Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Occult blood negative, Orthopnoea, PCO2 normal, PO2 normal, Prothrombin time prolonged
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: Atrial Fibrillation   Performed By: MD on July 20, 2021 20:02   Verified By: MD on July 21, 2021 07:28   Encounter Info: Hospital, Observation, 07/20/21 - 07/23/21    * Final Report *        Basic Information  Time Seen: MD / 07/20/2021 20:00     Chief Complaint  UC - Atrial Fibrillation (Complaint of)  History of Present Illness     HxPI: obtained from patient, nurse, son, daughter, EMS & old record.  Went into afib on Weds; today is Tues.  This despite being on amiodarone.  Seen in Dr's office today, and sent home on additional 50 mg metoprolol for rate control.  Called EMS because dyspneic.  No home O2.  No pain, nor radiations thereof.  RA sats drop to 86% here.   PMHx: Medical records were reviewed, revealing L4 to S1 Right Lumbar Spondylosis, with L5 radiculopathy and foraminal stenosis, CHF in January, echo in 2018 and EF 55% with mild LV dilatation, electrical cardioversion for Atrial Fibrillation in 2018, Carotid Doppler in 2019 50-70% Right internal carotid stenosis but less than 50% left internal carotid stenosis, RLE DVT, GERD, anemia with Hb 10.4 but Hb in clinic today was 7.3, obesity, Lumbar DDD, HTN, Asthma.  Patient injured her right hip in a fall last Autumn. She was seen at an urgent care and followed by Dr. She was found only to have contusion, not fracture.  Soc Hx: lives at home, not driving  Review of Systems     See HxPI above for cardiovascular & respiratory.  No complaints to the ophthalmologic, ENT, integumentary, neurologic, GI, GU, immunologic, nor psychiatric systems.   Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       37.1 DegC  Heart Rate:       92 bpm  Resp Rate:       24 br/min  BP #1:       121 / 72 mmHg  SpO2 (%):       99 %  O2 Flow (l/min):          2 L/min  O2 Device:       Nasal Cannula     Height CM: 165.19 cm  Weight KG: 123.2 kg  Ideal Body Weight: 57.08 kg     Physical Exam:         Constitutional: Pulse:   See vitals above.  Alert, moderate distress        Skin:  DNormal by inspection and palpation       HENT:  Normocephalic.  Normal oral and nasal mucosae.       Eyes:  Normal conjunctivae and pupils.       Neck:  Supple, no stridor, not hoarse.       Heart:  Regular rate, irregularly irregular rhythm, no murmur, no rub.  Point of maximal impulse in the normal location.       Lungs:  Crackles in bases, orthopneic, increased respiratory effort.       Abdomen:  Soft, nontender, no CVA tenderness; no appreciable mass, bruit, nor femoral bruit.       Hematologic:  No lymphadenopathy to neck nor axillae.       Musculoskeletal:             No associated bony tenderness, bony deformity, muscle weakness, instability, nor limitation of motion.            Neurovascular and tendon functions are intact distally.       Psychiatric:  Alert and oriented x 4.  Normal speech.  Euthymic.  Seems stable and appropriate.   Medical Decision Making     Consultations:         Time: 20:43       Discussion: Dr., who states she will admit the patient to the medical/surgical floor, with observation    See the imported lab and radiology results   EKG:  Atrial fibrillation - New / Resumed since 1/2/20.  Interpreted at: 19:23     Pt was on continuous cardiopulmonary monitoring.     30 ml/kg IBW bolus was not ordered because she's in fluid overload  Time of decision to admit:  2043      __________________________________________________   Scheduled Medications   Dt/Tm Order Placed        Order Detail    07/20/2021 20:31              furosemide (Lasix)                                              20 mg, IV Push, Injection, ONCE, NOW, 07/20/21 20:31:00, 07/20/21 20:31:00  __________________________________________________   Pulmonary Services   Dt/Tm Order Placed        Order Detail    07/20/2021 20:52              RT to Complete Education Documentation for Initial Tx                                              ONCE                                             Comment: Order secondary to Initial Treatment Documentation  __________________________________________________   Patient Care   Dt/Tm Order Placed        Order Detail    07/20/2021 20:52              Bed Request (Decision to Admit)                                              07/20/21 20:43:00, MD, Reason: recurrent afib, hypoxia, Observation, Level of Care: Regular Ward, Service: Hospitalist, tely & O2                                             Comment: This is NOT a Status Order.      07/20/2021 20:31              Intake + Output Assessment                                              Hourly, 07/20/21 20:31:00      07/20/2021 19:26              Patient Isolation                                              Respiratory Special Pathogen Isolation, Constant Indicator, Related to suspected COVID-19                                             Comment:  entered by  __________________________________________________   Laboratory Services   Dt/Tm Order Placed        Order Detail    07/20/2021 21:17              **Coronavirus SARS Ag FIA                                              Nasal, Stat, Results Needed: Stat, ONCE, 07/20/21 21:11:00, Nurse Collect      07/20/2021 21:00              Coronavirus SARS Ag                                              Nasal, Stat, Results Needed: Stat, ONCE, 07/20/21 21:00:00, Nurse Collect      07/20/2021 20:36              *Occult Blood Reflex Stool                                              Stool, Stat, Results Needed: Stat, ONCE, 07/20/21 20:26:00, Nurse Collect      07/20/2021 20:31              Magnesium SerPl QN                                              Blood, Stat, Results Needed: Stat, ONCE, 07/20/21 20:31:00, Nurse Collect      07/20/2021 20:15              Blood Gas Arterial QN (ABG)                                              Blood, Stat, Results Needed: Stat, ONCE, 07/20/21 20:15:00, Nurse Collect      07/20/2021 20:15              Lactate Pl Venous QN (Lactic Acid Venous)                                              Blood, Stat, Results Needed: Stat, ONCE, 07/20/21 20:15:00, Nurse Collect      07/20/2021 20:15              Occult Bld (Hemoccult Bld)                                              Stool, Stat, Results Needed: Stat, ONCE, 07/20/21 20:15:00, Nurse Collect      07/20/2021 20:14              PTINR (PT with INR)                                              Blood, Stat, Results Needed: Stat, ONCE, 07/20/21 20:14:00, Nurse Collect      07/20/2021 20:14              aPTT Pl QN                                              Blood, Stat, Results Needed: Stat, ONCE, 07/20/21 20:14:00, Nurse Collect  __________________________________________________   Other Departments   Dt/Tm Order Placed        Order Detail    07/20/2021 20:53              Medicare Outpatient Observation Notice                                              07/20/21 20:53:11, ONCE      07/20/2021 19:44              FN Fall Risk                                              07/20/21 19:44:28, ONCE                                             Comment: Order entered secondary to Fall Risk Scale score or Humpty Dumpty Fall Score        Diagnostic impressions:        1.  Recurrent A-fib      2.  Acute Anemia      3.  CHF with Hypoxia          Condition at admission:  fair to serious, stable for admission, emergency conditions addressed    Patient/Family counseled regarding lab results, diagnostic impression & treatment plan, and indicated understanding of instructions.  Attestations:   I, acting as scribe for Dr. at 07/20/21 20:46:58 Signed by, Scribe, at 07/20/21 20:46:58  I, MD, attest that the scribe's documentation has been prepared under my direction, in person, and viewed by me in its entirety. I confirm that this note reflects all work, treatment, procedures, and medical decision making performed by me.        Chronic Problem List    Anemia  Asthma  Asthma  Asthmatic bronchitis  Atrial fibrillation  CHF with unknown LVEF  DDD (degenerative disc disease), lumbar  GERD (gastroesophageal reflux disease)  Hot flashes  HTN (hypertension)  Local skin infection  Lumbar radiculopathy  Obesity  Right hip pain  Urinary incontinence  Procedure/Surgical History  ?Cardioversion (11/19/2018) ?MRI of lumbar spine (03/09/2015) ?epidurals (2015) ?Appendectomy ?Arthroscopy of knee joint ?Breast Biopsy ?Carpal Tunnel Repair ?Cholecystectomy Laparoscopic ?Colonoscopy ?Hysterectomy ?Knee Replacement ?lumbar 2 pinched nerves and buldging discs with Dr. Aug 2015  Medications  Home Medications (18) Active acetaminophen 500 mg oral tablet 500 mg = 1 Tablet, Orally, TID Advair Diskus 100 mcg-50 mCg inhalation powder 1 Puff, Inhalation, BID albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Inhalation, 4 Times Daily Allergy Relief (Fexofenadine HCl) 180 mg oral tablet 180 mg = 1 Tablet, Orally, Daily Calcium 600+D 1  tab, Orally, Daily Colcrys 0.6 mg oral tablet See Instructions, 2 po now, then 1 tab in 1 hour, repeat in AMName brand diclofenac sodium 100 mg oral tablet, extended release 100 mg = 1 Tablet, Orally, Daily folic acid 800 mCg, Orally, Daily lisinopril 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily Pacerone 400 mg oral tablet 400 mg = 1 Tablet, Orally, Daily Percocet 10 mg-325 mg oral tablet 1 Tablet, Orally, BID Prozac 20 mg oral capsule 20 mg = 1 Capsule, Orally, Daily Shingrix intramuscular injection 0.5 mL, IM, ONCE Singulair 10 mg oral tablet 10 mg = 1 Tablet, Orally, Every PM Ventolin HFA 90 mCg/inh inhalation aerosol 180 mCg = 2 Puff, PRN, Inhalation, 4 Times Daily, Every 4 - 6 hours as needed for shortness of breath and/or wheezing. verapamil 300 mg/24 hours oral capsule, extended release 300 mg = 1 Capsule, Orally, QHS Vitamin C 500 mg, Orally, Daily Xarelto 20 mg oral tablet 20 mg, Orally, With Dinner  Medication Administration   Given  doxycycline, IVPB  furosemide, 40 mg, IV Push  Lasix, 20 mg, IV Push  Percocet 10 mg-325 mg oral tablet, 1 Tablet, Orally  rivaroxaban, 20 mg, Orally. For: Right leg DVT  Allergies   Darvocet  Darvon  Neurontin  baclofen  Social History    Alcohol   Denies   Home/Environment   married, 1 child- daughter    Substance Abuse   Denies   Tobacco   Tobacco Use: Former Smoker. Cigarettes, 2 per day. 24 year(s).  Family History   Congestive heart failure..: Mother.  Heart attack..: Father.  Lab Results      Routine Coagulation Studies FS  LATEST RESULTS        PT  07/20/21 20:14  13.1        INR  07/20/21 20:14  1.18        aPTT  07/20/21 20:14  25.8              Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Magnesium SerPl QN  07/20/21 19:36  2.0   07/20/21  2.0          Lactate Venous Pl QN  07/20/21 20:15  1.6                 Blood Gases FS  LATEST RESULTS        pH Bld Arterial QN  07/20/21 20:50  7.40        PCO2 Bld Arterial QN  07/20/21 20:50  41        PO2 Bld Arterial QN  07/20/21 20:50  92        Base Excess Bld Arterial  07/20/21 20:50  0        Bicarb Bld Arterial Calc  07/20/21 20:50  25        O2 Sat Bld Arterial Calc  07/20/21 20:50  97        FIO2  07/20/21 20:50  2 L        Patient Temperature  07/20/21 20:50  37.0        Blood Gas Comment  07/20/21 20:50  2L             Fecal Studies FS  LATEST RESULTS        Specimen Type Occult Blood  07/20/21 20:26  Stool        Occult Blood Stool  07/20/21 20:26  Negative             Serology Tests  LATEST RESULTS        Coronavirus SARS Ag FIA  07/20/21 21:11  Not Detected      Diagnostic Results  No qualifying data available.  earlier cxr today had cardiomegaly w/ nl lung fields      Signature Line Electronically Signed on 07/20/21 22:00  ________________________________________________________  Electronically Signed on 07/21/21 07:28  ________________________________________________________ MD  Reviewed by MD