnormal finding on GI tract imaging  Anxiety  B12 deficiency  Blue toe syndrome of right lower extremity  Carotid bruit  CHF (congestive heart failure)  Chronic back pain  COPD (chronic obstructive pulmonary disease)  ED (erectile dysfunction)  Encounter for long-term (current) use of medications  Fatigue  Foot pain, right  History of DVT (deep vein thrombosis)  History of fall  Hyperlipidemia  Hypertension  Hypokalemia  PVD (peripheral vascular disease) with claudication  Status post transmetatarsal amputation of right foot  Tobacco abuse  Tobacco use  Vertigo  Procedure/Surgical History  ?Drug eluding stent (03/22/2018) ?PSA - Prostate-specific antigen level (09/29/2014) ?rt 5th diigit ?Stent placement  Surgical History Internal  07/09/2017    Toe Amputation  (Poss)   DPM  07/30/2016    Toe Amputation  (Right)    DPM  07/29/2016    AARO  (Left)   MD  Medications  Home Medications (15) Active albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H, J44.1, R06.02 amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily Anoro Ellipta 62.5 mCg-25 mCg inhalation powder 2 Puff, Inhalation, Daily aspirin 81 mg oral delayed release tablet 81 mg = 1 Tablet, Orally, Daily atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID DME Nebulizer Machine Not Applicable, Other, ONCE, Lifetime UseJ44.1, R06.02 ipratropium 0.5 mg/2.5 mL (0.02%) inhalation solution 0.5 mg = 2.5 mL, Neb Inhal, Q6 losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily nitroglycerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min Percocet 10 mg-325 mg oral tablet 1 Tablet, Orally, 4 Times Daily Plavix 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily prednisone 10 mg oral tablet See Instructions, 6 tab x 3 days, then 5 tab x 3 days, then 4 tab x 3 days, then 3 tab x 3 days, then 2 tab x 3 days, then 1 tablet x 3 days ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q6H Voltaren-XR 100 mg oral tablet, extended release 100 mg = 1 Tablet, Orally, Daily  Medication Administration   Given  albuterol 2.5 mg/0.5mL (0.5%) inhalation solution, 7.5 mg, Neb Inhal  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL, 3 mL, Neb Inhal  Allergies   penicillins (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Divorced, 3 children   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days. 3 packs per day.  Family History   COPD: Brother.  Cancer: Mother.  Emphysema: Mother.  Liver disease: Brother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  05/22/23 23:55  12.0  High  03/09/23  16.7  High          RBC  05/22/23 23:55  5.33  03/09/23  5.62  High          Hgb  05/22/23 23:55  15.9  03/09/23  16.3          Hct  05/22/23 23:55  46.7  03/09/23  49.5          MCV  05/22/23 23:55  88  03/09/23  88          MCH  05/22/23 23:55  29.8  03/09/23  29.0          MCHC  05/22/23 23:55  34.0  03/09/23  32.9          RDW  05/22/23 23:55  15.1  High  03/09/23  13.5          Platelet  05/22/23 23:55  240  03/09/23  291          MPV  05/22/23 23:55  7.7  03/09/23  8.1           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  05/22/23 23:55  137  03/09/23  135          Potassium SerPl QN  05/22/23 23:55  4.0  03/09/23  4.3          Chloride SerPl QN  05/22/23 23:55  104  03/09/23  100          Carbon Dioxide SerPl QN  05/22/23 23:55  26  03/09/23  36  High          Anion Gap  05/22/23 23:55  7  03/09/23  -1  Low          BUN SerPl QN  05/22/23 23:55  11  03/09/23  18          Creatinine SerPl QN  05/22/23 23:55  0.90  03/09/23  0.80          Estimated GFR (CKD-EPI, no race)  05/22/23 23:55  >90  03/09/23  >90          Estimated CRCL (CG)  05/22/23 23:55  71  03/09/23  78          Glucose SerPl QN  05/22/23 23:55  139  High  03/09/23  135  High          Calcium Total SerPl QN  05/22/23 23:55  8.7  03/09/23  9.2          Troponin-I High Sensitivity  05/22/23 23:55  24  High  03/09/23  22  High          BNP Pl QN  05/22/23 23:55  362  High  03/09/23  357  High           Blood Gases FS  LATEST RESULTS  HISTORICAL RESULTS          pH Bld Venous QN  05/22/23 23:55  7.38  03/09/23  7.39          PCO2 Bld Venous QN  05/22/23 23:55  46  03/09/23  44          PO2 Bld Venous QN  05/22/23 23:55  79  High  03/09/23  77  High          Base Excess Bld Venous  05/22/23 23:55  2  03/09/23  1          Bicarb Bld Venous Calc  05/22/23 23:55  27  03/09/23  27          O2 Sat Bld Venous Calc  05/22/23 23:55  95  03/09/23  95          Patient Temperature  05/22/23 23:55  37.0  03/09/23  37.0           Molecular Diagnostic Tests  LATEST RESULTS  HISTORICAL RESULTS          COVID 19 Specimen Source  05/22/23 23:55  Nasal  03/07/23  Nasopharyngeal          Coronavirus SARS-CoV2 Rapid  05/22/23 23:55  Not Detected  03/07/23  Not Detected      Diagnostic Results  XR Chest PA or AP Portable    05/23/23 01:01:39  IMPRESSION:  1. No obvious infiltrate or effusion.  2. Bilateral upper lobe centrilobular emphysematous changes  confirmed on prior CT.   Template Version: IUHPR_STR   Thank you for consulting our team of subspecialty radiologists    Please contact us   with any questions.   Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 05/23/23 02:55  MD