Age: 74.0
Sex: M
Vaccine: FLU3
Symptoms: Hyperlipidaemia, Hypertension, Hypothyroidism, Hypoxia, Left ventricular dysfunction
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Performed By: MD on November 08, 2024 11:26 EST   Verified By: MD on November 08, 2024 11:26 EST   Encounter Info: Hospital, Inpatient, 11/07/24 -     * Final Report *        Subjective     This note was dictated using Dictation. If any errors with dictation, please contact me via diagnotes for clarification.   Assuming care from Dr.  This is a 74-year-old male initially admitted on 11/5/2024 with atrial fibrillation with RVR and acute kidney injury.  Cardiology and nephrology were consulted.   Nothing acute overnight.  Vital signs appear to be stable.  CBC stable.  Creatinine appears to have peaked at 2.83 and is downtrending to 2.35 today.  LFTs are stable.   ???????Seen and examined earlier today.  Reports that his lower extremity edema is improving.  Denies any shortness of breath.  Denies chest pain.  Reporting urine output.  Discussed with cardiology.  Nephrology was consulted.  Review of Systems     Per HPI.  Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 36.5 °C (Oral)  TMIN: 36.4 °C (Oral)  TMAX: 36.9 °C (Oral)  BP: 132/87  HR: 64 (Monitored)  RR: 20  SpO2: 98%  Oxygen Therapy: Room air  WT: 99.5 kg (Estimated)    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight    Patient Height  Current Height:    170.2 cm            Nutritional Orders:  180 gm Carb per day Diet, Start on: 11/07/24 15:01:00 EST, "No Fluid Restrictions" mL Nursing  ----------------------     Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 11/07 - 11/08  Total Intake 619.87 mL    Total Output 3725.00 mL     Balance -3105.13 mL     Physical Exam     Constitutional:  No acute distress Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Skin: + Lower extremity wounds, + lower extremity pitting edema bilaterally up to the thighs??????? Neurologic:  Alert & oriented x 3, no cognitive impairment,  no focal deficits      Lines, Tubes, and Drains  IV cannula Antecubital Right 20 gauge   PIV     IV cannula Antecubital Left 20 gauge   PIV     Assessment/Plan       1. Atrial fibrillation with RVR   I48.91  Cardiology consulted.  Continue with apixaban and metoprolol   2. Anticoagulated   Z79.01  Continue with apixaban   3. (HFpEF) heart failure with preserved ejection fraction   I50.30  Diuretics per nephrology/cardiology  Continue with metoprolol  Holding off on ACE inhibitor/ARB/ARNI due to acute renal failure   Echo 11/5/24: 1. Left ventricular systolic function is low normal with an ejection fraction of 50 %.  2. Left ventricular segmental wall motion is normal.  3. Severe concentric left ventricular hypertrophy.  4. Moderate left atrial dilatation.  5. There is severe aortic valve stenosis with a peak velocity of 4.16 m/s, mean gradient of 44 mmHg, DVI 0.15, and aortic valve  area of 0.5 cm2. Calcified echodensity noted on right coronary cusp.  6. Right ventricular systolic pressure estimated to be elevated _45__ mmHg.  7. Prior study from 2020 AS has progressed.   4. Aortic stenosis with bicuspid valve   Q23.0  Appears to have progressed based on echocardiogram.  Follow-up with his outpatient cardiologist next week.   5. Acute kidney injury   N17.9  Nephrology consulted.  Creatinine is trending downwards.  (11/07/2024 14:36 EST US Renal and Bladder) IMPRESSION: 1. Normal sonographic appearance of the kidneys. 2. The patient voided just prior to the examination and the urinary bladder remains distended. The patient refused to attempt voiding further. [1]   6. Respiratory failure with hypoxia   J96.91  Weaning supplemental oxygen.  RT protocol.   7. Hyperlipidemia   E78.5  Statin   8. Hypertension   I10  Currently on metoprolol  Titrate antihypertensives accordingly   9. Hypothyroidism   E03.9  TSH Last 3 TSH 3rd Gen SerPl QN: 2.702 mcU/mL (11/04/24)  TSH 3rd Gen SerPl QN: 1.98 mcU/mL (04/18/22)  TSH 3rd Gen SerPl QN: 1.6 mcU/mL (09/27/18)  Currently not on any thyroid replacement.  TSH levels are within normal limits.    Fluids: P.o.   Diet: Low-carb diet  Lines, Tubes, and Drains  IV cannula Antecubital Right 20 gauge   PIV     IV cannula Antecubital Left 20 gauge   PIV     Code Status: Resuscitation Status - Ordered    -- 11/07/24 15:04:00 EST, Full Code   VTE ppx: Apixaban???????   Dispo:    Labs reviewed  Imaging reviewed  Echo reviewed  Cardiology consulted  Nephrology consulted  Continue to monitor for nephrotoxicity while on Lasix drip  Discussed with case management   Discharge Disposition: ??Expect the patient to be medically ready for discharge in 48 hours approximately, pending ?patient vital signs (HR/BP/RR/T) are within stable discharge parameters?    Location: Plan for discharge ?to be determined after appropriate therapy evaluations and engagement from case management.   Discharge Needs: ?TBD w/ assistance of case management.    Case Management Engaged        Code Status  Resuscitation Status - Ordered    -- 11/07/24 15:04:00 EST, Full Code   Medications   Active Scheduled Inpatient Medications  apixaban, Tablet, 5 mg, Orally, BID, Start: 11/07/24 21:00:00  aspirin, Tab, Chewable, 81 mg, Orally, Daily, Start: 11/08/24 09:00:00  docusate (docusate sodium), Capsule, 100 mg, Orally, BID, Start: 11/07/24 21:00:00  melatonin, Tablet, 6 mg, Orally, At Bedtime, Start: 11/07/24 21:00:00  metoPROLOL (metoPROLOL tartrate), Tablet, 25 mg, Orally, BID, Start: 11/07/24 21:00:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 11/08/24 09:00:00  polyethylene glycol 3350 (polyethylene glycol 3350 oral powder for reconstitution), Powder, 17 GM, Orally, Daily, Start: 11/08/24 09:00:00  Furosemide + Bag, Viaflex IV Continuous 0.5 mL/hr [5 mg/hr] 5 mg/hr  11/08/24  Dextrose 5% in Water 500 mL IV Continuous Other - See Comments     Sodium Chloride 0.9% 100 mL IV Continuous Other - See Comments 0  11/08/24  Sodium Chloride 0.9% 500 mL IV Continuous Other - See Comments       One-Time Medications Given 11/07/24 00:00:00 TO 11/08/24 11:26:36  None Reported  PRN Medications (0600 - 0559) from 11/07 - 11/08  ALprazoLAM, 0.5 mg, Orally, TID, 1  Dose(s)   HYDROmorphone, 0.5 mg, IV Push, Q4H, 0  Dose(s)   HYDROmorphone, 1 mg, IV Push, Q4H, 0  Dose(s)   OXYcodone, 2.5 mg, Orally, Q4H, 0  Dose(s)   OXYcodone, 5 mg, Orally, Q4H, 0  Dose(s)   acetaminophen, 1,000 mg, Orally, Q8H, 1  Dose(s)   albuterol, 2 Puff, Inhalation, Q6H, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   magnesium sulfate, 2 GM, IVPB, Q12H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   potassium chloride, 20 mEq, IVPB, Unscheduled, 0  Dose(s)   potassium chloride, 30 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 40 mEq, Orally, Unscheduled, 0  Dose(s)   potassium phosphate, 14 mmol, IVPB, Unscheduled, 0  Dose(s)   potassium phosphate, 21 mmol, IVPB, Unscheduled, 0  Dose(s)   promethazine, 12.5 mg, IVPB, Q6H, 0  Dose(s)   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.1 k/cumm (11/08/24 03:44:00)  RBC: 4.63 million/cumm (11/08/24 03:44:00)  Hgb: 14.5 GM/dL (11/08/24 03:44:00)  Hct: 43 % (11/08/24 03:44:00)  MCV: 93 fL (11/08/24 03:44:00)  MCH: 31.4 pg (11/08/24 03:44:00)  MCHC: 33.8 GM/dL (11/08/24 03:44:00)  RDW: 14.1 % (11/08/24 03:44:00)  Platelet: 158 k/cumm (11/08/24 03:44:00)  MPV: 9.9 fL (11/08/24 03:44:00)  Neutrophils %: 72 % (11/08/24 03:44:00)  Lymphocytes %: 11 % (11/08/24 03:44:00)  Monocytes %: 8 % (11/08/24 03:44:00)  Eosinophils %: 6 % (11/08/24 03:44:00)  Basophils %: 3 % (11/08/24 03:44:00)  Absolute Neutrophil: 5.1 k/cumm (11/08/24 03:44:00)  Absolute Lymphocyte: 0.8 k/cumm Low (11/08/24 03:44:00)  Absolute Monocyte: 0.6 k/cumm (11/08/24 03:44:00)  Absolute Eosinophil: 0.4 k/cumm High (11/08/24 03:44:00)  Absolute Basophil: 0.2 k/cumm (11/08/24 03:44:00)  Chemistry:  Sodium SerPl QN: 137 mmol/L (11/08/24 03:44:00)  Potassium SerPl QN: 3.9 mmol/L (11/08/24 03:44:00)  Chloride SerPl QN: 107 mmol/L (11/08/24 03:44:00)  Carbon Dioxide SerPl QN: 25 mmol/L (11/08/24 03:44:00)  Anion Gap: 5 mmol/L (11/08/24 03:44:00)  BUN SerPl QN: 57 mg/dL High (11/08/24 03:44:00)  Creatinine SerPl QN: 2.35 mg/dL High (11/08/24 03:44:00)  Estimated GFR (CKD-EPI, no race): 28 mL/min/1.73m2 Low (11/08/24 03:44:00)  Estimated CRCL (CG): 32 mL/min Low (11/08/24 03:44:00)  Glucose SerPl QN: 88 mg/dL (11/08/24 03:44:00)  Calcium Total SerPl QN: 9.5 mg/dL (11/08/24 03:44:00)  Phosphorus SerPl QN: 4.1 mg/dL (11/08/24 03:44:00)  Alkaline Phos SerPl QN: 67 Units/L (11/08/24 03:44:00)  ALT SerPl QN: 12 Units/L (11/08/24 03:44:00)  AST SerPl QN: 12 Units/L Low (11/08/24 03:44:00)  Bilirubin Total SerPl QN: 0.9 mg/dL (11/08/24 03:44:00)  Total Protein SerPl QN: 6.6 GM/dL (11/08/24 03:44:00)  Albumin SerPl QN: 3.6 GM/dL (11/08/24 03:44:00)  Magnesium SerPl QN: 1.6 mg/dL (11/08/24 03:44:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/07/2024 14:36 - US Renal and Bladder  IMPRESSION: 1.  Normal sonographic appearance of the kidneys.2.  The patient voided just prior to the examination and the urinarybladder remains distended. The patient refused to attempt voidingfurther.               [1] US Renal and Bladder; MD 11/07/2024 14:36 EST   Signature Line Electronically Signed on 11/08/24 11:26 EST ________________________________________________________ MD