Age: 69.0
Sex: F
Vaccine: FLU3
Symptoms: Coma scale normal, Computerised tomogram abdomen abnormal, Condition aggravated, Constipation, Dyspnoea
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on October 21, 2024 14:50   Verified By: NP on October 21, 2024 14:50  Encounter Info: Hospital, Emergency, 10/21/24 - 10/21/24    * Final Report *  Document Has Been Revised And Contains Addenda        Chief Complaint   shortness of breath  History of Present Illness/Subjective     This is a 69 year old patient with a past medical history significant for GERD, COPD, DM, HLD, Hypothyroidism, and Afib that presented to ED on 10/21/2024 with c/o shortness of breath and is being admitted to CHF exacerbation.    This patient was seen and evaluated while still in the ED.  She was found to be sitting up on the side of the bed, alert and oriented and in no distress.  She notes she has had chest heaviness with shortness of breath for a few months.  It has worsened in the last couple of weeks.  Denies chest pain, fever, and cough.  Notes it worsens when laying flat or ambulating.  She has a hx of COPD and normally wears 2 liters of O2.  Former smoker.  Quit in 2008.  She notes a few weeks she was admitted to hospital for colitis.  She had pedal edema after discharge but notes that has resolved. Then on Oct 15 she had a  AV nodal ablation and pacemaker implantation.  Her cardiologist is Dr. and her pacemaker was placed by Dr.     EKG reviewed by ED provider, shows a paced rhythm and no changes from previous.  Chest x-ray shows some pulmonary edema. D dimer negative, CBC shows normal WBC, hemoglobin at 10.7, but stable per patient.  Coagulation studies are within normal limits.  Troponin is elevated at 84, repeat is 81.  BNP is 425.  Electrolytes and creatinine are stable.  UA shows glucose urea, but no infection.  COVID and flu are negative. CT A/P  1. Findings of pulmonary interstitial edema with small bilateral pleural effusions, right greater than left. 2. Previously seen colonic wall thickening has resolved. No liquid stool in the current examination. There is however formed stool throughout the colon for which correlation for constipation is recommended. 3. New low ventral abdominal wall skin thickening and subcutaneous edema, which could be due to fluid status or represent cellulitis. Correlate with physical examination. 4. Hepatomegaly and hepatic steatosis. 5. Additional chronic and incidental findings as noted above.  Review of Systems     Constitutional:  No fevers,  no chills Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No sore throat Respiratory:  + Shortness of breath,  no cough Cardiovascular:  No chest pain,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea Genitourinary:  No dysuria,  no hematuria Endocrine:  No polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash Neurologic:  No headache,  no focal weakness       Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.1 °C (Oral)  BP: 143/92  HR: 94 (Monitored)  HR: 94 (Peripheral)  RR: 17  SpO2: 98%  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 2 (L/min)  WT: 106.60 kg (WFC)   Hemodynamics   Neurologic  Glasgow Coma Score: 15   Patient Weight  Current Daily Weight:    106.6 kg    10/21/24    Patient Height  Current Height:    167.6 cm    10/21/24           Constitutional:  No acute distress Respiratory:  Lungs crackles  Cardiovascular:   Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Skin:  Intact, warm, dry no rashes Neurologic:   Alert & oriented x 3, no cognitive impairment,  no focal deficits       Assessment/Plan      1. CHF exacerbation I50.9  continue home carvedilol and lisinopril  previous echo in Apri, EF was 55%.  repeat echo pending    hold home oral lasix, will start IV lasix BID   given recent procedure, will need to reach out patients cardiologist     2. Elevated troponin level R79.89  Trending down  likely demand ischemia   see plan above    3. Shortness of breath R06.02  2/2 to above  on baseline home 3 liters  treatment plan as noted above    4. S/P AV nodal ablation Z98.890  will consult cardiology   5. S/P cardiac pacemaker procedure Z95.0  as above  EKG shows a paced rhythm, will defer to cardiology to see if an interrogation needs to be completed    6. CAD in native artery I25.10  Resumed home statin, lisinopril, and ace. No current chest pain or ACS symptoms.  7. COPD with emphysema J43.9  not in exacerbation   RT eval and treat    8. Diabetes mellitus with neuropathy E11.40  hold home oral medications   CDA protocol    9. Essential hypertension I10  note well controlled   10. GERD (gastroesophageal reflux disease) K21.9  resume home ppi   11. Anemia D64.9  stable, monitor   12. Hyperlipidemia E78.5  resume home statin   13. Hypothyroidism E03.9  resume home levothyroxine   14. Constipation K59.00  bowel regimen   15. Hepatomegaly R16.0  noted   Inpatient, medical floor  Daily labs - CBC, CMP Daily   IV fluids sl   Telemetry  Full Code Status  VTE Prophylaxis - heparin         Code Status   Full Code   Chronic Problem List    Anemia  Arthritis  B12 deficiency  CAD in native artery  Calcaneal bursitis, right  Chronic back pain  Chronic respiratory failure with hypoxia  COPD with emphysema  Diabetes mellitus with neuropathy  Encounter for long-term current use of medication  Essential hypertension  Gastric ulcer  GERD (gastroesophageal reflux disease)  Hallux abductovalgus with bunions  Hemorrhoids  Hepatic artery stenosis  History of myocardial infarction  History of Nissen fundoplication  Hx of colonic polyps  Hyperlipidemia  Hypokalemia  Hypothyroidism  IBS (irritable bowel syndrome)  Impaired mobility  Impingement syndrome of right shoulder  Insomnia  Lateral epicondylitis, right elbow  Lung fibrosis  Lung nodules  Morbid obesity  Morton's neuroma of third interspace of right foot  Obesity  Onychogryphosis  Onychomycosis  Osteoarthritis  Persistent atrial fibrillation  Plantar fasciitis of right foot  Presence of Watchman left atrial appendage closure device  Right rotator cuff tendinitis  Superior mesenteric artery stenosis  Tarsal tunnel syndrome of right side  Type 2 diabetes mellitus with peripheral neuropathy  Procedure/Surgical History  ?Anterior Cervical Fusion and Discectomy C4/5 C5/6 C6/7 (01/04/2024) ?tarsal trunnel surgery. (09/01/2023) ?Colonoscopy (01/01/2023) ?Diabetic retinal eye exam (04/07/2022) ?EGD - Esophagogastroduodenoscopy (09/02/2020) ?egd w bravo (09/05/2017) ?lap nissen (09/2017) ?left heart catherization (08/09/2017) ?Colonoscopy (05/09/2017) ?Esophagogastroduodenoscopy (05/09/2017) ?Shoulder repair (09/2013) ?Cardiac catheterization (1998) ?Cholecystectomy (1997) ?angioplasty ?Carpal tunnel release ?Watchman Procedure   Surgical History Internal  01/04/2024    Cervical Fusion Anterior    MD  01/01/2023    Colonoscopy Diagnostic/Screen    MD  12/29/2022    EGD Diagnostic    MD  09/02/2020    EGD Balloon Dilate Less 30mm    MD  03/12/2020    Tarsal Tunnel Release  (Right, Bilateral)   DPM  01/30/2018    Shoulder Arthroscopy  (Right)   MD     Medications   Home Medications (27) Active  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, Neb Inhal, Q6H  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, PRN, Neb Inhal, 4 Times Daily  atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, BID  Blood Glucose Meter See Instructions, To check BS 2x/daily Please dispense what brand patient insurance will cover  Blood Glucose Test Strips See Instructions, Check BS 2x/daily Please dispense what brand insurance will cover  Carafate 1 g oral tablet 1 GM = 1 Tablet, Orally, BID  carvedilol 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, BID  clopidogrel 75 mg oral tablet , TAKE 1 TABLET BY MOUTH EVERY EVENING  cycloBENZaprine 10 mg oral tablet 10 mg = 1 Tablet, PRN, Orally, BID  dicyclomine 10 mg oral capsule 10 mg = 1 Capsule, Orally, Before Meals and HS  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME Lift Chair Not Applicable, Other, Unscheduled  DME Nebulizer Machine Not Applicable, Other, ONCE, Lifetime UseDiagnosis: COPD  DME Nebulizer Supplies Not Applicable, Other, Unscheduled  DME Power/Motorized Scooter Not Applicable, Other, Unscheduled, Motorized scooter  Farxiga 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Flonase 50 mCg/inh nasal spray 1 Spray, Nostrils, Both, BID  glipiZIDE 5 mg oral tablet, extended release 5 mg = 1 Tablet, Orally, Daily  Lancets Not Applicable, Other, Daily  Lasix 20 mg oral tablet 20 mg = 1 Tablet, Orally, QAM  levothyroxine 125 mCg (0.125 mg) oral tablet 125 mCg = 1 Tablet, Orally, Daily  lisinopril 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Lyrica 300 mg oral capsule 300 mg = 1 Capsule, Orally, BID  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  Ozempic 2 mg/3 mL (0.25 mg or 0.5 mg dose) subcutaneous solution 0.5 mg, Subcutaneous, Every Week  Symbicort 160 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  traZODONE 50 mg oral tablet 50 mg = 1 Tablet, PRN, Orally, At Bedtime                Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 10/20/24 00:00:00 TO 10/21/24 14:49:39  furosemide (Lasix), Injection, 80 mg, IV Push, ONCE, (1 DOSE 10/21/24 10:18:00)    PRN Medications (0600 - 0559) from 10/20 - 10/21  None Reported   Allergies   Zetia (itching)  sulfa drugs (Itching)  metFORMIN (Itching)  morphine liposomal (doesn't like how it makes her feel)  penicillin (Hives)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Alone.   Nutrition/Health   Caffeine intake amount: 6 per day.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. 1 packs per day. Started age 13.0 Years. Stopped age 45 Years.  Family History   Alcohol abuse: Father.  Alcohol user: Father, Sister and Brother.  Cancer: Father and Sister.  Cancer of colon: Father.  Heart attack: Father and Grandfather (P).  Heart disease..: Father.  Stroke: Grandmother (Dx at 80).   Deceased Family Member(s)  Relationship: Father, Age: 48 Years  Relationship: Mother, Age: 39 Years, Cause: MVA  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.4 k/cumm (10/21/24 08:28:00)  RBC: 4 million/cumm (10/21/24 08:28:00)  Hgb: 10.7 GM/dL Low (10/21/24 08:28:00)  Hct: 33.2 % Low (10/21/24 08:28:00)  MCV: 83 fL (10/21/24 08:28:00)  MCH: 26.6 pg Low (10/21/24 08:28:00)  MCHC: 32 GM/dL (10/21/24 08:28:00)  RDW: 16.2 % High (10/21/24 08:28:00)  Platelet: 253 k/cumm (10/21/24 08:28:00)  MPV: 10.4 fL (10/21/24 08:28:00)  Neutrophils %: 72 % (10/21/24 08:28:00)  Lymphocytes %: 19 % (10/21/24 08:28:00)  Monocytes %: 5 % (10/21/24 08:28:00)  Eosinophils %: 4 % (10/21/24 08:28:00)  Basophils %: 1 % (10/21/24 08:28:00)  Absolute Neutrophil: 6.8 k/cumm (10/21/24 08:28:00)  Absolute Lymphocyte: 1.8 k/cumm (10/21/24 08:28:00)  Absolute Monocyte: 0.5 k/cumm (10/21/24 08:28:00)  Absolute Eosinophil: 0.4 k/cumm High (10/21/24 08:28:00)  Absolute Basophil: 0.1 k/cumm (10/21/24 08:28:00)  Chemistry:  Sodium SerPl QN: 141 mmol/L (10/21/24 08:28:00)  Potassium SerPl QN: 3.8 mmol/L (10/21/24 08:28:00)  Chloride SerPl QN: 103 mmol/L (10/21/24 08:28:00)  Carbon Dioxide SerPl QN: 28 mmol/L (10/21/24 08:28:00)  Anion Gap: 10 mmol/L (10/21/24 08:28:00)  BUN SerPl QN: 13 mg/dL (10/21/24 08:28:00)  Creatinine SerPl QN: 0.87 mg/dL (10/21/24 08:28:00)  Estimated GFR (CKD-EPI, no race): 72 mL/min/1.73m2 (10/21/24 08:28:00)  Estimated CRCL (CG): 75 mL/min (10/21/24 08:28:00)  Glucose SerPl QN: 158 mg/dL High (10/21/24 08:28:00)  Calcium Total SerPl QN: 8.5 mg/dL (10/21/24 08:28:00)  Alkaline Phos SerPl QN: 76 Units/L (10/21/24 08:28:00)  ALT SerPl QN: 13 Units/L (10/21/24 08:28:00)  AST SerPl QN: 15 Units/L (10/21/24 08:28:00)  Bilirubin Direct SerPl QN: 0.2 mg/dL (10/21/24 08:28:00)  Bilirubin Total SerPl QN: 0.9 mg/dL (10/21/24 08:28:00)  Total Protein SerPl QN: 6.4 GM/dL (10/21/24 08:28:00)  Albumin SerPl QN: 3.9 GM/dL (10/21/24 08:28:00)  Magnesium SerPl QN: 1.7 mg/dL (10/21/24 08:28:00)  Lipase SerPl QN: 12 Units/L (10/21/24 08:28:00)  Troponin-I High Sensitivity: 81 ng/L High (10/21/24 09:59:00)  BNP Pl QN: 425 pg/mL High (10/21/24 08:28:00)  Lactate Venous Pl QN: 1.8 mmol/L (10/21/24 11:15:00)  Sodium, ePOC: 139 mmol/L (10/21/24 08:46:00)  Potassium, ePOC: 3.7 mmol/L (10/21/24 08:46:00)  Ionized Ca, ePOC: 1.15 mmol/L (10/21/24 08:46:00)  Chloride, ePOC: 102 mmol/L (10/21/24 08:46:00)  CO2-Tot, ePOC: 27 mmol/L (10/21/24 08:46:00)  Glucose, ePOC: 179 mg/dL High (10/21/24 08:46:00)  BUN, ePOC: 13 mg/dL (10/21/24 08:46:00)  Creatinine, ePOC: 0.8 mg/dL (10/21/24 08:46:00)  Anion Gap, ePOC: 15 mmol/L (10/21/24 08:46:00)  Estimated CRCL (CG), POC: 82 mL/min (10/21/24 08:46:00)  Estimated GFR (CKD-EPI, no race), POC: 80 mL/min/1.73m2 (10/21/24 08:46:00)  Coagulation:  PT: 12.6 seconds (10/21/24 08:28:00)  INR: 1.08 (10/21/24 08:28:00)  aPTT: 33.4 seconds (10/21/24 08:28:00)  D-Dimer Pl QN: 269 ng/mL DDU (10/21/24 08:28:00)  Urine Studies:  Color: Yellow (10/21/24 09:28:00)  Clarity: Clear (10/21/24 09:28:00)  Specific Gravity: 1.01 (10/21/24 09:28:00)  pH: 7.5 (10/21/24 09:28:00)  Protein: NEGATIVE (10/21/24 09:28:00)  Glucose: >=1000 Abnormal (10/21/24 09:28:00)  Ketones: NEGATIVE (10/21/24 09:28:00)  Bilirubin: NEGATIVE (10/21/24 09:28:00)  Hgb Ur: NEGATIVE (10/21/24 09:28:00)  Nitrite: NEGATIVE (10/21/24 09:28:00)  Urobilinogen: NormalUro (10/21/24 09:28:00)  Leukocyte Esterase Ur: NEGATIVE (10/21/24 09:28:00)  WBC: 0-5 (10/21/24 09:28:00)  RBC: 0-2 (10/21/24 09:28:00)  Bacteria: TRACE. (10/21/24 09:28:00)  Squamous Epithelial: Few (10/21/24 09:28:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (10/21/24 08:28:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (10/21/24 08:28:00)                                          Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (10/21/24 08:28:00)  Rapid Influenza A PCR: Not Detected (10/21/24 08:28:00)  Rapid Influenza B PCR: Not Detected (10/21/24 08:28:00)   Diagnostics  Radiology Results - Last 24 hours Across Visits 10/21/2024 08:47 - XR Chest PA or AP Portable  IMPRESSION:1.  Cardiomegaly and pulmonary vascular congestion. Suspect earlyfluid overload/pulmonary edema.2.  Trace bilateral pleural effusions.3.  Bibasilar opacities, favor atelectasis.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    10/21/2024 11:03 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Findings of pulmonary interstitial edema with small bilateralpleural effusions, right greater than left.2.  Previously seen colonic wall thickening has resolved. No liquidstool in the current examination. There is however formed stoolthroughout the colon for which correlation for constipation isrecommended.3.  New low ventral abdominal wall skin thickening and subcutaneousedema, which could be due to fluid status or represent cellulitis.Correlate with physical examination.4.  Hepatomegaly and hepatic steatosis.5.  Additional chronic and incidental findings as noted above.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                  Signature Line Electronically Signed on 10/21/24 14:50 ________________________________________________________ NP     Addendum by MD on Oct 21, 2024 18:27 (Verified)    General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. No added sounds Cardiovascular: Normal rate, Regular rhythm. s1 s2 positive Gastrointestinal: Soft, Non-tender. BS present all 4 quadrants, no rebound tenderness Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry Neurologic: No focal weakness. Sensation intact. Normal mood and affect.     I saw and evaluated the patient in addition to the APP. I provided a substantive portion of the care for this patient. I personally performed in its entirety examfor this encounter. I have reviewed and verified this documentation and it accurately reflects our care.    MD     Signature Line Electronically Signed on 10/21/24 18:28 ________________________________________________________ MD