Age: 66.0
Sex: F
Vaccine: FLU4
Symptoms: Urine abnormality, Urine ketone body absent, White blood cell count increased, White blood cells urine negative, White blood cells urine positive
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 16, 2023 15:21 EST   Verified By: MD on November 16, 2023 15:21 EST   Encounter Info: Hospital, Inpatient, 11/16/23 -     * Final Report *        Chief Complaint   Shortness of breath   History of Present Illness/Subjective     Patient is a 67 year old woman w/ severe COPD who presents to the ER w/ acute hypoxic and hypercarbic respiratory failure. EMS was called to patient's house due to report of respiratory distress. Upon arrival the patient was tripoding and struggling to breathe. She then became unresponsive and turned blue. HR dropped to the 30s. She was quickly intubated in the field and her color improved and her sats were in the 90s. She was brought to the ER for further evaluation. She was briefly paced in the field as well but has since had a normal HR w/out any pacer needs. Temp was low at 35.6. BP was normal. Labs were notable for a WBC count of 12K. Lactate was 4.4 and repeat was 2.5. Trop was 18 and went up to 300. EKG showed no acute ST changes. CTA was negative for PE but did show c/f bronchitis and possible RUL infiltrate. ABG showed a PCO2 of 71 and repeat was 63 after adjustment of the vent settings. She was sedated w/ propofol as she was biting the ET tube in the ER. She was given steroids and breathing treatments and admitted to the medicine service for further management.  Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 35.6 °C (Rectal)  BP: 123/75  HR: 94 (Monitored)  RR: 12  SpO2: 90%  Oxygen Therapy: Ventilator  FiO2: 0.30   Neurologic  Glasgow Coma Score: 7     Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa, ETT in place Respiratory:  coarse mechanical breath sounds bilaterally Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: sedated     Assessment/Plan     Patient is a 67 year old woman admitted w/ acute on chronic hypoxic and hypercarbic respiratory failure.      1. Acute on chronic respiratory failure with hypoxia and hypercapnia   J96.21  -Intubated now  -Repeat VBG now  -See problem #3      2. Elevated troponin   R77.8  -Likely demand ischemia  -Serial troponin until downtrending  -TTE to assess for new wall motion abnormalities  -Telemetry      3. COPD exacerbation   J44.1  -Solumedrol   -Duonebs  -Procal  -Will treat w/ CTX and doxycycline for now given possible R sided infiltrate  -Urine legionella and strep Ag      4. Coronary artery disease   I25.10  -Continue statin and ASA      5. Diet-controlled diabetes mellitus   E11.9  -CDA power plan in place  -Carb controlled diet  -Hypoglycemia protocol  -Hold oral DM meds      6. Hyperlipidemia   E78.2  -Continue statin       7. Hypertension   I10  -Continue home antihypertensive regimen      8. Tobacco use   Z72.0  -Encourage cessation  -Nicotine patch PRN      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   Resuscitation Status - Ordered    -- 11/16/23 15:11:00 EST, Full Code   Chronic Problem List    Abnormal LFTs  Allergic rhinitis  Cervix dysplasia  COPD mixed type  Coronary artery disease  Diet-controlled diabetes mellitus  Diverticulosis  Elevated hemoglobin  Encounter for long-term current use of medication  Endometriosis of ovary  Endometriosis of pelvic peritoneum  Fatty liver  History of GI bleed  Hyperlipidemia  Hypertension  Menopausal syndrome  Newly converted positive PPD test  Nocturnal hypoxemia due to emphysema  Osteopenia  Parotid mass rt  Pelvic congestion syndrome  Screening for lung cancer  Skin lesions  Tobacco use  Type 2 diabetes mellitus  Procedure/Surgical History  ?Colonoscopy (10/11/2023) ?Diabetic retinal eye exam (07/30/2021) ?Diabetic retinal eye exam (07/03/2021) ?Eye examination (03/03/2020) ?colonoscopy (12/08/2017) ?egd (12/07/2017) ?Mammogram (07/23/2014) ?exploratory lab (02/20/2006) ?Tubal ligation (1987) ?Tonsillectomy (1962) ?Cesarean Section ?heart cath with stents ?Oophorectomy ?T & A   Surgical History Internal  10/11/2023    Colonscpy Diagnostic/Screen     MD  12/08/2017    Colonscpy Diagnostic/Screen     MD  12/07/2017    EGD Diagnostic    MD  03/01/2017    Colonscpy Bx     MD  Medications   Home Medications (17) Active  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Inhalation, Q6H  Alcohol Swabs Not Applicable, Topical, Unscheduled, 1 per month to clean injection site.  aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, QAM  atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, At Bedtime  Bevespi Aerosphere 9 mCg-4.8 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  carvedilol 3.125 mg oral tablet 1 Tablet, Orally, BID  cyanocobalamin 1000 mCg/mL injectable solution 1,000 mCg = 1 mL, Subcutaneous, Every Month  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  lisinopril 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Melatonin 6 mg, At Bedtime  Nasonex 50 mCg/inh nasal spray 2 Spray, Nostrils, Both, Daily  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  pantoprazole 40 mg oral delayed release tablet 1 Tablet, Orally, QAM  Syringes - Vitamin B12 3 mL with attached 21 gauge 1 inch needle, Injection, Every Month  Vitamin D3 50,000 intl units oral capsule See Instructions, Take 1 capsule orally x 8 weeks, then every other week. Then go to OTC Vitamin D 800 IU daily  Active Scheduled Inpatient Medications  albuterol-ipratropium (albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL), Inhalation SOLN, 3 mL, Neb Inhal, Q6H, Start: 11/16/23 16:00:00  ceftRIAXone, Injection, 1 GM, IVPB, ONCE, Indication: Pneumonia - CAP, Start: 11/16/23 15:11:00  ceftRIAXone, Injection, 1 GM, IVPB, Q24H, Indication: Pneumonia - CAP, Start: 11/17/23 16:00:00  doxycycline, Capsule, 100 mg, Orally, BID, Indication: COPD Exacerbation, Start: 11/16/23 22:00:00  doxycycline, Capsule, 100 mg, Orally, BID, Indication: COPD Exacerbation, Start: 11/16/23 22:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 11/16/23 16:00:00  methylPREDNISolone (methylPREDNISolone sodium succinate), Injection, 40 mg, IV Push, Q12H, Start: 11/16/23 16:00:00  Propofol + Solution PREMIX IV Continuous  Titrate - See Comments 40 mCg/kg/min  11/16/23  NORepinephrine PREMIX + Sodium Chloride 0.9% PREMIX IV Continuous Titrate - See Comments 6 mCg/min  11/16/23  Lactated Ringers  1,000 mL IV Continuous  100 mL/hr     Dextrose 10% in Water  500 mL IV Continuous  Per Core Diabetes App - See Comments     Propofol + Solution PREMIX IV Continuous  Titrate - See Comments       One-Time Medications Given 11/15/23 00:00:00 TO 11/16/23 15:15:21  None Reported  PRN Medications (0600 - 0559) from 11/15 - 11/16  glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Core Diabetes App , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Per Core Diabetes App , Subcutaneous, Unscheduled, 0  Dose(s)   propofol infusion bolus dose, 20 mg, Via Infusion Pump, Q15min, 0  Dose(s)   Allergies   codeine (Itching)  morphine (Itching)  Demerol. (critical)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Work/School description: The patient is retired with no exposure to dust or fumes..   Home/Environment   Lives with Family.   Nutrition/Health   Type of diet: The patient tries to limit her sodium and saturated fat intake.. Diet: Low sodium.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Alcoholism: Father.  Epilepsy...: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12 k/cumm High (11/16/23 11:09:00)  RBC: 5.74 million/cumm High (11/16/23 11:09:00)  Hgb: 16.3 GM/dL High (11/16/23 11:09:00)  Hct: 49.6 % High (11/16/23 11:09:00)  MCV: 86 fL (11/16/23 11:09:00)  MCH: 28.4 pg (11/16/23 11:09:00)  MCHC: 32.9 GM/dL (11/16/23 11:09:00)  RDW: 15 % High (11/16/23 11:09:00)  Platelet: 321 k/cumm (11/16/23 11:09:00)  MPV: 9 fL (11/16/23 11:09:00)  Neutrophils %: 46 % (11/16/23 11:09:00)  Lymphocytes %: 33 % (11/16/23 11:09:00)  Monocytes %: 6 % (11/16/23 11:09:00)  Eosinophils %: 14 % (11/16/23 11:09:00)  Basophils %: 1 % (11/16/23 11:09:00)  Absolute Neutrophil: 5.5 k/cumm (11/16/23 11:09:00)  Absolute Lymphocyte: 4 k/cumm High (11/16/23 11:09:00)  Absolute Monocyte: 0.7 k/cumm (11/16/23 11:09:00)  Absolute Eosinophil: 1.7 k/cumm High (11/16/23 11:09:00)  Absolute Basophil: 0.2 k/cumm (11/16/23 11:09:00)  Chemistry:  Sodium SerPl QN: 140 mmol/L (11/16/23 11:09:00)  Potassium SerPl QN: 5.2 mmol/L (11/16/23 11:09:00)  Chloride SerPl QN: 103 mmol/L (11/16/23 11:09:00)  Carbon Dioxide SerPl QN: 26 mmol/L (11/16/23 11:09:00)  Anion Gap: 11 mmol/L (11/16/23 11:09:00)  BUN SerPl QN: 13 mg/dL (11/16/23 11:09:00)  Creatinine SerPl QN: 1.1 mg/dL (11/16/23 11:09:00)  Estimated GFR (CKD-EPI, no race): 55 mL/min/1.73m2 Low (11/16/23 11:09:00)  Estimated CRCL (CG): 46 mL/min Low (11/16/23 11:09:00)  Glucose SerPl QN: 222 mg/dL High (11/16/23 11:09:00)  Calcium Total SerPl QN: 9.1 mg/dL (11/16/23 11:09:00)  Troponin-I High Sensitivity: 398 ng/L High (11/16/23 13:35:00)  BNP Pl QN: 41 pg/mL (11/16/23 11:09:00)  Lactate Venous Pl QN: 2.5 mmol/L High (11/16/23 13:35:00)  Blood Gas Comment: 30% vent (11/16/23 12:23:00)  pH Bld Arterial QN: 7.2 Low (11/16/23 12:23:00)  PCO2 Bld Arterial QN: 63 mmHg Critical (11/16/23 12:23:00)  PO2 Bld Arterial QN: 88 mmHg (11/16/23 12:23:00)  Base Excess Bld Arterial: -5 mmol/L Low (11/16/23 12:23:00)  Bicarb Bld Arterial Calc: 25 mmol/L (11/16/23 12:23:00)  O2 Sat Bld Arterial Calc: 94 % Low (11/16/23 12:23:00)  FIO2: 100% VENT (11/16/23 11:03:44)  Patient Temperature: 37 DegC (11/16/23 12:23:00)  Coagulation:  PT: 10.9 seconds (11/16/23 11:09:00)  INR: 0.95 (11/16/23 11:09:00)  aPTT: 34.7 seconds (11/16/23 11:09:00)  Urine Studies:  Color: Light-Yellow (11/16/23 12:29:00)  Clarity: Slightly Cloudy (11/16/23 12:29:00)  Specific Gravity: 1.012 (11/16/23 12:29:00)  pH: 7.5 (11/16/23 12:29:00)  Protein: 300 Abnormal (11/16/23 12:29:00)  Glucose: 70 Abnormal (11/16/23 12:29:00)  Ketones: NEGATIVE (11/16/23 12:29:00)  Bilirubin: NEGATIVE (11/16/23 12:29:00)  Hgb Ur: Large 3+ Abnormal (11/16/23 12:29:00)  Nitrite: NEGATIVE (11/16/23 12:29:00)  Urobilinogen: Normal (11/16/23 12:29:00)  Leukocyte Esterase Ur: NEGATIVE (11/16/23 12:29:00)  WBC: 21-50 Abnormal (11/16/23 12:29:00)  RBC: >100 Abnormal (11/16/23 12:29:00)  Bacteria: NONE (11/16/23 12:29:00)  Squamous Epithelial: Few (11/16/23 12:29:00)  Hyaline Casts: 11-20 (11/16/23 12:29:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (11/16/23 11:03:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/16/23 11:03:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/16/2023 11:20 - XR Chest PA or AP Portable  IMPRESSION:1.  The endotracheal tube terminates 5.5 cm above the carina.2.  No acute cardiopulmonary findings.    11/16/2023 12:12 - XR Chest PA or AP Portable  IMPRESSION:1.  Endotracheal tube and nasogastric tube as expected.2.  Possible right apical airspace opacity.Thank you for consulting our team of subspecialty radiologists at Radiology.      11/16/2023 12:51 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for pulmonary embolus.2.  Advanced emphysema with 6 mm noncalcified pulmonary nodule in theright middle lobe. Non-contrast chest CT at 6-12 months isrecommended. If the nodule is stable at time of repeat CT, thenfuture CT at 18-24 months (from today?s scan) recommended forhigh-risk patients.3.  Bilateral upper lobe bronchial wall thickening, which can be seenin the setting of acute or chronic bronchitis.4.  Saccular aneurysm arising from the left lateral margin of thedistal descending thoracic aorta, common new from CT abdomen andpelvis 12/8/2017.Results were communicated and receipt was documented in the Reporting System.Thank you for consulting our team of subspecialty radiologists at Radiology.           Signature Line Electronically Signed on 11/16/23 15:21 EST ________________________________________________________ MD