Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Gastrooesophageal reflux disease, Haemoglobin decreased, Left ventricular failure, Medical diet, Pleural effusion
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on September 21, 2022 16:31 EDT   Verified By: MD on September 21, 2022 16:31 EDT   Encounter Info: Hospital, Inpatient, 09/21/22 - 09/30/22    * Final Report *  Document Has Been Revised        Chief Complaint   Shortness of breath  History of Present Illness/Subjective     Patient is a 72 year old woman who presents to Hospital w/ SOB. The patient reports that for the last few days she has had worsening shortness of breath. She also endorses some chest tightness. She cannot lie flat at all as this make sure SOB much worse. Upon arrival to the hospital she was satting normally on RA and normotensive but was tachypneic. EKG showed sinus tachycardia. CxR showed bilateral pleural effusions and pulmonary edema. Trop was mildly elevated. Here trop is 19 and EKG is unchanged. Hgb was 10. Cr was normal. Her case was discussed w/ her Cardiologist Dr. who recommended admission to hospital for further management. Upon arrival here the patient is on RA but endorses SOB particularly when not sitting upright. She has some chest tightness but no frank chest pain. No new complaints and the remainder of her vitals are stable.     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) 36.5 (36.5-36.5)  Temp (FAHR) 97.7 (97.7-97.7), BP 101/66 (101-101)/(66-66), HR 93 (93-93), RR 22 (22-22), O2Sat 91 (91-91)     Patient Height  Current Height:    165.1 cm            Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Breathing comfortably on room air 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 72 year old woman admitted w/ pulmonary edema due to a CHF exacerbation.      2. Elevated troponin   R77.8  -Serial troponin  -EKG w/out acute ischemic changes  -Nitro paste to ensure patient is CP free      3. GERD (gastroesophageal reflux disease)   K21.9  -Continue PPI       4. PAF (paroxysmal atrial fibrillation)   I48.0  -Continue amiodarone and apixaban      5. CAD in native artery   I25.10  -Continue DAPT and statin      6. Acute on chronic systolic CHF -Lasix 40mg IV q12H  -Low sodium diet, 1500cc/day fluid restriction  -TTE  -Dr. consulted  -Strict I/Os, daily weights  -Telemetry  -Nitro paste for preload reduction  -Most recent EF of 20%  -Life vest can be removed as long as patient is on telemetry  Code Status   Resuscitation Status - Ordered    -- 09/21/22 15:54:00 EDT, Full Code   Chronic Problem List    Arthritis  Family history of colon cancer  GERD (gastroesophageal reflux disease)  Hemorrhoids  IBS (irritable bowel syndrome)  Procedure/Surgical History  ?Colonoscopy (03/26/2019) ?knee replacement (10/2014) ?Colonoscopy (03/26/2014) ?Esophagogastroduodenoscopy and biopsy (02/02/2011) ?heart stent (1997) ?Appendectomy ?Cholecystectomy ?Tonsillectomy     Medications   Home Medications (21) Active  Allegra Allergy 1 Tablet, Orally, Daily  amiodarone 200 mg oral tablet 200 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  azelastine nasal 0.1% spray 1 Spray, intraNASAL, Daily  carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID  cholecalciferol (vitamin D3) 25 mCg (1,000 intl units) oral tablet 25 mCg = 1 Tablet, Orally, Daily  clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily  Co-Q10 100 mg oral capsule 100 mg = 1 Capsule, Orally, Daily  Eliquis 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  ezetimibe 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  hydrOXYzine hydrochloride 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, Q6H  losartan 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  metFORMIN 500 mg oral tablet 4 tablets, Orally, Daily  montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, Every PM  Nature's Bounty Hair Skin & Nails oral tablet, chewable 1 Tablet, Orally, Daily  Neuriva Brain performance Plus 1 Capsule, Orally, Daily  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, Sublingually, Q5min  Ocuvite 1 Tablet, Orally, Daily  traZODONE 100 mg oral tablet 100 mg = 1 Tablet, Orally, At Bedtime  Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  amiodarone, Tablet, 200 mg, Orally, Daily, Start: 09/22/22 09:00:00  apixaban, Tablet, 5 mg, Orally, BID, Start: 09/21/22 21:00:00  atorvastatin, Tablet, 40 mg, Orally, At Bedtime, Start: 09/21/22 21:00:00  carvedilol, Tablet, 6.25 mg, Orally, BID, Start: 09/21/22 21:00:00  cholecalciferol, Tablet, 25 mCg, Orally, Daily, Start: 09/22/22 09:00:00  clopidogrel, Tablet, 75 mg, Orally, Daily, Start: 09/22/22 09:00:00  cyanocobalamin, Tablet, 1,000 mCg, Orally, Daily, Start: 09/22/22 09:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 09/21/22 21:00:00  ezetimibe, Tablet, 10 mg, Orally, Daily, Start: 09/22/22 09:00:00  furosemide, Injection, 40 mg, IV Push, Q12, Start: 09/21/22 21:00:00  loratadine, Tablet, 10 mg, Orally, Daily, Start: 09/22/22 09:00:00  losartan, Tablet, 25 mg, Orally, Daily, Start: 09/22/22 09:00:00  montelukast (montelukast 10 mg oral tablet), Tablet, 10 mg, Orally, Every PM, Start: 09/21/22 18:00:00  traZODONE, Tablet, 100 mg, Orally, At Bedtime, Start: 09/21/22 21:00:00    One-Time Medications Given 09/20/22 00:00:00 TO 09/21/22 16:27:02  nitroGLYCerin (nitroGLYCerin 2% transdermal ointment), Ointment, 0.5 Inches, Topical, ONCE, (1 DOSE 09/21/22 16:19:00)  PRN Medications (0600 - 0559) from 09/20 - 09/21  None Reported  Allergies   penicillins (Swelling Lip)  lisinopril (Unknown)  Tetanus Toxoid (Unknown)  Social History    Alcohol   Current, 1-2 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Atrial septal defect..: Negative: Mother and Father.  Breast cancer: Sister.  Colon cancer..: Negative: Sister.  Diabetes..: Mother and Father.  Heart disease..: Father and Brother.  Throat cancer..: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Chemistry:  Troponin-I High Sensitivity: 19 ng/L High (09/21/22 15:48:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.          Signature Line Electronically Signed on 09/21/22 16:31 EDT ________________________________________________________ MD  Electronically Signed on 09/21/22 17:11 EDT ________________________________________________________ MD