Age: 87.0
Sex: F
Vaccine: DTAP
Symptoms: Chronic kidney disease-mineral and bone disorder, Coma scale normal, Condition aggravated, Creatinine renal clearance decreased, Dry skin
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Encounter Info: Observation, 03/20/25 - 03/24/25    * Final Report *        Subjective     Patient is an 87-year-old female past medical history of A-fib, CKD, GERD, hypothyroidism, hypertension, Raynaud's disease, rheumatoid arthritis, TIA, GERD who presented to the ER with complaints of nausea.    Patient was seen and evaluated by her bedside today.  She feels very tired.  She is attributing her tiredness to metoprolol as she endorsed that metoprolol always makes her feel that way.  At home, she is on bisoprolol due to intolerance to metoprolol.  Heart rate is still very difficult to control with metoprolol and diltiazem.  ???????Cardiology has been consulted to assist with heart rate control  Hypertensive on vitals  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI???????  Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 37.2 °C (Oral)  TMIN: 36.3 °C (Route Not Specified)  TMAX: 37.2 °C (Oral)  BP: 145/107  HR: 109 (Monitored)  RR: 16  SpO2: 93%  Oxygen Therapy: Room air  Oxygen Flow Rate: 2 (L/min)  WT: 59.1 kg    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    59.1 kg    03/24/25  Previous Daily Weight:    58.1 kg    03/23/25  Difference from Previous:    1.000 kg  Weight for Nutrition:    240 kg    03/22/25  BMI:    23.4    03/21/25    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    152.4 cm    03/24/25        Nutritional Orders:  Ensure Enlive., 03/21/25 17:22:00 EDT, With Meals  ----------------------  2000 mg Sodium, 20 gm Saturated Fat Diet, Start on: 03/21/25 1:16:00 EDT, "No Fluid Restrictions" mL Nursing  ----------------------     Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 03/23 - 03/24  Total Intake 480.00 mL    Total Output 0.00 mL     Balance 480.00 mL     Physical Exam     General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: No murmur. Respiratory: Lungs are clear to auscultation, Respirations are non-labored. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, ??????? Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling, ???????      Lines, Tubes, and Drains  IV cannula Forearm Right 22 gauge   PIV     Assessment/Plan       Acute-on-chronic kidney injury   N17.9    1. Acute-on-chronic kidney injury   N17.9 Improved today and almost back to baseline.  Nephrology following.  - will need to establish with nephro as o/p   Continue to hold nephrotoxics  2. Chronic kidney disease-mineral and bone disorder   N18.9 3. Hypokalemia   E87.6 Resolved with replacement  4. Elevated troponin   R79.89 Downtrended. 5. Prolonged QT interval   R94.31   replace electrolytes, avoid qtc prolonging meds   Repeat EKG 6. Anemia   D64.9   no overt bleeding, stable on recheck 7. Atrial fibrillation   I48.20  Still In RVR.  dced Metoprolol due to previous intolerance  replaced with carvedilol  Bisoprolol is unavailable in IUH  - continue  home apixaban renally dose,  Cardiology consulted  8. Hypertension   I10 Continue antihypertensives  9. Recurrent falls   R29.6   PT/OT consulted 10. Severe Aortic Stenosis   I35.0  noted   Outpt f/u  Dyslipidemia   E78.5 GERD (gastroesophageal reflux disease)   K21.9  not on medication tx  Hypothyroidism   E03.9  Just recently started on levothyroxine for tsh uptrending 18, symptomatic hypothyroid  T4 is normal  Rheumatoid arthritis   M06.9  continues home leflunomide and prednisone.    Rheumatoid arthritis (disorder)   M06.9 Skin pruritus   L29.9  resolving  Eucerin cream, appears this may be precipitated by dry skin resulting in excoriated areas    ppx - on Eliquis.         Fluids Lines:  PIV Diet:  Heart Healthy Code Status/Goals of Care Discussion: Full Code VTE ppx:  On therapeutic anticoagulation Dispo:  Inpatient Anticipated Length of stay on admission: Less than 2 midnights   Discharge Disposition: _Expect the patient to be medically ready for discharge in tomorrow, pending patient vital signs (HR/BP/RR/T) are within stable discharge parameters  Location: Plan for discharge to be determined after therapy evaluations Discharge Needs: None Case Management Engaged   Anemia   D64.9    Atrial fibrillation   I48.20    Chronic kidney disease-mineral and bone disorder   N18.9    Dyslipidemia   E78.5    Elevated troponin   R79.89    GERD (gastroesophageal reflux disease)   K21.9    Hypertension   I10    Hypokalemia   E87.6    Hypothyroidism   E03.9    Prolonged QT interval   R94.31    Recurrent falls   R29.6    Rheumatoid arthritis   M06.9    Rheumatoid arthritis (disorder)   M06.9    Severe Aortic Stenosis   I35.0    Skin pruritus   L29.9    Orders:   carvedilol, 25 mg, Orally, Tablet, BID, 03/24/25 21:00:00 EDT  Electrocardiogram   Code Status  Resuscitation Status - Ordered    -- 03/21/25 1:16:00 EDT, DNR/DNI/Comprehensive Care   Medications   Active Scheduled Inpatient Medications  apixaban, Tablet, 2.5 mg, Orally, BID, Start: 03/21/25 09:00:00  carvedilol, Tablet, 25 mg, Orally, BID, Start: 03/24/25 21:00:00  cetirizine, Tablet, 10 mg, Orally, Daily, Start: 03/21/25 12:03:00  diltiaZEM (diltiaZEM (Eqv-Cardizem CD) 120 mg/24 hours oral capsule, extended release), Cap, Extended Rel, 120 mg, Orally, Daily, Start: 03/23/25 22:00:00  folic acid, Tablet, 1 mg, Orally, Daily, Start: 03/21/25 12:04:00  leflunomide, Tablet, 10 mg, Orally, Daily, Start: 03/22/25 09:00:00  levothyroxine, Tablet, 25 mCg, Orally, Daily, Start: 03/22/25 06:00:00  predniSONE, Tablet, 2.5 mg, Orally, Daily, Start: 03/21/25 12:04:00    One-Time Medications Given 03/23/25 00:00:00 TO 03/24/25 12:13:42  metoPROLOL (metoPROLOL tartrate), Tablet, 25 mg, Orally, ONCE, (1 DOSE 03/23/25 11:44:00)  metoPROLOL (metoPROLOL tartrate), Injection, 5 mg, IV Push, ONCE, (1 DOSE 03/23/25 14:18:00)  metoPROLOL (metoPROLOL tartrate), Injection, 5 mg, IV Push, ONCE, (1 DOSE 03/23/25 17:09:00)  PRN Medications (0600 - 0559) from 03/23 - 03/24  OXYcodone, 2.5 mg, Orally, Q4H, 0  Dose(s)   acetaminophen, 1,000 mg, Orally, Q8H, 0  Dose(s)   fentaNYL, 12.5 mCg, IV Push, Q4H, 0  Dose(s)   hydrOXYzine, 25 mg, Orally, Q8, 0  Dose(s)   magnesium sulfate, 2 GM, IVPB, Q12H, 0  Dose(s)   magnesium sulfate, 4 GM, IVPB, Q12H, 0  Dose(s)   morphine, 1 mg, IV Push, Q10min, 0  Dose(s)   potassium chloride, 20 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 30 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 40 mEq, Orally, Unscheduled, 0  Dose(s)   potassium phosphate-sodium phosphate, 250 mg, Orally, Unscheduled, 0  Dose(s)   trimethobenzamide, 200 mg, IM, Q8H, 0  Dose(s)   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.1 k/cumm (03/24/25 02:15:00)  RBC: 3.6 million/cumm Low (03/24/25 02:15:00)  Hgb: 10.1 GM/dL Low (03/24/25 02:15:00)  Hct: 30.4 % Low (03/24/25 02:15:00)  MCV: 85 fL (03/24/25 02:15:00)  MCH: 28 pg (03/24/25 02:15:00)  MCHC: 33.1 GM/dL (03/24/25 02:15:00)  RDW: 19.4 % High (03/24/25 02:15:00)  Platelet: 477 k/cumm High (03/24/25 02:15:00)  MPV: 7.9 fL (03/24/25 02:15:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (03/24/25 02:15:00)  Potassium SerPl QN: 4.3 mmol/L (03/24/25 02:15:00)  Chloride SerPl QN: 100 mmol/L (03/24/25 02:15:00)  Carbon Dioxide SerPl QN: 25 mmol/L (03/24/25 02:15:00)  Anion Gap: 10 mmol/L (03/24/25 02:15:00)  BUN SerPl QN: 34 mg/dL High (03/24/25 02:15:00)  Creatinine SerPl QN: 1.28 mg/dL High (03/24/25 02:15:00)  Estimated GFR (CKD-EPI, no race): 41 mL/min/1.73m2 Low (03/24/25 02:15:00)  Estimated CRCL (CG): 24 mL/min Low (03/24/25 02:15:00)  Glucose SerPl QN: 94 mg/dL (03/24/25 02:15:00)  Calcium Total SerPl QN: 8.7 mg/dL (03/24/25 02:15:00)  Phosphorus SerPl QN: 3.5 mg/dL (03/24/25 02:15:00)  Magnesium SerPl QN: 2.1 mg/dL (03/24/25 02:15:00)  Urine Studies:  Color: Light-Yellow (03/23/25 18:24:00)  Clarity: Clear (03/23/25 18:24:00)  Specific Gravity: 1.017 (03/23/25 18:24:00)  pH: 6.5 (03/23/25 18:24:00)  Protein: 100 Abnormal (03/23/25 18:24:00)  Glucose: Normal (03/23/25 18:24:00)  Ketones: NEGATIVE (03/23/25 18:24:00)  Bilirubin: NEGATIVE (03/23/25 18:24:00)  Hgb Ur: NEGATIVE (03/23/25 18:24:00)  Nitrite: NEGATIVE (03/23/25 18:24:00)  Urobilinogen: 2.0 2 Abnormal (03/23/25 18:24:00)  Leukocyte Esterase Ur: NEGATIVE (03/23/25 18:24:00)  WBC: 0-5 (03/23/25 18:24:00)  RBC: None Seen (03/23/25 18:24:00)  Bacteria: NONE (03/23/25 18:24:00)  Squamous Epithelial: Few (03/23/25 18:24:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 03/24/2025 07:11 - XR Chest PA or AP Portable  IMPRESSION:1.  Large hiatal hernia.2.  Increasing bilateral infiltrates with increasing atelectasis andconsolidation in the left lower lobe and a small-moderate leftpleural effusion.