Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen abnormal, Cough, Creatinine renal clearance decreased, Dehydration, Dyspnoea
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 09, 2023 07:31   Verified By: MD on February 09, 2023 07:31   Encounter Info: Hospital, Observation, 02/08/23 - 02/09/23    * Final Report *        Chief Complaint   Nausea  History of Present Illness/Subjective     Patient is a 76 year old woman who presents w/ NV, fever and cough. The patient states that she tested positive for COVID-19 yesterday. She awoke this AM w/ fever, cough, NV, abd pain, myalgias. Upon arrival to the ER she was febrile. BP was 174/108. She was satting normally on RA. HR was 80. WBC count was normal. COVID-19 testing was positive. CxR was clear. CT abd/pelvis showed multiple ventral hernias that were not incarcerated. Na was 134. K was 3.3. Trop was 21. Patient was given fluids and zofran 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  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.9 (36.8-37.2)  Temp (FAHR) 98.4 (98.2-99.0), BP 174/108 (116-174)/(61-108), HR 80 (60-82), RR 18 (15-28), O2Sat 95 (93-95) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    105.8 kg    02/09/23  Previous Daily Weight:    106.0 kg    02/09/23  Difference from Previous:    -0.200000 kg  BMI:    45.6    02/09/23    Morbid Obesity (BMI > = 40) Patient Height  Current Height:    152.4 cm    02/09/23        Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Increased WOB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  Assessment/Plan     Patient is a 76 year old woman admitted w/ COVID-19 PNA.    1. Pneumonia due to COVID-19 virus   U07.1  -Dexamethasone (1/10)  -Does not meet criteria for remdesivir  -Procalcitonin now    2. Vomiting   R11.10  -Likely due to COVID-19  -LR at 75 cc/hr  -PRN antiemetics    3. Hypokalemia   E87.6 -Electrolyte repletion protocol     4. Hyponatremia   E87.1  -Mild and due to dehydration  -Fluids as above    5. CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min   D63.1 -Serum creatinine is at baseline  -Renally dose medications  -Avoid nephrotoxic agents  -Monitor with daily CMP    6. Chronic atrial fibrillation   I48.20  -Continue Xarelto and coreg  7. Chronic diastolic heart failure   I50.32  -Continue home CHF regimen  8. Essential hypertension   I10  -Continue home antihypertensive regimen    9. Hyperlipidemia   E78.5 -Continue statin     10. Hypothyroidism   E03.9  -Continue home levothyroxine    11. Non-insulin dependent type 2 diabetes mellitus   E11.9 -Sliding scale   -Carb controlled diet  -Hypoglycemia protocol  -Hold oral DM meds  12. Obesity, Class III, BMI 40-49.9 (morbid obesity)   E66.01  -Encourage weight loss  13. Pacemaker   Z95.0  -Noted  -Telemetry       Code Status   Resuscitation Status - Ordered    -- 02/09/23 2:45:00, DNR/Comprehensive Care   Chronic Problem List    Abdominal hernia  Anxiety  Chronic atrial fibrillation  Chronic back pain  Chronic diastolic heart failure  CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min  Essential hypertension  Gout  History of COPD  Hyperlipidemia  Hypothyroidism  Long term use of drug  Non-insulin dependent type 2 diabetes mellitus  Noncompliance with treatment  Obesity, Class III, BMI 40-49.9 (morbid obesity)  Pacemaker  Procedure/Surgical History  ?Esophagogastroduodenoscopy (04/17/2019) ?Diabetic retinal eye exam (04/04/2019) ?Colonoscopy (02/22/2019) ?Esophagogastroduodenoscopy (02/22/2019) ?Skin Cancer Removed Arm (2017) ?Cardiac Cath (2013) ?Colonoscopy (2011) ?Cystoscopy (2010) ?Lap Band Surgery (2005) ?Pacemaker Placement (2005) ?Breast Biopsy (1997) ?Breast Reduction (1986) ?Tonsillectomy (1953) ?Appendectomy (1946) ?Cholecystectomy ?Pacemaker Insertion ?Skin Caner Removed Arm   Surgical History Internal  09/09/2020    Soft Tissue I and D  (Left)   MD  10/08/2019    Hernia Repair Umbilical Laparoscopic    MD  04/17/2019    EGD Snare Tmr Polyp Lsn    MD  02/22/2019    Colonscpy Bx    MD  Medications   Home Medications (30) Active  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Blood Glucose Meter Not Applicable, Other, Unscheduled  carvedilol 25 mg oral tablet See Instructions, TAKE 1 TABLET BY MOUTH TWICE DAILY  Claritin 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  diclofenac 1% topical gel 4 GM, Topical, 4 Times Daily  DME Wheelchair Not Applicable, Other, Unscheduled  eplerenone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  FeroSul 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, BID  Flonase 50 mCg/inh nasal spray 1 Spray, Nostrils, Both, BID  isosorbide mononitrate 30 mg oral tablet, extended release 30 mg = 1 Tablet, Orally, QAM  ketoconazole 2% topical cream 1 App, Topical, BID, to affected area  Lancets Check daily, Other, Unscheduled, Dispense QS 90 days  levothyroxine 100 mCg (0.1 mg) oral tablet 100 mCg = 1 Tablet, Orally, Daily  Medrol Dosepak 4 mg oral tablet 1 packet(s), Orally, ONCE, as directed on package labeling  metFORMIN 500 mg oral tablet 500 mg = 1 Tablet, Orally, Daily  Misc Supplement , Probiotic daily. Patient is unsure of brand but states she stores it in the refrigerator  Nexium 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, Sublingually, Q5min  oxymetazoline 0.05% nasal spray 2 Spray, intraNASAL, BID  rOPINIRole 0.25 mg oral tablet 0.25 mg = 1 Tablet, Orally, At Bedtime  Strips - Glucose Test Check daily, Other, Unscheduled, QS 90 day supply  Syringes - Vitamin B12 Not Applicable, Other, Unscheduled  Tessalon Perles 100 mg oral capsule 100 mg = 1 Capsule, Orally, TID  torsemide 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  traZODONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, At Bedtime  Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily  Vitamin D3 25 mCg (1,000 intl units) oral tablet, chewable 1,000 Units = 1 Tablet, Orally, Daily  Xarelto 15 mg oral tablet 15 mg = 1 Tablet, Orally, Daily  Zithromax 250 mg oral tablet 1 packet(s), Orally, ONCE, as directed on package labeling  Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, Orally, Q6H, to treat and to prevent nausea and vomiting  Active Scheduled Inpatient Medications  albuterol (albuterol HFA MDI 90mCg/puff inhalation aerosol), Aerosol, 2 Puff, Inhalation, BID, Start: 02/09/23 07:00:00  dexamethasone, Tablet, 6 mg, Orally, Q24H, Start: 02/09/23 03:00:00  fluticasone-vilanterol (Breo Ellipta 100 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 02/09/23 07:00:00  rivaroxaban, Tablet, 15 mg, Orally, QPM, Start: 02/09/23 18:00:00  Lactated Ringers  1,000 mL IV  75 mL/hr     Dextrose 10% in Water  500 mL IV  PRN - See Comments       One-Time Medications Given 02/08/23 00:00:00 TO 02/09/23 07:29:13  acetaminophen, Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 02/08/23 06:12:00)  benzonatate (Tessalon Perles), Capsule, 100 mg, Orally, ONCE, (1 DOSE 02/08/23 06:52:00)  fentaNYL, Injection, 25 mCg, IV Push, ONCE, (1 DOSE 02/08/23 09:16:00)  hyoscyamine (Levsin), Injection, 0.5 mg, IV Push, ONCE, (1 DOSE 02/08/23 06:52:00)  ketoROLAC, Injection, 15 mg, IV Push, ONCE, (1 DOSE 02/08/23 06:52:00)  ketoROLAC, Injection, 15 mg, IV Push, ONCE, (1 DOSE 02/08/23 13:46:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 02/08/23 05:59:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, prn, Nausea/Vomiting IV - Use First, (1 DOSE 02/08/23 09:16:00)  ondansetron (Zofran), Injection, 4 mg, IV Push, ONCE, (1 DOSE 02/08/23 13:46:00)  pantoprazole, Injection, 40 mg, IV Push, ONCE, (1 DOSE 02/08/23 06:52:00)  rOPINIRole (Requip), Tablet, 0.25 mg, Orally, ONCE, (1 DOSE 02/08/23 09:16:00)  rOPINIRole (Requip), Tablet, 0.25 mg, Orally, ONCE, (1 DOSE 02/09/23 03:47:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 02/08/23 06:52:00)  traZODONE, Tablet, 50 mg, Orally, ONCE, (1 DOSE 02/09/23 03:47:00)  PRN Medications (0600 - 0559) from 02/08 - 02/09  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2 Puff, Inhalation, Q4H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   promethazine, 12.5 mg, IVPB, Q6H, 0  Dose(s)   Allergies   Augmentin (Vomiting, Nausea, Swelling Pharyngeal, Hives)  Aldactone (Rash, Hives)  AmLODIPine Besylate-Benazepril Hydrochloride (heavy muscles)  Mevacor (heavy muscles)  Multaq (Unknown)  Unlisted Diet Allergy (Rash)  sulfa drugs (Hives)  Biaxin (Nausea)  Singulair (Unknown)  baclofen (Vomiting)  doxycycline (Hallucinations)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Arthritis: Mother.  Cancer: Mother, Father, Son and Grandmother.  Cancer of colon: Grandmother.  Coronary artery disease: Mother and Son.Negative: Father.  Diabetes mellitus type 2: Daughter and Son.  Heart attack: Mother and Son.  Heart valve disease: Son.  Hypertension: Father and Son.  Kidney disease: Negative: Father.  Obesity: Daughter.  Peripheral vascular disease: Mother.  Stroke: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6 k/cumm (02/08/23 21:46:00)  RBC: 3.75 million/cumm (02/08/23 21:46:00)  Hgb: 12 GM/dL (02/08/23 21:46:00)  Hct: 36.1 % (02/08/23 21:46:00)  MCV: 96 fL (02/08/23 21:46:00)  MCH: 32 pg (02/08/23 21:46:00)  MCHC: 33.2 GM/dL (02/08/23 21:46:00)  RDW: 14.4 % (02/08/23 21:46:00)  Platelet: 131 k/cumm Low (02/08/23 21:46:00)  MPV: 9.9 fL (02/08/23 21:46:00)  Neutrophils %: 80 % (02/08/23 21:46:00)  Lymphocytes %: 9 % (02/08/23 21:46:00)  Monocytes %: 10 % (02/08/23 21:46:00)  Eosinophils %: 0 % (02/08/23 21:46:00)  Basophils %: 1 % (02/08/23 21:46:00)  Absolute Neutrophil: 4.8 k/cumm (02/08/23 21:46:00)  Absolute Lymphocyte: 0.6 k/cumm Low (02/08/23 21:46:00)  Absolute Monocyte: 0.6 k/cumm (02/08/23 21:46:00)  Absolute Eosinophil: 0 k/cumm (02/08/23 21:46:00)  Absolute Basophil: 0 k/cumm (02/08/23 21:46:00)  Chemistry:  Sodium SerPl QN: 130 mmol/L Low (02/08/23 21:46:00)  Potassium SerPl QN: 3.6 mmol/L (02/08/23 21:46:00)  Chloride SerPl QN: 95 mmol/L Low (02/08/23 21:46:00)  Carbon Dioxide SerPl QN: 21 mmol/L Low (02/08/23 21:46:00)  Anion Gap: 14 mmol/L High (02/08/23 21:46:00)  BUN SerPl QN: 16 mg/dL (02/08/23 21:46:00)  Creatinine SerPl QN: 1.25 mg/dL High (02/08/23 21:46:00)  Estimated GFR (CKD-EPI, no race): 45 mL/min/1.73m2 Low (02/08/23 21:46:00)  Estimated CRCL (CG): 42 mL/min Low (02/08/23 21:46:00)  Glucose SerPl QN: 175 mg/dL High (02/08/23 21:46:00)  Calcium Total SerPl QN: 8.8 mg/dL (02/08/23 21:46:00)  Alkaline Phos SerPl QN: 61 Units/L (02/08/23 21:46:00)  ALT SerPl QN: 8 Units/L (02/08/23 21:46:00)  AST SerPl QN: 19 Units/L (02/08/23 21:46:00)  Bilirubin Total SerPl QN: 1.5 mg/dL High (02/08/23 21:46:00)  Total Protein SerPl QN: 6.8 GM/dL (02/08/23 21:46:00)  Albumin SerPl QN: 4.2 GM/dL (02/08/23 21:46:00)  Troponin-I High Sensitivity: 21 ng/L High (02/08/23 21:46:00)  Lactate Venous Pl QN: 1.7 mmol/L (02/08/23 21:46:00)  Coagulation:  PT: 24 seconds High (02/08/23 21:46:00)  INR: 2.04 High (02/08/23 21:46:00)  Urine Studies:  Color: Yellow (02/08/23 11:32:00)  Clarity: Clear (02/08/23 11:32:00)  Specific Gravity: <=1.005 (02/08/23 11:32:00)  pH: 5.5 (02/08/23 11:32:00)  Protein: TRACE. Abnormal (02/08/23 11:32:00)  Glucose: NEGATIVE (02/08/23 11:32:00)  Ketones: NEGATIVE (02/08/23 11:32:00)  Bilirubin: NEGATIVE (02/08/23 11:32:00)  Hgb Ur: SMALL. Abnormal (02/08/23 11:32:00)  Nitrite: NEGATIVE (02/08/23 11:32:00)  Urobilinogen: NormalUro (02/08/23 11:32:00)  Leukocyte Esterase Ur: NEGATIVE (02/08/23 11:32:00)  WBC: 0-5 (02/08/23 11:32:00)  RBC: 0-2 (02/08/23 11:32:00)  Bacteria: Few Abnormal (02/08/23 11:32:00)  Squamous Epithelial: Moderate (02/08/23 11:32:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/08/23 06:49:00)  Rapid Influenza A PCR: Not Detected (02/08/23 06:49:00)  Rapid Influenza B PCR: Not Detected (02/08/23 06:49:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/08/2023 08:45 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Multiple ventral abdominal wall hernias. Several of the herniascontain small bowel. No current obstruction. Considering mildincrease in free fluid within the hernia, episodic or previousinflammation could be considered. Additional etiologies a smallquantity free peritoneal fluid may be secondary to liver inflammationor correlation with liver enzymes may be considered.2.  Skin thickening of the lower ventral abdomen. Correlate forcellulitis.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    02/08/2023 22:02 - XR Chest PA or AP Portable  IMPRESSION:1.  Stable chest. No new focal airspace diseaseThank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.             Signature Line Electronically Signed on 02/09/23 07:31 ________________________________________________________ MD