Age: 73.0
Sex: F
Vaccine: FLU4
Symptoms: Haemoglobin normal, Lymphocyte count, Lymphocyte percentage, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on November 22, 2022 09:50  Verified By: on November 22, 2022 14:29  Encounter Info: Emergency, 11/22/22 - 11/22/22    * Final Report *        Basic Information  Time Seen: 11/22/2022 09:44  Chief Complaint  Shortness of breath (Complaint of)  History of Present Illness     Patient seen: 11/22/22 09:53:52 A 73 year old female with Hx of HTN and T2DM, presents to the ED via private vehicle c/o shortness of breath. Patient presents from outpatient CT found bilateral lower lobe PEs. She does not wear oxygen at home. Denies long car rides, swelling in legs, or calf pain.   Chart Review: Patient had an outpatient CT scan today that showed bilateral lower lobe PEs. He was seen by NP yesterday for shortness of breath on exertion for 3 weeks that has been worse over the past week. He also reported questionable chest pressure.  Review of Systems     Constitutional: No fever, no chills Skin: No rash, no lesions Eyes: No recent vision problems, no icterus ENT: No ear pain, no sore throat, no sinus pain Resp: +SOB, no cough Cardio: No chest pain, no palpitations, no peripheral edema Gastro: No abdominal pain, no nausea, no vomiting, no diarrhea, no constipation Back: No back pain, no joint pain Neuro: No headache, no dizziness, no altered LOC, no numbness, no tingling Psych: No anxiety, no depression Additional ROS info: Except as noted in the above Review of Systems and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.5 DegC  Heart Rate:       102 bpm  Resp Rate:       22 br/min  BP:       194 / 86 mmHg  SpO2 (%):       88 %  O2 Device:       Room air     Height CM: 162.2 cm  Weight KG: 97.7 kg  Ideal Body Weight: 54.37 kg     General: Alert, no acute distress, elevated BMI Skin: Warm, dry, intact Head: Normocephalic, atraumatic ENT: Oral mucosa moist, no pharyngeal erythema or exudates Neck: Supple, no tenderness Cardiovascular: Regular rate and rhythm, no murmur, no lower extremity edema or asymmetric swelling, symmetric distal pulses Respiratory: Lungs CTA, non-labored respirations, breath sounds equal, no wheezes, rales, or rhonchi. 88% on RA. upper 90s on 2L. Musculoskeletal: No tenderness or deformity Abdomen: Soft, non-tender, non-distended Back: Non-tender, normal ROM Neuro: No focal neuro deficits, normal sensory, normal motor, normal speech, normal coordination Psych: Cooperative, appropriate mood  Medical Decision Making     Notes reviewed:  ED nurse, prior ED, prior records  Diagnostic results:  Labs: Reviewed Diagnostic imaging: Reviewed  11/22/22 11:37:12 Sent a message for bed request.  11/22/22 11:46:39 Dr. agrees to admit patient to inpatient Med/Surg for pulmonary embolism.  11/22/22 13:32:20 Spoke with Dr. At this time they are not recommending transfer for intraarterial treatment, but if patient begins to decline they would reconsider.     Re-Assessment  11/22/22 11:39:12 Discussed plan for admission. Patient is agreeable with plan, all questions addressed.  Condition     Stable Disposition: 11/22/22 11:47:02 Admit to, Location: Med/Surg  Scribe Attestation  I, acting as a scribe for on 11/22/22 09:47:15. Signed, 11/22/22 09:47:15.  I, MD, attest that the scribe's documentation has been prepared under my direction and personally reviewed by me in its entirety.  I confirmed that the note above accurately reflects all work, treatment, procedures, and medical decision-making preformed by me.  Assessment/Plan       Pulmonary embolism   I26.99    Orders:   heparin 25,000 Units + Sodium Chloride 0.45% 250 mL, Total Volume (mL) = 250, IV, 11/22/22 9:47:00, Per Nomogram  heparin infusion bolus dose, Per STANDARD Dose Heparin Nomogram, Via Infusion Pump, Infusion, Unscheduled, PRN, Other-See Comments, 11/22/22 9:47:00  **Coronavirus SARS-CoV2 Rapid  aPTT Pl QN  Auto Diff  Basic Metabolic Panel  Bed Request (Decision to Admit)  BNP Pl QN  Call Bleeding  Call PTT Results  Cardiac Monitor  CBC w/Differential  Collect Specimen  Collect Specimen  Collect Specimen  Continuous Oxygen Saturation  COVID 19 PCR  Diagnosis  Electrocardiogram  Height and Weight  PP Required: Initiate only  Troponin-I High Sensitivity    Chronic Problem List    CTS (carpal tunnel syndrome)  Diabetic neuropathy  Essential hypertension  Hyperlipidemia  Left otitis media  Major depression  Major depression, recurrent  Onychogryphosis  Onychomycosis  Pre-ulcerative calluses  Type 2 diabetes mellitus without complication  Procedure/Surgical History  ?Colonoscopy (11/03/2022) ?EGD (esophagogastroduodenoscopy) gastric outlet reduction (11/03/2022) ?Colonoscopy (08/24/2011) ?Removal of toenail ?right knee replacement ?surgery from mrsa  Surgical History Internal  11/03/2022    Colonscpy Diagnostic/Screen  06/17/2015    Knee Arthroplasty  (Right)  Medications  Home Medications (10) Active FreeStyle Test Strips Check up to 3 times daily, Other, TID, E11.9, on insulin HumULIN N (insulin NPH) human recombinant 100 units/mL subcutaneous injection See Instructions, INJECT 50 UNITS IN THE AM AND 30 UNITS IN THE PMDx E11.9 Hyzaar 100 mg-25 mg oral tablet 1 Tablet, Orally, Daily Lexapro 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily Lipitor 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily metFORMIN 500 mg (Eqv-Glumetza) oral tablet, extended release 1,000 mg = 2 Tablet, Orally, Daily Norvasc 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily Pen Needles - Insulin Check up to 2 times daily, Other, Unscheduled, E11.9 traZODONE 50 mg oral tablet 50 mg = 1 Tablet, PRN, Orally, At Bedtime  Medication Administration   Given  heparin additive (intermittent) 25,000 Units + Sodium Chloride 0.45% 250 mL, IV  heparin infusion bolus dose (Freetext), 6000 Units, Via Infusion Pump  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Work/School description: homemaker.   Home/Environment   widow, 2 children   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Heart disease..: Father.  Ovarian cancer..: Mother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  11/22/22 10:02  7.5  06/07/22  9.5          RBC  11/22/22 10:02  4.39  06/07/22  4.47          Hgb  11/22/22 10:02  12.0  06/07/22  12.3          Hct  11/22/22 10:02  36.4  06/07/22  37.6          MCV  11/22/22 10:02  83  06/07/22  84          MCH  11/22/22 10:02  27.3  06/07/22  27.4          MCHC  11/22/22 10:02  32.9  06/07/22  32.6          RDW  11/22/22 10:02  14.2  06/07/22  13.9          Platelet  11/22/22 10:02  243  06/07/22  386          MPV  11/22/22 10:02  8.0  06/07/22  8.6          Neutrophils %  11/22/22 10:02  54  06/07/22  53          Lymphocytes %  11/22/22 10:02  36  06/07/22  38          Monocytes %  11/22/22 10:02  8  06/07/22  6          Eosinophils %  11/22/22 10:02  2  06/07/22  3          Basophils %  11/22/22 10:02  1  06/07/22  0          Absolute Neutrophil  11/22/22 10:02  4.0  06/07/22  5.1          Absolute Lymphocyte  11/22/22 10:02  2.7  06/07/22  3.6  High          Absolute Monocyte  11/22/22 10:02  0.6  06/07/22  0.5          Absolute Eosinophil  11/22/22 10:02  0.2  06/07/22  0.3          Absolute Basophil  11/22/22 10:02  0.0  06/07/22  0.0          Routine Coagulation Studies FS  LATEST RESULTS        aPTT  11/22/22 10:02  31.2           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  11/22/22 10:02  133  Low  06/07/22  141          Potassium SerPl QN  11/22/22 10:02  3.8  06/07/22  4.0          Chloride SerPl QN  11/22/22 10:02  102  06/07/22  103          Carbon Dioxide SerPl QN  11/22/22 10:02  25  06/07/22  26          Anion Gap  11/22/22 10:02  6  06/07/22  12  High          BUN SerPl QN  11/22/22 10:02  18  06/07/22  14          Creatinine SerPl QN  11/22/22 10:02  0.88  06/07/22  0.90          Estimated GFR (CKD-EPI, no race)  11/22/22 10:02  69  06/07/22  68          Estimated CRCL (CG)  11/22/22 10:02  64  06/07/22  61          Glucose SerPl QN  11/22/22 10:02  153  High  06/07/22  81          Calcium Total SerPl QN  11/22/22 10:02  9.6  06/07/22  8.6          Troponin-I High Sensitivity  11/22/22 10:02  19  High              BNP Pl QN  11/22/22 10:02  70              Molecular Diagnostic Tests  LATEST RESULTS        COVID 19 Specimen Source  11/22/22 10:02  Nasal        Coronavirus SARS-CoV2 Rapid  11/22/22 10:02  Not Detected      Diagnostic Results  No qualifying data available.  EKG  Time: 11/22/2022 09:53 Rate: 89 bpm Rhythm: normal sinus rhythm Axis: normal ST-T segments: no changes T waves: normal Ectopy: none P waves and PR interval: within normal limits QT interval:within normal limits QRS interval: within normal limits Previous EKG:none available Interpretation      Signature Line Electronically Signed on 11/22/22 11:47 ________________________________________________________   Electronically Signed on 11/22/22 13:33 ________________________________________________________   Electronically Signed on 11/22/22 14:29 ________________________________________________________