Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Anion gap, Aspiration pleural cavity, Auscultation
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Performed By: MD on November 02, 2023 07:49   Verified By: MD on November 02, 2023 07:49   Encounter Info: Hospital Inpatient, 10/24/23 - 11/04/23    * Final Report *        Subjective      This patient is an 81 year old female with PMH of a-fib, COPD (on 3L at home), and GERD that presented to the ED on 10/24 for complaints of nausea and confusion. She was found to have a R sided loculated effusion on chest CT and E.coli bacteremia for which she was placed on zosyn. She had a chest tube placed in the effusion which was drained and fluid did not grow any invasive organisms and the effusion was transudative per Light's criteria. She was initially in ICU on BiPAP but was able to be transferred out after a few days. Her chest tube was removed on 10/28 after effusion was improved on CXR.   She is back down to her home oxygen but patient continued to complain of chills and generally not feeling well. Another CT chest was obtained which showed increase in bilateral pleural effusions (although still small in volume) which the R side appears loculated. [1] Resting comfortably this morning.      Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 36.9 °C (Oral)  BP: 100/83  HR: 96 (Monitored)  HR: 96 (Peripheral)  RR: 16  SpO2: 99%  Oxygen Therapy: OxyMask  Oxygen Flow Rate: 3 (L/min)  FiO2: 0.40    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    50.7 kg    10/24/23  Weight for Nutrition:    50.7 kg    10/25/23  BMI:    21.8    10/24/23    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    152.4 cm    10/24/23     Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 11/01 - 11/02  Total Intake 350.00 mL    Total Output 650.00 mL     Balance -300.00 mL     Physical Exam     Chest- Clear to auscultation. CV- RRR. No murmurs, gallops or rubs. ABD- Soft, non-tender. Non-distended. BS present. Ext.- No edema.  Assessment/Plan        1. Acute on chronic respiratory failure with hypoxia and hypercapnia   J96.21   Probably secondary to bacteremia and loculated pleural effusions.  Back to baseline on oxygen supplementation.   2. E coli bacteremia   R78.81   Has had 8 days of IV antibiotics.  IR asked that we continue with placement of chest tube for now.   3. Pleural effusion, right   J90   Planning IR placed chest tube to loculated fluid today.   4. Hypothyroidism   E03.9   Continue replacement therapy.   5. Atrial fibrillation   I48.91   Slightly tachycardic.  On anticoagulation.  Continue amiodarone.   6. Acute kidney injury   N17.9   Resolved.  Potassium replaced.   Chronic respiratory failure with hypoxia   J96.11    Constipation   K59.00    COPD exacerbation   J44.1    E-coli UTI   N39.0    Emphysema lung   J43.9    Hypernatremia   E87.0    Hypophosphatemia   E83.39    Leucocytosis   D72.829    Normocytic anemia   D64.9    Palliative care by specialist   Z51.5    RML pneumonia   J18.9    Septic shock   R65.21    Orders:   piperacillin-tazobactam, 3.375 GM, IVPB, Injection, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), 11/02/23 8:00:00    Code Status  Resuscitation Status - Ordered    -- 10/24/23 17:48:00, Full Code   Medications   Active Scheduled Inpatient Medications  albuterol-ipratropium (albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL), Inhalation SOLN, 3 mL, Neb Inhal, Q6, Start: 10/26/23 09:00:00  amiodarone, Tablet, 200 mg, Orally, Daily, Start: 10/24/23 17:54:00  apixaban, Tablet, 2.5 mg, Orally, BID, Start: 10/24/23 21:00:00  bisacodyl (Dulcolax Laxative), Suppository, 10 mg, Rectally, Daily, Start: 11/01/23 09:00:00  docusate (docusate sodium), Capsule, 100 mg, Orally, Daily, Start: 10/29/23 12:00:00  famotidine, Tablet, 20 mg, Orally, At Bedtime, Start: 10/30/23 21:00:00  levothyroxine (Synthroid), Tablet, 88 mCg, Orally, Before Breakfast, Start: 10/25/23 06:00:00  lidocaine topical (Lidoderm 5% topical film), Patch, 1 Patch, Topical, QAM, Start: 10/25/23 11:00:00  piperacillin-tazobactam (Zosyn), Injection, 3.375 GM, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 11/02/23 08:00:00  polyethylene glycol 3350, Powder, 17 GM, Orally, Daily, Start: 10/25/23 09:00:00  Sodium Chloride 0.9%  500 mL IV Continuous  Other - See Comments 0  10/26/23  Dextrose 5% in Water  500 mL IV Continuous  Other - See Comments       One-Time Medications Given 11/01/23 00:00:00 TO 11/02/23 07:49:28  metoPROLOL (Lopressor), Injection, 2.5 mg, IV Push, ONCE, (1 DOSE 11/01/23 00:56:00)  metoPROLOL (Lopressor), Injection, 5 mg, IV Push, ONCE, (1 DOSE 11/01/23 04:25:00)  PRN Medications (0600 - 0559) from 11/01 - 11/02  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2.5 mg, Neb Inhal, Q4H, 0  Dose(s)   alteplase, 1 mg, Dwell, Unscheduled, 0  Dose(s)   bisacodyl, 10 mg, Rectally, Daily, 0  Dose(s)   metoPROLOL, 5 mg, IV Push, Q6H, 2  Dose(s)   midodrine, 5 mg, Orally, Q8, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   promethazine, 6.25 mg, IVPB, Q6H, 0  Dose(s)   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10 k/cumm (11/02/23 02:30:00)  RBC: 3.38 million/cumm Low (11/02/23 02:30:00)  Hgb: 9.4 GM/dL Low (11/02/23 02:30:00)  Hct: 29.5 % Low (11/02/23 02:30:00)  MCV: 87 fL (11/02/23 02:30:00)  MCH: 27.7 pg (11/02/23 02:30:00)  MCHC: 31.7 GM/dL Low (11/02/23 02:30:00)  RDW: 18.2 % High (11/02/23 02:30:00)  Platelet: 215 k/cumm (11/02/23 02:30:00)  MPV: 8.7 fL (11/02/23 02:30:00)  Chemistry:  Sodium SerPl QN: 143 mmol/L (11/02/23 02:30:00)  Potassium SerPl QN: 4.6 mmol/L (11/02/23 02:30:00)  Chloride SerPl QN: 104 mmol/L (11/02/23 02:30:00)  Carbon Dioxide SerPl QN: 37 mmol/L High (11/02/23 02:30:00)  Anion Gap: 2 mmol/L Low (11/02/23 02:30:00)  BUN SerPl QN: 12 mg/dL (11/02/23 02:30:00)  Creatinine SerPl QN: 1.09 mg/dL (11/02/23 02:30:00)  Estimated GFR (CKD-EPI, no race): 51 mL/min/1.73m2 Low (11/02/23 02:30:00)  Estimated CRCL (CG): 30 mL/min Low (11/02/23 02:30:00)  Glucose SerPl QN: 77 mg/dL (11/02/23 02:30:00)  Calcium Total SerPl QN: 8 mg/dL Low (11/02/23 02:30:00)  Phosphorus SerPl QN: 2.4 mg/dL Low (11/02/23 02:30:00)  Magnesium SerPl QN: 2.4 mg/dL (11/02/23 02:30:00)  Coagulation:  PT: 15.6 seconds High (11/02/23 02:30:00)  INR: 1.35 High (11/02/23 02:30:00)  Micro - Last 7 days  Blood CX: NEG (10/26/23 14:33:00)  Blood CX: NEG (10/26/23 14:33:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.            [1] Consult Note; NP 11/01/2023 10:36    Signature Line Electronically Signed on 11/02/23 07:49 ________________________________________________________ MD