Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Atypical pneumonia, Base excess, Basophil count normal, Basophil percentage decreased, Benign prostatic hyperplasia
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 19, 2023 18:30   Verified By: MD on February 19, 2023 18:30   Encounter Info: Hospital, Emergency, 02/19/23 - 02/19/23    * Final Report *          History of Present Illness/Subjective     Patient is 75-year-old male with past history significant for chronic obstructive lung disease, type 2 diabetes mellitus and hypertension presented emergency room with increasing symptoms of shortness of breath and dyspnea on exertion.  Patient states that he was in the ER on the 14th with increased right lower extremity edema and erythema.  At that time he was very short of breath and was unable to lay flat on his back and therefore was unable to get an ultrasound of his leg.  His D-dimer was relatively low at that time as well.  He also had symptoms of cough and congestion but these were secondary to what he was complaining about with regards to leg erythema.Chest x-ray at that time showed multifocal interstitial airspace disease suspicious for atypical pneumonia with small bilateral pleural effusions.  He was discharged from the ER with oral antibiotic therapy.  Since that time he states the erythema in his leg have improved slowly and to some degree but his shortness of breath cough and congestion have persisted.  He still is unable to lay on his back because of shortness of breath and has had several episodes of paroxysmal nocturnal dyspnea.  His peripheral edema is partially dependent.  He has had low-grade fever at times but no chills.  No symptoms of nausea, vomiting, or diarrhea.  He presented back to the emergency room today having failed outpatient therapy.  Patient does continue to smoke and reportedly up to 4 packs/day.  He had been smoking up into the last ER visit.  Of note the x-ray of his right foot did show a very small foreign body in his right heel that was to be evaluated as an outpatient by podiatry.  O2 sat at home was found be 77% on room air he was placed on 6 L/min and given a nebulizer treatment by EMS prior to coming to the emergency room where his saturations were 95 to 97%.   In the emergency room his blood pressure was 156/127, heart rate 112, temperature 36.5, respiratory rate 30, O2 sat 97% on 6 L per nasal cannula.   Serology: White count 9100 over differential hemoglobin 13.1 hematocrit 40.3 and a platelet count of 205,000.  Sed rate was found to be 45.  INR 1.18 with a PTT of 33.4.  Sodium 139 potassium 3.6 chloride of 98 bicarb 30 BUN 8 creatinine 0.89 and a blood sugar of 277.  Magnesium 1.6 troponin I of 19 BNP 917 serum lactate 1.3.  Venous blood gas pH 7.40 PCO2 55 PO2 of 40 CRP was 2.7.  COVID PCR negative.  Chest x-ray showed increasing multifocal bilateral airspace disease with small bilateral pleural effusions.    Past medical history: Type 2 diabetes mellitus, hypertension, COPD, chronic pain syndrome, hyperlipidemia, osteoarthritis, low back pain, tobacco use  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  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.5 (36.5-36.5)  Temp (FAHR) 97.7 (97.7-97.7), BP 118/90 (118-179)/(86-127), HR 98 (98-135), RR 20 (16-38), O2Sat 99 (77-99) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    104.5 kg    02/19/23    Patient Height  Current Height:    177 cm    02/19/23             General:  Alert and oriented, moderate respiratory distress sitting upright and leaning forward to catch his breath       Eye:  Extraocular movements are intact, Vision unchanged       HEENT:  Normocephalic, Normal hearing       Neck:  Supple, Non-tender, elevated jugular venous pressure      Respiratory: Bibasilar crackles with accessory muscle use for breathing, diffuse scattered wheezing as well, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness.         Cardiovascular:  Regular rate, Normal rhythm, No murmur, No gallop, Normal peripheral perfusion, Good pulses equal in all extremities, 2+ right lower extremity edema 1+ left lower extremity edema.          Gastrointestinal:  Soft, nontender, nondistended, normal bowel sounds, no evidence of hepatosplenomegaly.       Lymphatics:  No lymphadenopathy neck       Musculoskeletal:  Normal range of motion, generalized weakness       Integumentary:  Warm, Dry, No rash.  Diffuse erythema extending from the distal foot up to just below the knee with associated warmth and edema of the right lower extremity       Feet: Diffusely edematous right greater than left, diminished pulses and sensation bilaterally.       Neurologic:  Alert, Oriented, Normal motor function       Psychiatric:  Cooperative, Appropriate mood & affect, Normal judgment.      Assessment/Plan       1. Acute respiratory failure with hypoxia     Patient has acute on chronic respiratory failure.  He has been placed on BiPAP at this time.  It appears to be combination of CHF exacerbation with COPD exacerbation and underlying pneumonia.  Unclear how much of the infiltrate is infection versus pulmonary edema.  Will start on IV diuretic therapy in conjunction with frequent nebulizer treatments, RT protocol, IV Solu-Medrol and treatment of underlying infection.  He will place in the intensive care setting and wean BiPAP accordingly.  Continue ongoing RT protocol.  We will check cardiac echo to evaluate LV systolic function continue to monitor renal function and electrolyte status closely.   2. Sepsis     Patient does meet sepsis criteria although many of the symptoms may be associated with CHF and pulmonary edema.  That being said sepsis protocol has been instituted.  Given his findings of heart failure we will not bolus or start him on IV fluids at this time.  Broad-spectrum IV antibiotic therapy has been started.  Source of combination of cellulitis of the right lower extremity and pneumonia.   3. COPD exacerbation     As above.  Ongoing RT protocol.  We stressed the need for him to stop smoking.  Frequent nebulizer treatments in conjunction with IV Solu-Medrol and treatment of underlying infection ongoing.  BiPAP therapy as needed and wean to O2 as best and quickly as possible.   4. CHF exacerbation     This appears to be new onset.  He has elevated jugular venous pressure, elevated BNP, what appears to be pulmonary edema on chest x-ray and significant peripheral edema.  We will continue cardiac echo to evaluate LV systolic function.  We will start him on ACE inhibitor and beta-blocker therapy once he is more stable hemodynamically.  IV Lasix over the next 24 to 48 hours and monitor urine output as well as peripheral edema.  Consider placing him on a Lasix drip at some point the near future.  May consider also adding an nitrate and/or nitroglycerin for symptoms persist.   5. Cellulitis of right leg     It appears he likely developed significant peripheral edema from either CHF or right-sided heart failure.  Cardiac echo pending.  Ill he placed on broad-spectrum IV antibiotic therapy.  Wound and blood cultures pending.  Continue close monitoring.   6. Multifocal pneumonia    There appears to multifocal pneumonia on chest x-ray although it may represent pulmonary edema.  Blood cultures x2 have been sent.  Urine for Legionella and strep antigens both pending.  Procalcitonin level pending as well.  Continue treatment of underlying respiratory compromise.  Broad-spectrum IV antibiotic therapy has been started.   7. Hypertension     Blood pressure was elevated in the emergency room but now improving.  We will titrate in his home medication as indicated.   8. Hyperlipidemia     Noted.  Restart home statin therapy   9. BPH (benign prostatic hyperplasia)     Clinically stable at this time.  We will start his Flomax therapy as well.   10. Tobacco use    Noted.  We will give him education regarding his need to stop smoking.  And offer him treatment options to aid with this.   GI and DVT prophylaxis have been addressed.   Home medications were reviewed and appropriate medications ordered at this time.   Total critical care time: Approximately 50 minutes?acute respiratory failure/CHF exacerbation/COPD exacerbation/sepsis/pneumonia/cellulitis  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 this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers.  This 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.  Code Status   None Recorded   Chronic Problem List    Anxiety  BPH (benign prostatic hyperplasia)  CHF exacerbation  Chronic pain syndrome  Chronic use of opiate for therapeutic purpose  Chronic, continuous use of opioids  Depression  Emphysema/COPD  Headache, migraine  Hyperlipidemia  Hypertension  Insomnia  Joint pain  Low back pain  Low vitamin D level  Pain in joint involving multiple sites  Pulmonary nodule  Right carotid bruit  Sepsis  Tobacco use  Type 2 diabetes mellitus  Vitamin D deficiency  Wrist joint pain  Procedure/Surgical History  ?Diabetic retinal eye exam (02/05/2019) ?Gallbladder (2012) ?Tonsillectomy     Medications   Home Medications (18) Active  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL See Instructions, INHALE 3ML BY MOUTH 4 TIMES DAILY  Amaryl 4 mg oral tablet 4 mg = 1 Tablet, Orally, BID  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Augmentin 875 mg-125 mg oral tablet 1 Tablet, Orally, Q12H  buDESOnide-formoterol 80 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  cloNIDine 0.1 mg oral tablet 0.1 mg = 1 Tablet, Orally, TID, to take prn if blood pressure over 160/90  doxycycline monohydrate 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID  EpiPen 2-Pak 0.3 mg injectable solution 0.3 mg, PRN, IM, ONCE  Glucophage XR 500 mg oral tablet, extended release 1,000 mg = 2 Tablet, Orally, BID, for sugar  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  mirtazapine 30 mg oral tablet See Instructions, TAKE 1 TABLET BY MOUTH EVERY NIGHT AT BEDTIME  Norvasc 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q6H  Singulair 10 mg oral tablet 10 mg = 1 Tablet, Orally, QPM, for cough / allergies  tamsulosin 0.4 mg oral capsule See Instructions, TAKE ONE CAPSULE BY MOUTH DAILY AT BEDTIME FOR PROSTATE AND BLOOD PRESSURE  Vitamin D3 1000 intl units oral capsule 1,000 IntlUnits = 1 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/18/23 00:00:00 TO 02/19/23 18:29:31  albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 10 mg, Neb Inhal, ONCE, (1 DOSE 02/19/23 06:09:00)  albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 5 mg, Neb Inhal, ONCE, (1 DOSE 02/19/23 07:42:00)  albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 5 mg, Neb Inhal, ONCE, (1 DOSE 02/19/23 17:21:00)  cefePIME, Injection, 1 GM, IV Push, ONCE, (1 DOSE 02/19/23 07:25:00)  doxycycline, Injection, 100 mg, IVPB, ONCE, (1 DOSE 02/19/23 07:29:00)  Lactated Ringers (Lactated Ringers - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 02/19/23 07:00:00)  magnesium sulfate, Infusion, 2 GM, IVPB, ONCE, (1 DOSE 02/19/23 07:29:00)  magnesium sulfate, Infusion, 2 GM, IVPB, ONCE, (1 DOSE 02/19/23 07:51:00)  Vancocin, Injection, 2 GM, IVPB, ONCE, (1 DOSE 02/19/23 08:38:00)  PRN Medications (0600 - 0559) from 02/18 - 02/19  None Reported  Allergies   Bee Stings (critical)  Cymbalta (critical)  sulfa drugs (critical)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   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   Lung cancer..: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.1 k/cumm (02/19/23 06:44:00)  RBC: 4.53 million/cumm (02/19/23 06:44:00)  Hgb: 13.1 GM/dL Low (02/19/23 06:44:00)  Hct: 40.3 % (02/19/23 06:44:00)  MCV: 89 fL (02/19/23 06:44:00)  MCH: 28.8 pg (02/19/23 06:44:00)  MCHC: 32.4 GM/dL (02/19/23 06:44:00)  RDW: 14.5 % (02/19/23 06:44:00)  Platelet: 285 k/cumm (02/19/23 06:44:00)  MPV: 9.7 fL (02/19/23 06:44:00)  Neutrophils %: 68 % (02/19/23 06:44:00)  Lymphocytes %: 13 % (02/19/23 06:44:00)  Monocytes %: 8 % (02/19/23 06:44:00)  Eosinophils %: 10 % (02/19/23 06:44:00)  Basophils %: 0 % (02/19/23 06:44:00)  Absolute Neutrophil: 6.2 k/cumm (02/19/23 06:44:00)  Absolute Lymphocyte: 1.2 k/cumm (02/19/23 06:44:00)  Absolute Monocyte: 0.7 k/cumm (02/19/23 06:44:00)  Absolute Eosinophil: 0.9 k/cumm High (02/19/23 06:44:00)  Absolute Basophil: 0.1 k/cumm (02/19/23 06:44:00)  Sed Rate: 45 mm/hr High (02/19/23 06:44:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (02/19/23 06:44:00)  Potassium SerPl QN: 3.6 mmol/L (02/19/23 06:44:00)  Chloride SerPl QN: 98 mmol/L (02/19/23 06:44:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (02/19/23 06:44:00)  Anion Gap: 11 mmol/L (02/19/23 06:44:00)  BUN SerPl QN: 8 mg/dL (02/19/23 06:44:00)  Creatinine SerPl QN: 0.89 mg/dL (02/19/23 06:44:00)  Estimated GFR (CKD-EPI, no race): 89 mL/min/1.73m2 (02/19/23 06:44:00)  Estimated CRCL (CG): 86 mL/min (02/19/23 06:44:00)  Glucose SerPl QN: 277 mg/dL High (02/19/23 06:44:00)  Calcium Total SerPl QN: 9.1 mg/dL (02/19/23 06:44:00)  Magnesium SerPl QN: 1.6 mg/dL (02/19/23 06:44:00)  Troponin-I High Sensitivity: 19 ng/L (02/19/23 08:37:00)  BNP Pl QN: 917 pg/mL High (02/19/23 06:44:00)  Lactate Venous Pl QN: 1.3 mmol/L (02/19/23 06:44:00)  pH Bld Venous QN: 7.4 (02/19/23 06:44:00)  PCO2 Bld Venous QN: 55 mmHg (02/19/23 06:44:00)  PO2 Bld Venous QN: 40 mmHg (02/19/23 06:44:00)  Base Excess Bld Venous: 8 mmol/L High (02/19/23 06:44:00)  Bicarb Bld Venous Calc: 34 mmol/L High (02/19/23 06:44:00)  O2 Sat Bld Venous Calc: 75 % (02/19/23 06:44:00)  C-Reactive Prot SerPl QN: 2.7 mg/dL High (02/19/23 06:44:00)  Coagulation:  PT: 13.5 seconds (02/19/23 06:44:00)  INR: 1.18 (02/19/23 06:44:00)  aPTT: 33.4 seconds (02/19/23 06:44:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (02/19/23 06:48:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/19/23 06:48:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/19/2023 08:48 - XR Chest PA or AP Portable  IMPRESSION:1.  Increasing multifocal bilateral airspace disease.2.  Small bilateral pleural effusions.Thank you for consulting our team of subspecialty radiologists at Physicians Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 02/19/23 18:30  ________________________________________________________ MD