Age: 68.0
Sex: M
Vaccine: FLU4
Symptoms: Cardiac failure acute, Cardiac failure congestive, Chest X-ray abnormal, Chronic obstructive pulmonary disease, Colonoscopy
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 18, 2023 15:00  Verified By:  MD on November 18, 2023 17:58   Encounter Info: Hospital, Inpatient, 11/18/23 -     * Final Report *          History of Present Illness/Subjective     Chief complaint low oxygen  HPI: Patient is a 68-year-old female patient well-known to me from my clinic history of severe COPD dependent on oxygen, anxiety, hypothyroidism, depression, hypertension, hyperlipidemia presented to emergency department via private vehicle complaining of shortness of breath that started about 2 weeks ago and progressively got worse.  She states that she has sore throat cough and weakness.  She states that her shortness of breath worsened significantly yesterday that prompted her to come to the emergency room today because he was getting even more worse.  She is taking 1 and half liter of oxygen at home denies history of congestive heart failure.  She is currently not taking any steroids.  Upon presentation to the emergency room patient presented with a blood pressure of 204/111 oxygen saturation 88% temperature 36.3 BP remained elevated throughout the course of ER visit patient was initially given clonidine which was not effective and started on Cardene drip.  Other laboratory data that was pertinent showed no white count normal kidney function normal liver enzymes BNP elevated 282 she does not have history of congestive heart failure recent echo few months ago showed normal EF.  X-ray of the chest revealed pulmonary edema.  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    Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported      General: Alert and oriented Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic Neck: Supple, normal range of motion Oropharynx: mild oropharynx erythema, post nasal drip Respiratory: Lungs are clear to auscultation. decreased air entry bilaterally Cardiovascular: Normal rate, Regular rhythm. Gastrointestinal: Soft, Non-tender. Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect    Assessment/Plan       1. COPD exacerbation   J44.1  Patient is having COPD exacerbation.  -Start COPD power plan.  -Admit to ICU for close care.  Patient is high risk for intubation.  BIPAP as needed.   2. Hypertensive emergency   I16.1   Evident from presenting blood pressure systolic blood pressure of 204.  -Endorgan damage causing pulmonary edema due to congestive heart failure secondary to hypertensive emergency.  -Start patient on Cardene drip with a goal of SBP 160 for next 24 hours.  -Monitor in ICU setting check cardiac enzymes.  -No need for echo since it was done just a few months ago.   3. Acute congestive heart failure   I50.9   See problem #2   4. Pulmonary edema   J81.1   Patient will be given Lasix 40 mg IV twice daily until resolution of pulmonary edema.   5. Acute on chronic respiratory failure   J96.20   Noted.  Continue with supplemental oxygen with oxygen saturation goal of 90 to 92%.   6. Hyperlipidemia   E78.5   Resume home medications   7. Myalgia & Myositis   M79.10   Resume home meds   8. Hypothyroidism   E03.9   Noted.  Latest TSH July of this year was normal.  -Continue with home medications.   9. Depression   F32.9   Continue with home meds.   Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent 40 minutes of critical care time directly and personally managing the patient. This critical care time included obtaining a history, examining the patient, pulse oximetry, ordering and reviewing the studies, arranging urgent treatment with development of a management plan, evaluation of the patient?s response to treatment, frequent reassessment, and discussions with other clinicians. The critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see the MDM section and the rest of this note for further information on patient assessment and treatment.  Code Status   None Recorded   Chronic Problem List    Anterior epistaxis  Anxiety  B12 deficiency  Benign positional vertigo  Chronic pain syndrome  Depression  Emphysema/COPD  Fibromyalgia  Hyperlipidemia  Hypertriglyceridemia  Hypothyroidism  Lip ulcer  Myalgia & Myositis  Nasal septal deviation  Nasal septal ulcer  Olecranon bursitis, left elbow  Olecranon bursitis, left elbow  Osteoarthritis  Osteopenia  Peripheral neuropathy  Polyp of labia and vulva  Preop examination  Sebaceous cyst  Tobacco use  Vaginal prolapse  Vitamin D deficiency  Procedure/Surgical History  ?Colonoscopy (10/18/2023) ?Ventral hernia repair (03/11/2020) ?Colonoscopy (01/14/2020) ?Endoscopy (01/14/2020) ?Mammogram (03/18/2014) ?Left shoulder replacement (2010) ?Appendectomy ?Arthroscopy ?BACK SURGERY ?Gallbladder ?Hip replacement ?Hysterectomy ?Tonsillectomy   Surgical History Internal  10/18/2023    Colonscpy Diagnostic/Screen     MD  03/11/2020    Hernia Repair Abdominal Laparoscopic     MD  01/14/2020    Colonscpy Diagnostic/Screen    MD  Medications   Home Medications (26) Active  albuterol 2.5 mg/3 mL (0.083%) inhalation solution See Instructions, PRN, 3 mL (1 vial)  Neb Inhal every 4-6 hours  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, 4 Times Daily, TAKE 25 UNITS (INHALATION) 4 TIMES PER DAY  Antivert 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, TID  atorvastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime  cetirizine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Cymbalta 60 mg oral delayed release capsule 120 mg = 2 Capsule, Orally, Daily, do not crush or chew  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  fluticasone 50 mCg/inh nasal spray 1 Spray, intraNASAL, BID  folic acid 1 mg oral tablet 1 mg = 1 Tablet, Orally, Daily  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Melatonin 5 mg oral capsule 5 mg = 1 Capsule, Orally, At Bedtime, Reported  Neurontin 800 mg oral tablet 800 mg = 1 Tablet, Orally, 4 Times Daily  olanzapine 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  pantoprazole 40 mg oral delayed release tablet 1 Tablet, Orally, Daily  Phenergan 25 mg oral tablet 25 mg = 1 Tablet, Orally, TID  primidone 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID  propranolol 60 mg oral tablet 60 mg = 1 Tablet, Orally, TID  Senna-Time 8.6 mg oral tablet 4 tablets, Orally, At Bedtime  sertraline 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Spiriva Respimat 2.5 mCg/inh inhalation aerosol  (60 actuations) 2 Puff, Inhalation, Daily  sucralfate 1 g oral tablet 1 GM = 1 Tablet, Orally, Before Meals and HS  Synthroid 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Daily  Trelegy Ellipta 100 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Daily  Voltaren Topical 1% topical gel 2 GM, Topical, BID  Xanax 0.5 mg oral tablet 0.5 mg = 1 Tablet, Orally, BID  Zanaflex 4 mg oral tablet 8 mg = 2 Tablet, Orally, TID  Active Scheduled Inpatient Medications  niCARdipine + Sodium Chloride 0.9% IV Continuous Titrate - See Comments 5 mg/hr      One-Time Medications Given 11/17/23 00:00:00 TO 11/18/23 15:00:46  None Reported  PRN Medications (0600 - 0559) from 11/17 - 11/18  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Former use, quit more than 90 days ago.   Home/Environment   married, 2 children   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   Cancer of colon: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.1 k/cumm (11/18/23 11:17:00)  RBC: 4.02 million/cumm (11/18/23 11:17:00)  Hgb: 10.7 GM/dL Low (11/18/23 11:17:00)  Hct: 33.3 % Low (11/18/23 11:17:00)  MCV: 83 fL (11/18/23 11:17:00)  MCH: 26.7 pg Low (11/18/23 11:17:00)  MCHC: 32.2 GM/dL (11/18/23 11:17:00)  RDW: 19.2 % High (11/18/23 11:17:00)  Platelet: 221 k/cumm (11/18/23 11:17:00)  MPV: 8.8 fL (11/18/23 11:17:00)  Neutrophils %: 79 % (11/18/23 11:17:00)  Lymphocytes %: 14 % (11/18/23 11:17:00)  Monocytes %: 7 % (11/18/23 11:17:00)  Eosinophils %: 1 % (11/18/23 11:17:00)  Basophils %: 0 % (11/18/23 11:17:00)  Absolute Neutrophil: 5.6 k/cumm (11/18/23 11:17:00)  Absolute Lymphocyte: 1 k/cumm (11/18/23 11:17:00)  Absolute Monocyte: 0.5 k/cumm (11/18/23 11:17:00)  Absolute Eosinophil: 0 k/cumm (11/18/23 11:17:00)  Absolute Basophil: 0 k/cumm (11/18/23 11:17:00)  Chemistry:  Sodium SerPl QN: 142 mmol/L (11/18/23 11:17:00)  Potassium SerPl QN: 3.5 mmol/L (11/18/23 11:17:00)  Chloride SerPl QN: 108 mmol/L (11/18/23 11:17:00)  Carbon Dioxide SerPl QN: 31 mmol/L High (11/18/23 11:17:00)  Anion Gap: 3 mmol/L (11/18/23 11:17:00)  BUN SerPl QN: 6 mg/dL (11/18/23 11:17:00)  Creatinine SerPl QN: 0.59 mg/dL Low (11/18/23 11:17:00)  Estimated GFR (CKD-EPI, no race): >90 (11/18/23 11:17:00)  Estimated CRCL (CG): 91 mL/min (11/18/23 11:17:00)  Glucose SerPl QN: 99 mg/dL (11/18/23 11:17:00)  Calcium Total SerPl QN: 8.9 mg/dL (11/18/23 11:17:00)  Alkaline Phos SerPl QN: 88 Units/L (11/18/23 11:17:00)  ALT SerPl QN: 9 Units/L (11/18/23 11:17:00)  AST SerPl QN: 13 Units/L (11/18/23 11:17:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (11/18/23 11:17:00)  Total Protein SerPl QN: 6.9 GM/dL (11/18/23 11:17:00)  Albumin SerPl QN: 4.1 GM/dL (11/18/23 11:17:00)  Troponin-I High Sensitivity: 8 ng/L (11/18/23 11:17:00)  BNP Pl QN: 282 pg/mL High (11/18/23 11:17:00)  Micro - Last 7 days  Rapid Strep A Method: EIA (11/18/23 13:48:00)  RapStrepA: Negative (11/18/23 13:48:00)  Rapid Influenza Method: FIA (11/18/23 13:48:00)  Rapid Influenza A: Negative (11/18/23 13:48:00)  Rapid Influenza B: Negative (11/18/23 13:48:00)  Coronavirus SARS Ag FIA: Not Detected (11/18/23 13:48:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/18/2023 11:28 - XR Chest PA or AP  IMPRESSION:1.  Chronic emphysema. Increased interstitial pulmonary markingsmainly seen in the bilateral lower lungs suggestive of pulmonaryedema. Stable cardiothoracic silhouette. No pneumothorax or largeeffusion.Thank you for consulting our team of subspecialty radiologists at  Physicians Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 11/18/23 17:58 ________________________________________________________ MD