Age: 81.0
Sex: F
Vaccine: FLU3
Symptoms: Glucose urine absent, Haematocrit normal, Haemoglobin normal, Haemoglobin urine absent, Hypovolaemia
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on March 20, 2025 16:26 EDT   Verified By: MD on March 20, 2025 17:54 EDT   Encounter Info: Hospital, Inpatient, 03/20/25 -     * Final Report *          History of Present Illness/Subjective     81 year old female with past medical history of asthma, HTN, HLD, CKD, presents to the ED for malaise, dyspnea/hypoxia that started few days prior to presentation.  According to the patient, she was in her usual state of health until about few days when she noticed shortness of breath and tiredness.  Shortness of breath is associated with cough productive of white sputum, congestion and sore throat.  She also endorsed nausea but denies vomiting.  No diarrhea or constipation. no fever or chills.   She denied any sick contacts or recent travel.   In the ER  Vital signs  Blood pressure 98/58, heart rate 90, respiratory rate 20, SpO2 94% on 4 L   Labs  WBC 9.4, hemoglobin 15.3, platelets 196, sodium 138, potassium 4.2, bicarb 102, BUN/creatinine 27/1.48, glucose 165, lactic venous 3.0  Urinalysis unremarkable  COVID-negative  Flu AB-positive   Imaging  Chest x-ray  1.  Coarse lower lung markings may indicate bronchitis, reactive  airways disease or early congestive changes.  2.  No consolidating infiltrates or other acute findings.   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, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: diffuse rales 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: bilat leg swelling, ???????L UE swelling    Assessment/Plan      1. Shortness of breath   R06.02    2. Hypoxia   R09.02    3. Acute bronchitis   J20.9    4. Influenza A   J10.1  81-year-old man with a history of hyperlipidemia, prediabetes, stage III CKD presents to the ER due to generalized weakness with labs showing positive flu A and patient is requiring 4 L of oxygen through nasal cannula.  Baseline is room air.  Diffuse Rales noticed on auscultation   Will start renal dose Tamiflu  Continue oxygen supplementation and wean as able  RT eval to follow  Prednisone  DuoNebs as needed  Airborne isolation   5. AKI (acute kidney injury)   N17.9  Likely prerenal from hypovolemia  Will minimize use of potentially nephrotoxic agents to the extent possible, and will monitor urine output and labs.  Low threshold to involve nephrology if renal function worsens.  Gentle hydration  Hold Lasix and lisinopril   6. Anxiety and depression   F41.9  Chronic.   7. History of Roux-en-Y gastric bypass   Z98.84  Noted   8. Hypertension   I10  Blood pressure currently soft.  Hold blood pressure medications   9. History of breast cancer   Z85.3  Noted.  Significant left arm swelling noted.  Patient endorsed it is chronic as a result of left mastectomy  Outpatient follow-up with oncologist   10. Prediabetes   R73.03  Obtain A1c   11. Stage 3 chronic kidney disease   N18.30  12.Severe sepsis  Inpatient Sepsis Bundle Care:  Sepsis Bundle was Started in the Emergency Department   Sepsis with End Organ dysfunction   _  Source _ Associated End Organ Dysfunction _  Associated Underlying Device  _ Drug Resistance Unknown at this time   Patient has chronic organ dysfunction as evidenced by _   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   _     Greater than 5???????5 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    Acid reflux  Anxiety and depression  Arthritis of right knee  Asthma  Edema  Encounter for follow-up  High cholesterol  History of breast cancer  History of Roux-en-Y gastric bypass  History of total left knee replacement  Hypertension  Left shoulder pain  Meningioma  Morbid obesity  Osteoarthritis of left shoulder  Prediabetes  Right shoulder pain  Stage 3 chronic kidney disease  Umbilical hernia  Ventral incisional hernia  Procedure/Surgical History  ?Total knee replacement (10/23/2023) ?back surgery x2 ?Bilateral cataracts ?bilateral foot surgery ?Bunionectomy ?Cataract ?Cholecystectomy ?Gallbladder ?Gastric bypass ?H/O: hysterectomy ?Heel ?History of left mastectomy ?Knee ?Left reverse total shoulder arthroplasty 02/15/24 ?Mastectomy ?nose surgery ?Thyroid surgery   Surgical History Internal  10/23/2023    Knee Arthroplasty  (Left) , MD  Medications   Home Medications (13) Active  allopurinol 300 mg oral tablet 300 mg = 1 Tablet, Orally, QAM  amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, QAM  DME (Vendor) Walker See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, QAM  lisinopril 10 mg oral tablet   lovastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, QAM  magnesium oxide See Instructions, Orally  montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, QAM  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, QAM  OXYcodone 5 mg oral tablet 5 mg = 1 Tablet, PRN, Orally, Q4H  PARoxetine 20 mg oral tablet 20 mg = 1 Tablet, Daily  Tylenol 1,000 mg, PRN, Orally, Q6H  Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 03/19/25 00:00:00 TO 03/20/25 16:25:47  None Reported  PRN Medications (0600 - 0559) from 03/19 - 03/20  None Reported  Allergies   Cats (Difficulty Breathing)  mixed grass pollens allergen extract (Unknown)  Social History    Alcohol   Current, 1-2 times per year   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Siblings.   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   Cancer: Mother, Sister and Brother.   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.4 k/cumm (03/20/25 13:39:00)  RBC: 5.02 million/cumm (03/20/25 13:39:00)  Hgb: 15.3 GM/dL High (03/20/25 13:39:00)  Hct: 46.4 % (03/20/25 13:39:00)  MCV: 93 fL (03/20/25 13:39:00)  MCH: 30.6 pg (03/20/25 13:39:00)  MCHC: 33.1 GM/dL (03/20/25 13:39:00)  RDW: 16.6 % High (03/20/25 13:39:00)  Platelet: 196 k/cumm (03/20/25 13:39:00)  MPV: 8.8 fL (03/20/25 13:39:00)  Neutrophils %: 80 % (03/20/25 13:39:00)  Lymphocytes %: 13 % (03/20/25 13:39:00)  Monocytes %: 6 % (03/20/25 13:39:00)  Eosinophils %: 0 % (03/20/25 13:39:00)  Basophils %: 0 % (03/20/25 13:39:00)  Absolute Neutrophil: 7.5 k/cumm (03/20/25 13:39:00)  Absolute Lymphocyte: 1.2 k/cumm (03/20/25 13:39:00)  Absolute Monocyte: 0.6 k/cumm (03/20/25 13:39:00)  Absolute Eosinophil: 0 k/cumm (03/20/25 13:39:00)  Absolute Basophil: 0 k/cumm (03/20/25 13:39:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (03/20/25 13:39:00)  Potassium SerPl QN: 4.2 mmol/L (03/20/25 13:39:00)  Chloride SerPl QN: 102 mmol/L (03/20/25 13:39:00)  Carbon Dioxide SerPl QN: 26 mmol/L (03/20/25 13:39:00)  Anion Gap: 10 mmol/L (03/20/25 13:39:00)  BUN SerPl QN: 27 mg/dL High (03/20/25 13:39:00)  Creatinine SerPl QN: 1.48 mg/dL High (03/20/25 13:39:00)  Estimated GFR (CKD-EPI, no race): 35 mL/min/1.73m2 Low (03/20/25 13:39:00)  Estimated CRCL (CG): 34 mL/min Low (03/20/25 13:39:00)  Glucose SerPl QN: 165 mg/dL High (03/20/25 13:39:00)  Calcium Total SerPl QN: 9.1 mg/dL (03/20/25 13:39:00)  Alkaline Phos SerPl QN: 85 Units/L (03/20/25 13:39:00)  ALT SerPl QN: 10 Units/L (03/20/25 13:39:00)  AST SerPl QN: 15 Units/L (03/20/25 13:39:00)  Bilirubin Total SerPl QN: 0.7 mg/dL (03/20/25 13:39:00)  Total Protein SerPl QN: 7.6 GM/dL (03/20/25 13:39:00)  Albumin SerPl QN: 4.2 GM/dL (03/20/25 13:39:00)  Troponin-I High Sensitivity: 6 ng/L (03/20/25 15:08:00)  BNP Pl QN: 46 pg/mL (03/20/25 13:39:00)  Lactate Venous Pl QN: 3 mmol/L High (03/20/25 13:39:00)  Urine Studies:  Color: Yellow (03/20/25 14:50:00)  Clarity: Clear (03/20/25 14:50:00)  Specific Gravity: 1.015 (03/20/25 14:50:00)  pH: 5.5 (03/20/25 14:50:00)  Protein: 30 Abnormal (03/20/25 14:50:00)  Glucose: Normal (03/20/25 14:50:00)  Ketones: NEGATIVE (03/20/25 14:50:00)  Bilirubin: NEGATIVE (03/20/25 14:50:00)  Hgb Ur: NEGATIVE (03/20/25 14:50:00)  Nitrite: NEGATIVE (03/20/25 14:50:00)  Urobilinogen: Normal (03/20/25 14:50:00)  Leukocyte Esterase Ur: NEGATIVE (03/20/25 14:50:00)  WBC: 0-5 (03/20/25 14:50:00)  RBC: 0-2 (03/20/25 14:50:00)  Bacteria: NONE (03/20/25 14:50:00)  Squamous Epithelial: Few (03/20/25 14:50:00)  Hyaline Casts: 0-2 (03/20/25 14:50:00)  Misc UA Micro: Misc UA Micro (03/20/25 14:50:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (03/20/25 13:41:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (03/20/25 13:41:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (03/20/25 13:41:00)  Rapid Influenza A PCR: Detected Abnormal (03/20/25 13:41:00)  Rapid Influenza B PCR: Not Detected (03/20/25 13:41:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 03/20/2025 14:02 - XR Chest PA or AP Portable  IMPRESSION:1.  Coarse lower lung markings may indicate bronchitis, reactiveairways disease or early congestive changes.2.  No consolidating infiltrates or other acute findings.                Signature Line Electronically Signed on 03/20/25 17:54 EDT ________________________________________________________ MD