Age: 26.0
Sex: M
Vaccine: FLU4
Symptoms: pH urine normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 25, 2022 12:39    Verified By: MD on November 25, 2022 15:48    Encounter Info: Hospital, Inpatient, 11/25/22 -     * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     26-year-old male with a past medical history of diabetes hypothyroidism, gout, iron deficiency anemia, mental deficiency, OSA presenting to the emergency department with fever, shortness of breath and hypoxia at home.    History was obtained through his mother by phone call due to inability of patient to provide detailed history.  Mother states patient was apparently well until yesterday around 1 AM when patient woke up and told her that he was not feeling well.  She immediately checked his oxygen saturation and noted that he was saturating between 83 to 84% he also had a fever of 102.1 at the same time.  Asides generalized weakness, there was no chest pain, headache, blurry vision, abdominal pain, dysuria nausea or vomiting.  No sick contacts or recent travel.   Of note, patient had influenza a in January 2022, when he was intubated for 11 days.  He was also recently admitted in Bedford Hospital 1 month ago for COVID-pneumonia and at that time required 6 L of oxygen to maintain saturations.  Was subsequently discharged on oxygen but mother reported that he has not used the oxygen until yesterday with acute onset shortness of breath and hypoxia.  For the above complaints, mother brought the patient to the ER for further evaluation.  CODE STATUS-full code   In the ER Vital signs Blood pressure 133/74, heart rate ranged between 10 5-1 1 7, temperature between 37.6-39, respiratory rate 22-28, SPO2 94% on 6 L of nasal cannula    On evaluation-patient is awake and alert, requiring 6 L of oxygen through nasal cannula and appears comfortable.  He was also having lunch and tolerating.  On chest auscultation, diffuse crackles and rails were heard all over lung bases.  Per labs WBC 7.7 neutrophils 78%,, hemoglobin 10.6, platelets 178, Sodium 142, potassium 3.9, chloride 103, bicarb 30, anion gap 9, BUN/creatinine 12/1.18, LFTs-ALT 69, AST 37, T bili 1.4, total protein 8.6 albumin 4.3 -Blood gas pH 7.46, PCO2 43, bicarb 31, oxygen saturation 96 Glucose 157, Troponin 7-- >8 Lactate venous 1.2-- >1.0 Urinalysis-protein 30 hemoglobin small nitrate negative WBC 21-50 RBC 21-50, bacteria few, epithelial cells none COVID negative influenza AB- negative Imaging Chest x-ray-hyperinflated lungs, lungs negative for pneumothorax, moderate to large pleural effusion and focal consolidation. CTA chest-negative for large saddle pulmonary embolism.  More distal branches not well assessed.  Study is limited for detection of pulmonary emboli.  No evidence of focal lung consolidation.  Lungs are hypoinflated with streaky perihilar lung markings likely due to respiratory motion, atelectasis, and bronchovascular crowding.   Patient is admitted for sepsis secondary to pneumonia  Review of Systems     Left lower quadrant abdominal pain.  Otherwise negative  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 38.9 (37.4-38.9)  Temp (FAHR) 102.0 (99.3-102.0), BP 118/61 (110-149)/(55-81), HR 114 (100-119), RR 28 (16-43), O2Sat 91 (86-91) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    118.7 kg    11/25/22  Previous Daily Weight:    118.7 kg    11/25/22  BMI:    33.6    11/25/22    Obese (BMI 30-39.9) Patient Height  Current Height:    188 cm    11/25/22        General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: Diffuse crackles on radial heard on auscultation, Respirations are non-labored.  On 6 L of oxygen through intranasal cannula Gastrointestinal: Soft, Non-distended, Normal bowel sounds, No organomegaly, mild left lower quadrant tenderness on deep palpation Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling,     Assessment/Plan     26-year-old male with a past medical history of diabetes hypothyroidism, gout, iron deficiency anemia, mental deficiency, OSA presenting to the emergency department with fever, shortness of breath and hypoxia at home admitted for sepsis likely from pneumonia.   1. Sepsis   A41.9  Meets SIRS criteria with tachycardia, tachypnea and fever.  Sepsis is present on admission, adequate capillary refill/perfusing pressure on repeat examination, imaging negative for infiltrate,   -Patient is at high risk for hemodynamic and respiratory instability due to high oxygen requirement therefore low threshold for ICU upgrade.   - Blood cultures pending, urinalysis appears weakly positive at this time, no urinary symptoms.  Procalcitonin pending, lactate repeat WNL.    -Continue empiric coverage for HCAP due to recent hospitalization.  Continue Zosyn, vancomycin and doxycycline.  De-escalate therapy as appropriate. SARS CoV 2 negative.   -CT abdomen pelvis with IV contrast for abdominal pain.  - Continue IVF at 150cc/hr   2. Pneumonia   J18.9  Likely viral pneumonia as no obvious consolidation seen on chest imaging.  No obvious contacts however mother reports that he was around his uncle who had sinus infection throughout yesterday. ??  Viral transmission.  -We will continue respiratory protocol  -Maintain oxygen supplementation above 92%  -We will monitor respiratory status closely and if patient decompensates respiratory wise and needs intubation, will intubate patient.  Patient is full code, confirmed with mother through the phone.  -Patient is high risk for respiratory decompensation, will monitor closely.  -Follow-up blood cultures, respiratory culture, MRSA, Legionella antigen, staph aureus, respiratory viral panel   3. Hypoxia   R09.02  As a result of problem #2  CT PE negative for PE.  We will monitor oxygenation closely  -Respiratory protocol in progress   4. Mixed hyperlipidemia   E78.2  Chronic  Continue home meds   5. Metabolic alkalosis   E87.3  Noted on blood gas, however patient has chronic elevation of bicarbonate likely due to OSA.  We will ensure electrolyte repletion if needed.   6. Type 2 diabetes mellitus with hyperglycemia   E11.65  Chronic, not on home insulin  -Insulin ISS as tolerated  -Diabetes diet  -We will follow-up with A1c   7. Acquired hypothyroidism   E03.9  Chronic  We will resume home meds  Get current TSH level   8. Gout   M10.9  Chronic  Resume home allopurinol   9. Iron deficiency anemia   D50.9  Chronic  Hold iron supplementation due to ongoing sepsis   10. Mental deficiency   F79  Chronic and mild. patient is said to be functional and independent at home.  Also verbal and conversive.  Lives with mother   11. OSA on CPAP   G47.33  Chronic  Not compliant with CPAP   Respiratory failure with hypoxia   J96.91  Acute respiratory failure likely secondary to viral pneumonia.  We will monitor respiratory status closely and provide oxygen supplementation as needed.  Low threshold for intubation if needed.   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 11/25/22 11:27:00   albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, PRN, Wheezing, 11/25/22 11:29:00, RT Care Assessment and Protocol per Policy  allopurinol, 300 mg, Orally, Tablet, Daily, 11/25/22 12:00:00   busPIRone, 15 mg, Orally, Tablet, BID, 11/25/22 12:00:00   ceftRIAXone, 1 GM, IVPB, Injection, Daily, 11/26/22 9:00:00, for 4 Doses, 11/29/22 9:00:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  ceftRIAXone, 1 GM, IVPB, Injection, ONCE, NOW, 11/25/22 11:27:00, 11/25/22 11:27:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  desmopressin, 0.1 mg, Orally, Tablet, At Bedtime, 11/25/22 21:00:00   divalproex sodium, 1,000 mg, Orally, Tab, Delayed Rel, QAM, 11/25/22 12:00:00   divalproex sodium, 500 mg, Orally, Tab, Delayed Rel, QPM, 11/25/22 18:00:00   doxycycline, 100 mg, IVPB, Injection, Q12, 11/25/22 22:00:00, for 9 Doses, 11/29/22 22:00:00, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100  doxycycline, 100 mg, IVPB, Injection, ONCE, NOW, 11/25/22 11:27:00, 11/25/22 11:27:00, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100  enoxaparin, 40 mg, Subcutaneous, Injection, At Bedtime, Routine, 11/25/22 21:00:00   fluticasone-vilanterol, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 11/25/22 12:00:00   levothyroxine, 150 mCg, Orally, Tablet, Daily, 11/26/22 6:00:00   lithium, 300 mg, Orally, Capsule, Daily1800, 11/25/22 18:00:00   lithium, 600 mg, Orally, Capsule, QAM, 11/25/22 12:00:00   metoPROLOL, 25 mg, Orally, Tab, Extended Rel, Daily, 11/25/22 12:00:00   montelukast, 10 mg, Orally, Tablet, At Bedtime, 11/25/22 21:00:00   olanzapine, 10 mg, Orally, Tab, Oral Disintegrating, BID, 11/25/22 12:00:00   ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 11/25/22 11:27:00   polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 11/25/22 11:27:00   Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 11/25/22 11:27:00 , 150 mL/hr, Clinical Weight  Admit to Inpatient   Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  CBC w/Differential  Comp Metabolic Panel  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Electrocardiogram  Hyperinflation Therapy  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  L pneumophila Ag Ur QL  Level of Care  Lithium SerPl QN  MRSA PCR  OT Evaluation and Treatment  Peripheral IV Insertion  Procalcitonin  Procalcitonin  PT Evaluation and Treatment  Regular Diet  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  RVP2 PCR  Strep pneumoniae Ag Urine  Vital Signs  Vital Signs  Weight  Greater than 70 minutes total with greater than 50% of time face-to-face with patient and mother through phone call reviewing course, plan of care, and in care coordination  Code Status   Resuscitation Status - Ordered    -- 11/25/22 11:27:00, Full Code   Chronic Problem List    Acquired hypothyroidism  Asthma  Asthma exacerbation  At high risk for adverse medication event  Congestive splenomegaly  COVID-19  Elevated liver enzymes  Encounter for long-term (current) use of medications  Gout  Hyperglycemia  Hypertrophy of inferior nasal turbinate  Hypothyroidism, adult  Hypoxia  Iron deficiency anemia  Mental deficiency  Mixed hyperlipidemia  Nasal septal deviation  Nocturnal hypoxemia  Nonalcoholic steatohepatitis (NASH)  Obesity  OSA on CPAP  Other specified problems related to psychosocial circumstances  Peripheral sensory neuropathy  Pneumonia  Pneumonia due to COVID-19 virus  Right upper quadrant pain  Secondary thrombocytopenia  Sepsis  Smith-Magenis syndrome  Type 2 diabetes mellitus  Type 2 diabetes mellitus with hyperglycemia  Wolff-Parkinson-White (WPW) syndrome  Procedure/Surgical History  ?heart ablation ?testicle hernia repair   Surgical History Internal  08/02/2004    RADIOLOGY MRI.    MD  Medications   Home Medications (20) Active  Advair HFA 115mCg-21mCg/inh inhalation aerosol 1 Puff, Inhalation, BID  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H  allopurinol 300 mg oral tablet 300 mg = 1 Tablet, Orally, Daily, failed on colchicine  busPIRone 15 mg oral tablet 15 mg = 1 Tablet, Orally, BID  Depakote 500 mg oral delayed release tablet 1,000 mg = 2 Tablet, Orally, QAM  Depakote 500 mg oral delayed release tablet 500 mg = 1 Tablet, Orally, QPM  desmopressin 0.1 mg oral tablet 0.1 mg = 1 Tablet, Orally, At Bedtime  ferrous sulfate 160 mg, Orally, Daily  Flonase 50 mcg/inh nasal spray 1 Spray, Nostrils, Both, Daily, prnin each nostril  Glucophage XR 500 mg oral tablet, extended release 500 mg = 1 Tablet, Orally, With Dinner  lithium 300 mg oral capsule 600 mg = 2 Capsule, Orally, QAM  lithium 300 mg oral capsule 300 mg = 1 Capsule, Orally, Daily1800  metoPROLOL succinate 25 mg oral tablet, extended release 25 mg = 1 Tablet, Orally, Daily  montelukast 10 mg oral tablet 10 mg, Orally, Daily  naltrexone 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  olanzapine 20 mg oral tablet 10 mg = 0.5 Tablet, Orally, BID  Proventil HFA 90 mCg/inh inhalation aerosol 180 mCg = 2 Puff, PRN, Inhalation, 4 Times Daily  Synthroid 150 mCg (0.15 mg) oral tablet 150 mCg = 1 Tablet, Orally, Daily  Tylenol Extra Strength 500 mg oral tablet 1,000 mg = 2 Tablet, PRN, Orally, Q6H  Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q6H  Active Scheduled Inpatient Medications  allopurinol, Tablet, 300 mg, Orally, Daily, Start: 11/25/22 12:00:00  busPIRone, Tablet, 15 mg, Orally, BID, Start: 11/25/22 12:00:00  ceftRIAXone, Injection, 1 GM, IVPB, ONCE, Start: 11/25/22 11:27:00  ceftRIAXone, Injection, 1 GM, IVPB, Daily, Start: 11/26/22 09:00:00  desmopressin, Tablet, 0.1 mg, Orally, At Bedtime, Start: 11/25/22 21:00:00  divalproex sodium (Depakote 500 mg oral delayed release tablet), Tab, Delayed Rel, 500 mg, Orally, QPM, Start: 11/25/22 18:00:00  divalproex sodium (Depakote 500 mg oral delayed release tablet), Tab, Delayed Rel, 1,000 mg, Orally, QAM, Start: 11/25/22 12:00:00  doxycycline, Injection, 100 mg, IVPB, ONCE, Start: 11/25/22 11:27:00  doxycycline, Injection, 100 mg, IVPB, Q12, Start: 11/25/22 22:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, At Bedtime, Start: 11/25/22 21:00:00  fluticasone-vilanterol (fluticasone-vilanterol 100 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 11/25/22 12:00:00  levothyroxine (Synthroid), Tablet, 150 mCg, Orally, Daily, Start: 11/26/22 06:00:00  lithium (lithium carbonate), Capsule, 300 mg, Orally, Daily1800, Start: 11/25/22 18:00:00  lithium (lithium carbonate), Capsule, 600 mg, Orally, QAM, Start: 11/25/22 12:00:00  metoPROLOL (metoPROLOL succinate), Tab, Extended Rel, 25 mg, Orally, Daily, Start: 11/25/22 12:00:00  montelukast (montelukast 10 mg oral tablet), Tablet, 10 mg, Orally, At Bedtime, Start: 11/25/22 21:00:00  olanzapine, Tab, Oral Disintegrating, 10 mg, Orally, BID, Start: 11/25/22 12:00:00  Sodium Chloride 0.9%  1,000 mL IV  150 mL/hr       One-Time Medications Given 11/24/22 00:00:00 TO 11/25/22 12:39:23  acetaminophen, Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 11/25/22 03:53:00)  ampicillin-sulbactam, Injection, 3 GM, IVPB, ONCE, (1 DOSE 11/25/22 03:53:00)  ampicillin-sulbactam, Injection, 3 GM, IVPB, ONCE, (1 DOSE 11/25/22 07:51:00)  azithromycin, Injection, 500 mg, IVPB, ONCE, (1 DOSE 11/25/22 04:38:00)  PRN Medications (0600 - 0559) from 11/24 - 11/25  Lactated Ringers, 1,000 mL, IVPB, Unscheduled, 0  Dose(s)   acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2.5 mg, Neb Inhal, Q6H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   Adderall (Aggressive- Mean)  Ritalin (Aggressive/ mean)  traZODone (Aggressive / Mean)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Unemployed, Work/School description: The patient has a developmental disorder and lives with his family and has never worked..   Exercise   Exercise duration: 30. Exercise frequency: Daily. Self assessment: Fair condition. Exercise type: The patient's bedroom is upstairs and he climbs the stairs several times each day..   Home/Environment   Lives with Mother. Home equipment: Respiratory treatments. Alcohol abuse in household: No. Substance abuse in household: No. Smoker in household: Yes. Injuries/Abuse/Neglect in household: No. Feels unsafe at home: No. Safe place to go: Yes. Agency(s)/Others notified: No. Family/Friends available for support: Yes.   Nutrition/Health   Type of diet: The patient's appetite is good and he does have some fresh fruits and vegetables in his diet.. Diet: Regular.   Other   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Anxiety: Mother.  Bipolar disorder: Father.  Thyroid disorder: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.7 k/cumm (11/25/22 03:54:00)  RBC: 3.94 million/cumm Low (11/25/22 03:54:00)  Hgb: 10.6 GM/dL Low (11/25/22 03:54:00)  Hct: 33 % Low (11/25/22 03:54:00)  MCV: 84 fL (11/25/22 03:54:00)  MCH: 26.9 pg Low (11/25/22 03:54:00)  MCHC: 32.1 GM/dL (11/25/22 03:54:00)  RDW: 16.9 % High (11/25/22 03:54:00)  Platelet: 178 k/cumm (11/25/22 03:54:00)  MPV: 7.9 fL (11/25/22 03:54:00)  Neutrophils %: 78 % (11/25/22 03:54:00)  Lymphocytes %: 12 % (11/25/22 03:54:00)  Monocytes %: 9 % (11/25/22 03:54:00)  Eosinophils %: 1 % (11/25/22 03:54:00)  Basophils %: 0 % (11/25/22 03:54:00)  Absolute Neutrophil: 6 k/cumm (11/25/22 03:54:00)  Absolute Lymphocyte: 0.9 k/cumm Low (11/25/22 03:54:00)  Absolute Monocyte: 0.7 k/cumm (11/25/22 03:54:00)  Absolute Eosinophil: 0.1 k/cumm (11/25/22 03:54:00)  Absolute Basophil: 0 k/cumm (11/25/22 03:54:00)  Chemistry:  Sodium SerPl QN: 142 mmol/L (11/25/22 03:54:00)  Potassium SerPl QN: 3.9 mmol/L (11/25/22 03:54:00)  Chloride SerPl QN: 103 mmol/L (11/25/22 03:54:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (11/25/22 03:54:00)  Anion Gap: 9 mmol/L (11/25/22 03:54:00)  BUN SerPl QN: 12 mg/dL (11/25/22 03:54:00)  Creatinine SerPl QN: 1.18 mg/dL (11/25/22 03:54:00)  Estimated GFR (CKD-EPI, no race): 87 mL/min/1.73m2 (11/25/22 03:54:00)  Estimated CRCL (CG): >120 (11/25/22 03:54:00)  Glucose SerPl QN: 157 mg/dL High (11/25/22 03:54:00)  Calcium Total SerPl QN: 10 mg/dL (11/25/22 03:54:00)  Alkaline Phos SerPl QN: 89 Units/L (11/25/22 03:54:00)  ALT SerPl QN: 69 Units/L High (11/25/22 03:54:00)  AST SerPl QN: 37 Units/L (11/25/22 03:54:00)  Bilirubin Total SerPl QN: 1.4 mg/dL High (11/25/22 03:54:00)  Total Protein SerPl QN: 8.6 GM/dL High (11/25/22 03:54:00)  Albumin SerPl QN: 4.3 GM/dL (11/25/22 03:54:00)  Troponin-I High Sensitivity: 7 ng/L (11/25/22 07:49:00)  Lactate Venous Pl QN: 1.2 mmol/L (11/25/22 03:54:00)  Blood Gas Comment: venous (11/25/22 03:54:00)  pH Bld Venous QN: 7.46 High (11/25/22 03:54:00)  PCO2 Bld Venous QN: 43 mmHg (11/25/22 03:54:00)  PO2 Bld Venous QN: 74 mmHg High (11/25/22 03:54:00)  Base Excess Bld Venous: 6 mmol/L High (11/25/22 03:54:00)  Bicarb Bld Venous Calc: 31 mmol/L High (11/25/22 03:54:00)  O2 Sat Bld Venous Calc: 96 % (11/25/22 03:54:00)  Patient Temperature: 37 DegC (11/25/22 03:54:00)  Urine Studies:  Color: Yellow (11/25/22 04:17:00)  Clarity: Clear (11/25/22 04:17:00)  Specific Gravity: 1.010 (11/25/22 04:17:00)  pH: 6.0 (11/25/22 04:17:00)  Protein: 30 Abnormal (11/25/22 04:17:00)  Glucose: NEGATIVE (11/25/22 04:17:00)  Ketones: NEGATIVE (11/25/22 04:17:00)  Bilirubin: NEGATIVE (11/25/22 04:17:00)  Hgb Ur: SMALL. Abnormal (11/25/22 04:17:00)  Nitrite: NEGATIVE (11/25/22 04:17:00)  Urobilinogen: NormalUro (11/25/22 04:17:00)  Leukocyte Esterase Ur: NEGATIVE (11/25/22 04:17:00)  WBC: 21-50 Abnormal (11/25/22 04:17:00)  RBC: 21-50 Abnormal (11/25/22 04:17:00)  Bacteria: Few Abnormal (11/25/22 04:17:00)  Squamous Epithelial: NONE (11/25/22 04:17:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/25/22 03:54:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/25/22 03:54:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (11/25/22 03:54:00)  Rapid Influenza A PCR: Not Detected (11/25/22 03:54:00)  Rapid Influenza B PCR: Not Detected (11/25/22 03:54:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/25/2022 04:22 - XR Chest PA or AP Portable  IMPRESSION:1.  Hypoinflated lungs.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss this case further cancontact the Emergency Radiology Reading Room.    11/25/2022 06:15 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for large saddle pulmonary embolus. More distal branchesnot well assessed. Study limited for detection of pulmonary emboli.2.  Motion degraded examination of the lungs. Lungs are hypoinflatedwith streaky perihilar lung markings, likely due to respiratorymotion, atelectasis, and bronchovascular crowding. No evidence offocal lung consolidation.3.  Hepatic steatosis and splenomegaly.4.  Additional incidental and chronic findings as noted above.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss this case further cancontact the Emergency Radiology Reading Room.                Signature Line Electronically Signed on 11/25/22 15:48 ________________________________________________________  MD  Electronically Signed on 11/25/22 15:51  ________________________________________________________ MD