Age: 74.0
Sex: M
Vaccine: COVID19
Symptoms: Chronic obstructive pulmonary disease, Coagulation test, Coma scale, Condition aggravated, Creatinine renal clearance decreased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on May 29, 2023 09:26 EDT   Verified By: MD on May 29, 2023 09:26 EDT   Encounter Info: Hospital, Inpatient, 05/29/23 -     * Final Report *        Chief Complaint   Shortness of breath  History of Present Illness/Subjective     Patient is a 76 year old man w/ h/o COPD who presents w/ SOB for the last 3 days. The patient is only able to speak in short sentences. He denies any fevers, chest pain, NVD. Upon arrival to the ER he was satting 79% on RA. Labs were normal. CxR showed no e/o PNA. VBG showed a normal pCO2. Patient was given steroids and breathing treatments. He was subsequently admitted to the medicine service for further management.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours   Hemodynamics   Neurologic  Glasgow Coma Score: 15     Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Increased WOB 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 76 year old man admitted w/ a COPD exacerbation and acute hypoxic respiratory failure.      1. Acute respiratory failure with hypoxia   J96.01  -Due to COPD exacerbation  -No e/o hypercarbia on VBG  -Wean O2 as able  -Remote h/o lung cancer s/p resection and treatment      2. COPD exacerbation   J44.1  -Solumedrol  -Duonebs  -Zithromax  -No e/o PNA      3. Hyperglycemia due to type 2 diabetes mellitus (disorder)   E11.65  -Sliding scale   -Carb controlled diet  -Hypoglycemia protocol  -Hold oral DM meds      4. Hyperlipidemia   E78.5  -Continue statin        Code Status   Resuscitation Status - Ordered    -- 05/29/23 9:19:00 EDT, Full Code   Chronic Problem List    Adenocarcinoma of lung  COPD (chronic obstructive pulmonary disease)  Hyperglycemia due to type 2 diabetes mellitus (disorder)  Hyperlipidemia  Procedure/Surgical History  ?infusaport (2013) ?right thoracotomy with wedge resection (2013) ?Cholecystectomy (2011) ?eye muscle surgery (2011) ?laparotomy with bowel resection and appendectomy (2001) ?open reduction internal fixation right ankle with plate and screws (1966) ?Colonoscopy   Surgical History Internal  06/06/2018    Portacath Removal.     MD  09/02/2016    EGD Bx     MD  05/15/2015    Bronchoscopy Diagnostic w Fluoro     MD  10/31/2011    Eye Muscle Repair  (Bilateral)    MD  Medications   Home Medications (8) Active  Aspirin Low Dose 81 mg oral delayed release tablet 81 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  GaviLyte-G oral powder for reconstitution See Instructions, as directed  magnesium oxide 250 mg oral tablet 250 mg = 1 Tablet, Orally, Daily  metFORMIN 500 mg (Eqv-Glucophage XR) oral tablet, extended release 500 mg = 1 Tablet, Orally, Daily  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  sertraline 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, Inhalation, Q4H, and  as  needed  Active Scheduled Inpatient Medications  albuterol-ipratropium (albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL), Inhalation SOLN, 3 mL, Neb Inhal, Q6H, Start: 05/29/23 10:00:00  azithromycin, Tablet, 500 mg, Orally, Daily, Indication: COPD Exacerbation, Start: 05/30/23 09:00:00  azithromycin, Tablet, 500 mg, Orally, Daily, Indication: COPD Exacerbation, Start: 05/30/23 09:00:00  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 05/29/23 10:00:00  methylPREDNISolone (methylPREDNISolone sodium succinate), Injection, 40 mg, IV Push, Q12H, Start: 05/29/23 10:00:00  Sodium Chloride 0.9% 500 mL IV 42 mL/hr Days 1, 3, 5     Dextrose 10% in Water  500 mL IV  PRN - See Comments       One-Time Medications Given 05/28/23 00:00:00 TO 05/29/23 09:21:24  None Reported  PRN Medications (0600 - 0559) from 05/28 - 05/29  glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Current, Beer, 1-2 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Married, 2 children   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Blood clot: Mother and Sister.  Parkinson's disease..: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.5 k/cumm (05/29/23 06:20:00)  RBC: 4.83 million/cumm (05/29/23 06:20:00)  Hgb: 15.2 GM/dL (05/29/23 06:20:00)  Hct: 44.6 % (05/29/23 06:20:00)  MCV: 92 fL (05/29/23 06:20:00)  MCH: 31.4 pg (05/29/23 06:20:00)  MCHC: 34.1 GM/dL (05/29/23 06:20:00)  RDW: 13.9 % (05/29/23 06:20:00)  Platelet: 175 k/cumm (05/29/23 06:20:00)  MPV: 9.2 fL (05/29/23 06:20:00)  Neutrophils %: 65 % (05/29/23 06:20:00)  Lymphocytes %: 16 % (05/29/23 06:20:00)  Monocytes %: 7 % (05/29/23 06:20:00)  Eosinophils %: 10 % (05/29/23 06:20:00)  Basophils %: 1 % (05/29/23 06:20:00)  Absolute Neutrophil: 6.9 k/cumm (05/29/23 06:20:00)  Absolute Lymphocyte: 1.7 k/cumm (05/29/23 06:20:00)  Absolute Monocyte: 0.8 k/cumm (05/29/23 06:20:00)  Absolute Eosinophil: 1 k/cumm High (05/29/23 06:20:00)  Absolute Basophil: 0.1 k/cumm (05/29/23 06:20:00)  Chemistry:  Sodium SerPl QN: 142 mmol/L (05/29/23 06:20:00)  Potassium SerPl QN: 4.1 mmol/L (05/29/23 06:20:00)  Chloride SerPl QN: 105 mmol/L (05/29/23 06:20:00)  Carbon Dioxide SerPl QN: 27 mmol/L (05/29/23 06:20:00)  Anion Gap: 10 mmol/L (05/29/23 06:20:00)  BUN SerPl QN: 33 mg/dL High (05/29/23 06:20:00)  Creatinine SerPl QN: 1.14 mg/dL (05/29/23 06:20:00)  Estimated GFR (CKD-EPI, no race): 67 mL/min/1.73m2 (05/29/23 06:20:00)  Estimated CRCL (CG): 61 mL/min (05/29/23 06:20:00)  Glucose SerPl QN: 217 mg/dL High (05/29/23 06:20:00)  Calcium Total SerPl QN: 9.3 mg/dL (05/29/23 06:20:00)  Alkaline Phos SerPl QN: 75 Units/L (05/29/23 06:20:00)  ALT SerPl QN: 13 Units/L (05/29/23 06:20:00)  AST SerPl QN: 15 Units/L (05/29/23 06:20:00)  Bilirubin Total SerPl QN: 0.7 mg/dL (05/29/23 06:20:00)  Total Protein SerPl QN: 7.7 GM/dL (05/29/23 06:20:00)  Albumin SerPl QN: 4.5 GM/dL (05/29/23 06:20:00)  Troponin-I High Sensitivity: 10 ng/L (05/29/23 07:25:00)  BNP Pl QN: 55 pg/mL (05/29/23 06:20:00)  Lactate Venous Pl QN: 1.5 mmol/L (05/29/23 06:26:00)  pH Bld Venous QN: 7.31 Low (05/29/23 06:20:00)  PCO2 Bld Venous QN: 57 mmHg (05/29/23 06:20:00)  PO2 Bld Venous QN: 56 mmHg High (05/29/23 06:20:00)  Base Excess Bld Venous: 1 mmol/L (05/29/23 06:20:00)  Bicarb Bld Venous Calc: 29 mmol/L (05/29/23 06:20:00)  O2 Sat Bld Venous Calc: 86 % (05/29/23 06:20:00)  Patient Temperature: 37 DegC (05/29/23 06:20:00)  Coagulation:  D-Dimer Pl QN: <200 (05/29/23 06:20:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (05/29/23 06:26:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (05/29/23 06:26:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 05/29/2023 06:43 - XR Chest PA or AP Portable  IMPRESSION:1.  Postsurgical changes related to partial right pneumonectomy.2.  Small right pleural effusion. No focal pulmonary consolidation orpneumothorax.Thank you for consulting our team of subspecialty radiologists Radiology.            Signature Line Electronically Signed on 05/29/23 09:26 EDT ________________________________________________________ MD