Age: 81.0
Sex: F
Vaccine: COVID19-2
Symptoms: Carbon dioxide normal, Cardiac failure congestive, Chest discomfort, Chromaturia, Chronic obstructive pulmonary disease
Clinical narrative: Document Type: History and Physical  Document Subject: History & Physical Note  Performed By: MD on December 16, 2022 15:37   Verified By: MD on December 16, 2022 15:37   Encounter Info: Hospital, Inpatient, 12/16/22 - 12/23/22   * Final Report *          History of Present Illness/Subjective    Patient is an 81-year-old female with past history significant for hypertension, COPD, paroxysmal atrial fibrillation, liver cirrhosis and recent history of influenza A present management increase into the shortness of breath and dyspnea on exertion. Patient recently was admitted on 12 8 with influenza pneumonia but was transferred to another facility    Document Type:  History and Physical  Document Subject:  History & Physical Note  Performed By:  MD on December 16, 2022 15:37  Verified By:  MD on December 16, 2022 15:37  Encounter Info:  Hospital, Inpatient, 12/16/22 - 12/23/22    * Final Report *          History of Present Illness/Subjective    Patient is an 81-year-old female with past history significant for hypertension, COPD, paroxysmal atrial fibrillation, liver cirrhosis and recent history of influenza A present management increase into the shortness of breath and dyspnea on exertion. Patient recently was admitted on 12 8 with influenza pneumonia but was transferred to another facility as there were no beds available in this region. She was there until last Monday when she was discharged home. She stated upon discharge she felt fairly well until yesterday. She began feeling a little bit more tired than usual and had a couple of loose stools. Early in the morning she awoke and with acute onset of shortness of breath and some associated chest pressure. No symptoms of vomiting but she had mild nausea. She was weakened with ambulation and felt very tired. Mild shortness of breath. She was unaware of any symptoms of palpitations. The symptoms awoke her from sleep. No symptoms of fever or chills. No symptoms of myalgias or arthralgias.  In the emergency room her blood pressure was 186/75 heart rate 140 respiratory rate 32 temperature 98.1 oxygen saturation was 96% on room air  Serology: White count 9900 with normal differential hemoglobin 12.0 hematocrit 35.7 and a platelet count of 1 84,000. D-dimer 544. Sodium 136 potassium 3.3 chloride of 91 bicarb 29 BUN 7 creatinine 0.51 and a blood sugar of 94. Calcium 9.2 alkaline phosphatase 78 ALT 14 AST 22 total bilirubin 1.5 total protein 6.2 albumin 3.2 magnesium 1.3 initial troponin of 24 BNP 241 ammonia 27 serum lactate 1.3. Urinalysis to gravity 1.010 with pH of 7 trace leukocyte Estrace 11-20 WBCs. COVID PCR negative. Influenza AMB PCR negative. CTA chest:IMPRESSION:  1. Negative for pulmonary embolism.  2. There is tree-in-bud nodularity with bronchial wall thickening.  Findings are suggestive of infectious or inflammatory bronchitis with  airway centered bronchiolitis.  3. Small left and questionable trace right effusions. More confluent  opacity in the left lower lobe more likely reflects atelectasis.  4. Stigmata of previous granulomatous disease.  Past medical history: Chronic pain syndrome/low back pain, COPD, coronary artery disease, liver cirrhosis, paroxysmal atrial fibrillation for which she is not anticoagulated due to her risk of bleeding from her cirrhosis, GERD, hepatic encephalopathy, hypertension, hyperlipidemia, history of C. difficile colitis, tobacco use, recurrent UTIs, osteoarthritis  Review of Systems    All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.4 (37.4-37.4) Temp (FAHR) 99.3 (99.3-99.3), BP 157/69 (147-169)/(68-91), HR 141 (70-141), RR 26 (22-49), O2Sat 99 (92-99)    Patient Weight  Current Daily Weight: 65 kg 12/16/22    Patient Height  Current Height: 175.3 cm 12/16/22        General: Alert and oriented, No mild respiratory distress.  Eye: Extraocular movements are intact, Vision unchanged  HEENT: Normocephalic, Normal hearing  Neck: Supple, Non-tender  Respiratory: Bilateral crackles with scant wheezing, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness.  Cardiovascular: Tachycardic rate, irregularly irregular rhythm, No murmur, No gallop, Normal peripheral perfusion, Good pulses equal in all extremities, No edema.  Gastrointestinal: Soft, nontender, nondistended, normal bowel sounds, no evidence of hepatosplenomegaly.  Lymphatics: No lymphadenopathy neck  Musculoskeletal: Normal range of motion, generalized weakness  Integumentary: Warm, Dry, No rash.  Feet: Normal by visual exam, Normal pulses, Sensation intact.  Neurologic: Alert, Oriented, Normal motor function  Psychiatric: Cooperative, Appropriate mood & affect, Normal judgment.    Assessment/Plan      1. Atrial fibrillation with rapid ventricular response I48.91  Likely brought on by recent pneumonia and associated sepsis and influenza. She was placed in the ICU setting on a Cardizem drip. We will uptitrate both her beta-blocker and calcium channel blocker therapy. We will obtain a cardiac echo to reevaluate her LV systolic function. Thyroid function testing pending. We will replete both magnesium and potassium. We will continue to follow closely in ICU setting. Cardiology has deferred anticoagulation because of her history of liver cirrhosis and risk of bleeding.    2. Sepsis A41.9  Patient fulfills criteria for sepsis with source likely being that of pneumonia. Blood cultures x2 as well as procalcitonin, urine for Legionella and strep antigens, and sputum cultures all pending. Patient has several allergies/intolerances. She had been placed on appropriate broad-spectrum IV antibiotic therapy. We will follow-up on culture data make adjustments accordingly. Sepsis power plan has been initiated. Holding IV fluid boluses and IV fluids due to underlying CHF exacerbation    3. Pneumonia J18.9  As above.    4. CHF exacerbation I50.9  Likely due to her A. fib RVR in conjunction with sepsis. Continue treatment of above-mentioned rhythm and infection. We will start IV Lasix therapy for the next 24 hours and monitor her renal function and electrolyte status closely.    5. COPD mixed type J44.9  Noted. Mild evidence of bronchospasm. RT protocol for now. Hold off steroid therapy at this time and will utilize as needed albuterol/ipratropium.    6. UTI (urinary tract infection) N39.0  Urinalysis consistent with UTI. Will await urine culture. Antibiotics as mentioned above.    7. Hypomagnesemia E83.42  Noted. Will replete currently and continue electrolyte replacement protocol.    8. Liver cirrhosis K74.60  Noted. Ammonia levels were low and no evidence of encephalopathy at this time. Continue Xifaxan therapy and close monitoring for mentation changes with repeat ammonia level at that time.    9. Hypokalemia E87.6  Noted. Potassium replacement protocol in place.    10. Hyperlipidemia E78.5  Noted. We will start patient's statin therapy as well.    Ordered:    pramipexole, 0.25 mg, Orally, Tablet, At Bedtime, 12/16/22 21:00:00     11. Hypertension I10  Clinically stable this time. We will titrate in her home regimen as indicated.    12. GERD (gastroesophageal reflux disease) K21.9  Continue reflux precautions and PPI therapy.    Ordered:    pramipexole, 0.25 mg, Orally, Tablet, At Bedtime, 12/16/22 21:00:00     Orders:  acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 12/16/22 14:08:00  acetaminophen, 1,000 mg, Orally, Tablet, Q8H, PRN, Pain Mild PO (1-3 out of 10), 12/16/22 14:08:00   albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q4H, PRN, Dyspnea, 12/16/22 14:27:00, RT Care Assessment and Protocol per Policy  albuterol-ipratropium, 3 mL, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, PRN, Wheezing/Shortness of Breath, 12/16/22 15:31:00  atorvastatin, 20 mg, Orally, Tablet, At Bedtime, 12/16/22 21:00:00  benzonatate, 100 mg, Orally, Capsule, TID, 12/16/22 15:00:00  cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), 12/16/22 15:00:00, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  diltiaZEM, 240 mg, Orally, Cap, Extended Rel, Daily, NOW, 12/16/22 14:14:00  diltiaZEM 125 mg + Dextrose 5% in Water 125 mL, Total Volume (mL) = 125, IV, 12/16/22 14:10:00, Titrate - See comments  doxycycline, 100 mg, IVPB, Injection, Q12, 12/16/22 14:45:00, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100  enoxaparin, 40 mg, Subcutaneous, Injection, Daily, Routine, 12/17/22 9:00:00  furosemide, 40 mg, IV Push, Injection, TID, 12/16/22 15:00:00  hydrALAZINE, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 12/16/22 14:08:00  magnesium sulfate, 2 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 12/16/22 14:09:00, 25 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 50  magnesium sulfate, 4 GM, IVPB, Infusion, ONCE, 12/16/22 15:00:00 EST, 12/16/22 15:00:00, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  magnesium sulfate, 4 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 12/16/22 14:09:00, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  metoPROLOL, 50 mg, Orally, Tab, Extended Rel, Daily, NOW, 12/16/22 14:14:00  pantoprazole, 40 mg, Orally, Tab, Delayed Rel, Daily, 12/16/22 15:00:00  potassium chloride, 20 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 12/16/22 14:09:00  potassium chloride, 40 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 12/16/22 14:09:00  potassium chloride, 30 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 12/16/22 14:09:00  rifaXIMin, 550 mg, Orally, Tablet, BID, 12/16/22 21:00:00  vancomycin, 750 mg = 7.5 mL, IVPB, Injection, Q12H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 12/17/22 2:00:00  vancomycin, 1,250 mg, IVPB, Injection, ONCE, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 12/16/22 15:00:00, 12/16/22 15:00:0, 125 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 250  2000 mg Sodium, 20 gm Saturated Fat Diet  Admit to Inpatient CAH  Blood CX  Blood CX  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  CBC w/Differential  Collect Specimen  Collect Specimen  Comp Metabolic Panel  Continuous Oxygen Saturation  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Echocardiogram with Cardiac Doppler PW/CW/Color  Incentive Spirometry  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  Level of Care  Magnesium SerPl QN  Medical Service  MRSA PCR  Nasal Cannula  Nasal Cannula  Notify Provider  Notify Provider  Notify Provider  OT Evaluation and Treatment  Peripheral IV Insertion  Potassium SerPl QN  Procalcitonin  PT Evaluation and Treatment  Resp CX + Stn  Resp Evaluation or Assessment  Resuscitation Status  RVP2 PCR  Strep pneumoniae Ag Urine  Troponin-I High Sensitivity  Troponin-I High Sensitivity  TSH w FreeT4 reflex  Vancomycin Pharmacy Dosing Consult  Vital Signs  Vital Signs  Weight  GI and DVT prophylaxis have been addressed.  Home medications were reviewed and appropriate medications ordered at this time.  Total critical care time: Approximately 40 minutesA. fib with RVR/sepsis/pneumonia/COPD/CHF exacerbation  Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers.  This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time.  Code Status  Resuscitation Status - Ordered  -- 12/16/22 14:08:00, Full Code    Chronic Problem List    Abnormal liver function test  Abscess of oral tissue  Acute UTI  AF (atrial fibrillation)  Atrial fibrillation with rapid ventricular response  Back pain  Bartholin's cyst  Benign esophageal stricture  CHF exacerbation  Chronic anemia  Chronic diarrhea  Cirrhosis  Clostridium difficile colitis  Confusion  COPD mixed type  Coronary artery disease involving native coronary artery of native heart without angina pectoris  Cough  Diverticulosis of colon  Dyslipidemia  Dysphagia  Dysuria  Emphysema/COPD  Esophagitis, reflux  Essential hypertension  Frequency of urination and polyuria  Generalized weakness  GERD (gastroesophageal reflux disease)  H/O fall  Hearing loss  Hepatic encephalopathy  Hyperlipidemia  Hypertension  Hypokalemia  Hypomagnesemia  Incomplete bladder emptying  Irritable bowel syndrome  Leg edema  Limb cramps  Liver cirrhosis  Loose stools  Mixed hyperlipidemia  NASH (nonalcoholic steatohepatitis)  Oral lesion  Oral mucosal lesion  Osteoarthritis  Osteoarthritis of right knee  Other idiopathic peripheral autonomic neuropathy  Paroxysmal atrial fibrillation  Pedal edema  Pneumonia  Recurrent UTI  Sepsis  Shoulder pain  Tobacco use  Tobacco use  Unsteady gait  UTI (urinary tract infection)  UTI symptoms  Vitamin D deficiency  Procedure/Surgical History  oMammogram - screening (12/23/2019)  oBone density scan (07/20/2017)  oColonoscopy (2014)  oEsophagogastroduodenoscopy (EGD) with closed biopsy (2014)  oCataract Extraction (2012)  oColectomy (1997)  oHysterectomy (1970)  oLaparototomy (1970)  oLaminectomy, Cervical (1967)  oAppendectomy (1965)  oAnterior cervical discectomy and fusion  oleft hip fx repair  oMiscellaneous  oNACL    Surgical History Internal  07/27/2021 EGD Clip Placement Secondary, MD  05/03/2021 EGD Diagnostic, MD  04/19/2021 Colonscpy Bx, MD  09/06/2019 EGD Balloon Dilate Less 30mm, MD  03/16/2019 EGD Balloon Dilate Less 30mm, MD  08/30/2018 EGD Balloon Dilate Less 30mm, MD  02/10/2018 EGD Diagnostic, MD  01/24/2018 EGD Balloon Dilate Less 30mm, MD  01/26/2015 Colonscpy Diagnostic/Screen, MD  Medications  Home Medications (24) Active  Acidophilus Probiotic Blend oral capsule 1 Tablet, Orally, Every Noon  Advil , PRN, Orally, Q6H  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H, COPD J44.9 Diagnosis  Anoro Ellipta 62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  ascorbic acid 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, QAM, Vitamin C  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, QAM  chlorthalidone 25 mg oral tablet See Instructions, TAKE ONE-HALF TABLET BY MOUTH EVERY MORNING  Compression Stockings (ONCE) Not Applicable, Other, Unscheduled, Dispense 1 pair of stockings; wear as directed.  Diflucan 200 mg oral tablet 200 mg = 1 Tablet, Orally, Every Friday  diltiaZEM (Eqv-Cardizem CD) 180 mg/24 hours oral capsule, extended release 180 mg = 1 Capsule, Orally, Daily  fosfomycin 3 g oral granule for reconstitution 3 GM = 1 Each, Orally, ONCE, dissolve in 4 ounces of water, once per week for 3 months  gabapentin 100 mg oral capsule See Instructions, TAKE 1 CAPSULE BY MOUTH FOUR TIMES DAILY  lactulose 10 GM/15 mL oral syrup See Instructions, TAKE 15-20 ML BY MOUTH 2-3 TIMES A DAY TO HAVE 2-3 BOWEL MOVEMENTS DAILY  lidocaine 5% topical film 1 Patch, Topical, Daily  Marys Magic Potion oral soln (Compounded Product) Use as directed, Orally, BID, 5mL. Swish and swallow for 14 days  metoPROLOL succinate 25 mg oral capsule, extended release 25 mg = 1 Capsule, Orally, Daily  Misc Supplies See Instructions, Rollator walker with seat  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  omeprazole 40 mg oral delayed release capsule See Instructions, TAKE 1 CAPSULE BY MOUTH EVERY MORNING  potassium chloride 10 mEq oral capsule, extended release 10 mEq = 1 Capsule, Orally, TID  pramipexole 0.25 mg oral tablet 0.25 mg = 1 Tablet, Orally, At Bedtime  rosuvastatin 5 mg oral tablet 1 Tablet, Orally, Daily  Vitamin D3 5,000 intl units oral tablet 5,000 IntlUnits = 1 Tablet, Orally, Every Noon  Xifaxan 550 mg oral tablet 550 mg = 1 Tablet, Orally, BID  Active Scheduled Inpatient Medications  atorvastatin, Tablet, 20 mg, Orally, At Bedtime, Start: 12/16/22 21:00:00  benzonatate, Capsule, 100 mg, Orally, TID, Start: 12/16/22 15:00:00  cefePIME, Injection, 1 GM, IVPB, Q8H, Indication: Sepsis (Update Indication in 36-48 hrs), Start: 12/16/22 15:00:00  diltiaZEM (Cardizem CD 240 mg/24 hours oral capsule, extended release), Cap, Extended Rel, 240 mg, Orally, Daily, Start: 12/16/22 14:14:00  doxycycline, Injection, 100 mg, IVPB, Q12, Start: 12/16/22 14:45:00  enoxaparin, Injection, 40 mg, Subcutaneous, Daily, Start: 12/17/22 09:00:00  furosemide (Lasix), Injection, 40 mg, IV Push, TID, Start: 12/16/22 15:00:00  magnesium sulfate, Infusion, 4 GM, IVPB, ONCE, Start: 12/16/22 15:00:00  metoPROLOL (metoPROLOL Succinate ER), Tab, Extended Rel, 50 mg, Orally, Daily, Start: 12/16/22 14:14:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 12/16/22 15:00:00  pramipexole (pramipexole 0.25 mg oral tablet), Tablet, 0.25 mg, Orally, At Bedtime, Start: 12/16/22 21:00:00  rifaXIMin (Xifaxan), Tablet, 550 mg, Orally, BID, Start: 12/16/22 21:00:00  vancomycin, Injection, 1,250 mg, IVPB, ONCE, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), Start: 12/16/22 15:00:00  Vancocin, Injection, 750 mg, IVPB, Q12H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), Start: 12/17/22 02:00:00  diltiaZEM PREMIX + Dextrose 5% in Water PREMIX IV Titrate - See comments 5 mg/hr    One-Time Medications Given 12/15/22 00:00:00 TO 12/16/22 15:36:50  None Reported  PRN Medications (0600 - 0559) from 12/15 - 12/16  acetaminophen, 1,000 mg, Orally, Q8H, 0 Dose(s)  acetaminophen, 650 mg, Orally, Q4H, 0 Dose(s)  albuterol, 2.5 mg, Neb Inhal, Q4H, 0 Dose(s)  albuterol-ipratropium, 3 mL, Neb Inhal, Q6H, 0 Dose(s)  hydrALAZINE, 10 mg, IV Push, Q6H, 0 Dose(s)  magnesium sulfate, 2 GM, IVPB, Q12H, 0 Dose(s)  magnesium sulfate, 4 GM, IVPB, Q12H, 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)  Allergies  Demerol. (nausea, difficult waking)  LORazepam (confusion)  Biaxin (hard for liver to process)  Zithromax (hard for liver to process)  clindamycin (hx of c.diff)  sulfa drugs (pt/daughter not sure of reaction)  Augmentin (Confusion with 875 mg only)  Cipro (Confusion)  Haldol (daughter stated aggitation)  Keflex (Confusion)  Social History    Alcohol    Denies    Electronic Cigarette/Vaping    E-Cigarette Use Never.    Employment/School    Retired, Work/School description: The patient worked as a hairdressor and akso as a gas keak inspector. She did have some exposure to dust and fumes.. Workplace hazards: Hazardous materials.    Exercise    Exercise duration: 30. Exercise frequency: 5-6 times/week. Self assessment: Poor condition. Exercise type: Walking, The patient has a ramp built at her house where she walks up and down for strength training. Before falling and breaking her hip in June of this year she walked frequently..    Home/Environment    Lives with Significant other. Home equipment: Respiratory treatments. Alcohol abuse in household: No. Substance abuse in household: No. Smoker in household: Yes. Injuries/Abuse/Neglect in household: No. Feels unsafe at home: No. Safe place to go: Yes. Agency(s)/Others notified: No. Family/Friends available for support: Yes.    Nutrition/Health    Type of diet: The patient has had oral surgery limits recently which have her drinking a lot of her nutrients.. She uses Boost nutritional drinks to improve her nutrtional intake.. Diet: Regular.    Other    Substance Abuse    Denies    Tobacco    Tobacco Use: Smokeless tobacco user within last 30 days.  Family History  Aneurysm..: Brother.  Factor 5 Leiden mutation, heterozygous...: Brother.  Heart disease..: Father and Sister.  Myocardial infarction: Father.  Parathyroid: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.9 k/cumm (12/16/22 05:20:00)  RBC: 4.08 million/cumm (12/16/22 05:20:00)  Hgb: 12 GM/dL (12/16/22 05:20:00)  Hct: 35.7 % (12/16/22 05:20:00)  MCV: 87 fL (12/16/22 05:20:00)  MCH: 29.4 pg (12/16/22 05:20:00)  MCHC: 33.6 GM/dL (12/16/22 05:20:00)  RDW: 13 % (12/16/22 05:20:00)  Platelet: 184 k/cumm (12/16/22 05:20:00)  MPV: 8.9 fL (12/16/22 05:20:00)  Neutrophils %: 76 % (12/16/22 05:20:00)  Lymphocytes %: 12 % (12/16/22 05:20:00)  Monocytes %: 11 % (12/16/22 05:20:00)  Eosinophils %: 1 % (12/16/22 05:20:00)  Basophils %: 0 % (12/16/22 05:20:00)  Absolute Neutrophil: 7.5 k/cumm (12/16/22 05:20:00)  Absolute Lymphocyte: 1.1 k/cumm (12/16/22 05:20:00)  Absolute Monocyte: 1.1 k/cumm (12/16/22 05:20:00)  Absolute Eosinophil: 0.1 k/cumm (12/16/22 05:20:00)  Absolute Basophil: 0 k/cumm (12/16/22 05:20:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (12/16/22 05:20:00)  Potassium SerPl QN: 3.4 mmol/L Low (12/16/22 15:08:00)  Chloride SerPl QN: 91 mmol/L Low (12/16/22 05:20:00)  Carbon Dioxide SerPl QN: 29 mmol/L (12/16/22 05:20:00)  Anion Gap: 16 mmol/L High (12/16/22 05:20:00)  BUN SerPl QN: 7 mg/dL (12/16/22 05:20:00)  Creatinine SerPl QN: 0.51 mg/dL Low (12/16/22 05:20:00)  Estimated GFR (CKD-EPI, no race): >90 (12/16/22 05:20:00)  Estimated CRCL (CG): 93 mL/min (12/16/22 05:20:00)  Glucose SerPl QN: 94 mg/dL (12/16/22 05:20:00)  Calcium Total SerPl QN: 9.2 mg/dL (12/16/22 05:20:00)  Alkaline Phos SerPl QN: 78 Units/L (12/16/22 05:20:00)  ALT SerPl QN: 14 Units/L (12/16/22 05:20:00)  AST SerPl QN: 22 Units/L (12/16/22 05:20:00)  Bilirubin Total SerPl QN: 1.5 mg/dL High (12/16/22 05:20:00)  Total Protein SerPl QN: 6.2 GM/dL Low (12/16/22 05:20:00)  Albumin SerPl QN: 3.2 GM/dL Low (12/16/22 05:20:00)  Magnesium SerPl QN: 1.3 mg/dL Low (12/16/22 06:45:00)  Troponin-I High Sensitivity: 24 ng/L High (12/16/22 06:45:00)  BNP Pl QN: 241 pg/mL High (12/16/22 05:20:00)  Ammonia Pl QN: 27 mCmol/L (12/16/22 05:20:00)  Lactate Venous Pl QN: 1.3 mmol/L (12/16/22 05:20:00)  Coagulation:  D-Dimer Pl QN: 544 ng/mL DDU High (12/16/22 05:20:00)  Urine Studies:  Color: Yellow (12/16/22 07:32:00)  Clarity: Clear (12/16/22 07:32:00)  Specific Gravity: 1.010 (12/16/22 07:32:00)  pH: 7.0 (12/16/22 07:32:00)  Protein: NEGATIVE (12/16/22 07:32:00)  Glucose: NEGATIVE (12/16/22 07:32:00)  Ketones: 15 Abnormal (12/16/22 07:32:00)  Bilirubin: NEGATIVE (12/16/22 07:32:00)  Hgb Ur: NEGATIVE (12/16/22 07:32:00)  Nitrite: NEGATIVE (12/16/22 07:32:00)  Urobilinogen: NormalUro (12/16/22 07:32:00)  Leukocyte Esterase Ur: TRACE. Abnormal (12/16/22 07:32:00)  WBC: 11-20 Abnormal (12/16/22 07:32:00)  RBC: None Seen (12/16/22 07:32:00)  Bacteria: TRACE. (12/16/22 07:32:00)  Squamous Epithelial: Few (12/16/22 07:32:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (12/16/22 05:20:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (12/16/22 05:20:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/16/22 05:20:00)  Rapid Influenza A PCR: Not Detected (12/16/22 05:20:00)  Rapid Influenza B PCR: Not Detected (12/16/22 05:20:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits  12/16/2022 06:24 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1. Negative for pulmonary embolism.2. There is tree-in-bud nodularity with bronchial wall thickening.Findings are suggestive of infectious or inflammatory bronchitis withairway centered bronchiolitis.3. Small left and questionable trace right effusions. More confluentopacity in the left lower lobe more likely reflects atelectasis.4. Stigmata of previous granulomatous disease.Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Cardiothoracic. For after-hours or emergency department cases, pleasecall.              Signature Line  Electronically Signed on 12/16/22 15:37  ________________________________________________________  MD