Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Pneumonia, Procalcitonin, Protein total normal, Protein urine, Pyrexia
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 05, 2023 12:04   Verified By: MD on November 05, 2023 12:40   Encounter Info: Hospital, Inpatient, 11/05/23 -     * Final Report *          History of Present Illness/Subjective     87-year-old female with past medical history of COPD on 2 L of oxygen at baseline through nasal cannula, CHF, afib, diabetes, hypothyroidism, hypertension hyperlipidemia presenting with shortness of breath x few days  Patient was noted to be apparently well until few days ago when she said shortness of breath began.  She had just recovered from COVID diagnosed more than 10 days ago.  She never needed hospitalization or increasing oxygen requirements during her COVID treatments but remembered she was on antibiotics that she could not remember the name.   Shortness of breath progressively got worse until few hours prior to presentation when her oxygen was noted to be low.  She normally uses 2 L of oxygen at home through nasal cannula, while she was checked in the home it was noted that her oxygen saturation dropped to the 70s leading to increased oxygen requirements.  This was associated with altered mental status leading to presentation to the hospital.   No chest pain, abdominal pain, nausea vomiting diarrhea constipation, urinary symptoms, lower extremity or swelling.  No recent travel or sick contacts.  No recent trauma.  She reports fever of 101 this morning   On bedside evaluation, patient is awake and alert AOx3, endorses improvement in shortness of breath.  She notes recurrent episodes of vomiting but no diarrhea.   In the ER  Vitals  Blood pressure 135/62, heart rate 95, respiratory rate 21, SPO2 96% on 2 L of OxiMax   Labs  WBC 21,000, hemoglobin 12.1, platelets 248,  Sodium 141, potassium 4.0, chloride 96, bicarb 36, BUN/creatinine 31/1.04, LFTs unremarkable troponin 29  Lactate 2.6 down trended to 2.1  Blood gas pH 7.43, PCO2 61, bicarb 40  Urinalysis pH 6.5, protein 30, ketones trace, leukocyte esterase trace, WBC 0-5, RBC 3-5  COVID-negative  Flu AB undetected   Imaging CXR  1. Small left pleural effusion and probable left basilar atelectasis, infiltrate and/or parenchymal scarring.  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 Vitals & Measurements most recent past 24 hours  WT: 119.90 kg (WFC)  BMI: 49   Hemodynamics   Neurologic   Patient Weight  Current Daily Weight:    119.9 kg    11/05/23  BMI:    49    11/05/23    Morbid Obesity (BMI > = 40) Patient Height  Current Height:    156.5 cm    11/05/23        General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: Lungs are clear to auscultation, Respirations are non-labored. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling,     Assessment/Plan     87-year-old female with past medical history of COPD on 2 L of oxygen at baseline through nasal cannula, CHF, afib, diabetes, hypothyroidism, hypertension hyperlipidemia presenting with shortness of breath x few days   1. Severe sepsis   R65.20  Evidenced by leukocytosis, lactic acidosis, tachypnea and fever  Source of severe sepsis is likely due to pneumonia.  Recent history of COVID that did not require hospitalization  adequate capillary refill/perfusing pressure on repeat examination, imaging positive for infiltrate,   Patient is already improving and therefore at low risk for hemodynamic and respiratory instability.  Blood cultures pending, urinalysis appears weakly negative at this time,  procalcitonin pending, lactate repeat WNL.    Continue empiric coverage with ceftriaxone and doxycycline.    De-escalate therapy as appropriate. SARS CoV 2 negative.   Continue IVF at 100cc/hr and encourage p.o. hydration   2. Pneumonia   J18.9  Seen on x-ray.  RT eval to follow.  Not requiring 2.5 L of oxygen through facemask.  Baseline is 2 L through nasal cannula.  Reports to be feeling much better.  RT eval to follow  Continue oxygen supplementation to greater than 92%  Takes prednisone 10 mg chronically for unknown reason.  Resume   3. Hypoxia   R09.02  Already improving.  Continue to monitor.  Telemetry   4. Chronic hypercapnic respiratory failure   J96.12  Blood gas shows well compensated respiratory acidosis  RT eval to follow  Continue oxygen supplementation and wean as able   5. Chronic hypoxemic respiratory failure   J96.11    6. Diabetes mellitus type 2, noninsulin dependent   E11.9  CDU protocol in place.  Carb controlled diet   7. Chronically on opiate therapy   Z79.891  Resumed   8. Essential hypertension   I10  Hold antihypertensives due to ongoing sepsis   9. Hyperlipidemia   E78.5  Resume.  Follow-up on lipid profile.   10. Hypothyroidism   E03.9  Follow-up TSH.  Resume current home dose of levothyroxine   11. Obstructive sleep apnea   G47.33  RT eval to follow   12. On apixaban therapy   Z79.01  Resume home meds   13. Severe obesity   E66.01  Counseled on lifestyle modification to encourage weight loss, patient is however not ambulatory  PT eval to follow    Code Status   None Recorded   Chronic Problem List    Abnormal CT of the abdomen  Chronic hypoxemic respiratory failure  Chronically on opiate therapy  Diabetes mellitus type 2, noninsulin dependent  Diuretic-induced hypokalemia  Essential hypertension  History of lumbar laminectomy  History of total knee replacement  Hyperlipidemia  Hypothyroidism  Nausea & vomiting  Noncompliance with CPAP treatment  Obstructive sleep apnea  On apixaban therapy  Severe obesity  Stage 1 mild COPD by GOLD classification  Procedure/Surgical History  ?EGD - Esophagogastroduodenoscopy (11/24/2021) ?Cholecystectomy (12/05/2020) ?Biopsy of breast (01/01/2000) ?Post-surgery back pain (01/01/1999) ?Abdominal hysterectomy (01/01/1987) ?Birth of child  ?Knee Replacement   Surgical History Internal  11/24/2021    EGD Diagnostic    MD  12/05/2020    Cholecystectomy Laparoscopic   MD  Medications   Home Medications (35) Active  acetaminophen 650 mg, PRN, Orally, Q4H  Adalat CC 60 mg oral tablet, extended release 60 mg = 1 Tablet, Orally, Daily  albuterol (Eqv-ProAir HFA) 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H, as needed  albuterol-ipratropium See Instructions, Q 6 HRS  ascorbic acid 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, BID  Aspercreme with Lidocaine 4% topical cream See Instructions, BID right shoulder  Biofreeze 4% topical gel See Instructions, PRN, q 6 hours  Breo Ellipta 200 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  calcium carbonate 500 mg oral tablet, chewable 500 mg = 1 Tablet, PRN, Q2  cholecalciferol (vitamin D3) 50 mCg (2,000 intl units) oral capsule 50 mCg = 1 Capsule, Orally, Daily  Claritin 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  cyanocobalamin 250 mCg oral tablet 2,000 mCg = 8 Tablet, Orally, Daily  diclofenac 1% topical gel See Instructions, TWICE DAILY  ferrous sulfate 325 mg (65 mg elemental iron) oral delayed release tablet 325 mg = 1 Tablet, Orally, BID  guaiFENesin 600 mg oral tablet, extended release 600 mg = 1 Tablet, Orally, BID  hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q6H  Incruse Ellipta 62.5 mCg inhalation powder , 62.5 MG DAILY  Lasix 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  levothyroxine 100 mCg (0.1 mg) oral tablet 100 mCg = 1 Tablet, Orally, Daily  lysine 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  magnesium oxide 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  metFORMIN 750 mg oral tablet, extended release 750 mg = 1 Tablet, Orally, Daily  metOLAzone 2.5 mg oral tablet 2.5 mg = 1 Tablet, Orally, Daily  metoPROLOL succinate 100 mg oral tablet, extended release 100 mg = 1 Tablet, Orally, Daily  Mirapex 1 mg oral tablet 1 mg = 1 Tablet, Orally, BID  montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, QPM  Mucinex DM 30 mg-600 mg oral tablet, extended release 1 Tablet, PRN, Orally, Q12H  Paxil HCl Tab 20 mg 20 mg = 1 Tablet, Orally, Daily  Potassium Chloride (Eqv-K-Tab) 20 mEq oral tablet, extended release 60 mEq = 3 Tablet, Orally, BID  predniSONE 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  PreserVision AREDS 2 oral capsule 1 Capsule, Orally, BID  PreserVision AREDS 2 oral capsule 1 Capsule, Orally, Daily  Refresh ophthalmic solution 1 Drop, PRN, Eyes, Both, Q6H  zinc sulfate 50 mg, Orally, Daily  Zofran 4 mg oral tablet 4 mg = 1 Tablet, PRN, Orally, Q6H  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 11/04/23 00:00:00 TO 11/05/23 12:04:47  None Reported  PRN Medications (0600 - 0559) from 11/04 - 11/05  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Diabetes mellitus: Grandfather (P) and Grandmother (P).  Kidney disease: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 21 k/cumm High (11/05/23 01:38:00)  RBC: 4.32 million/cumm (11/05/23 01:38:00)  Hgb: 12.1 GM/dL (11/05/23 01:38:00)  Hct: 38.3 % (11/05/23 01:38:00)  MCV: 89 fL (11/05/23 01:38:00)  MCH: 28 pg (11/05/23 01:38:00)  MCHC: 31.5 GM/dL Low (11/05/23 01:38:00)  RDW: 17.6 % High (11/05/23 01:38:00)  Platelet: 248 k/cumm (11/05/23 01:38:00)  MPV: 7.7 fL (11/05/23 01:38:00)  Neutrophils %: 84 % (11/05/23 01:38:00)  Lymphocytes %: 12 % (11/05/23 01:38:00)  Monocytes %: 2 % (11/05/23 01:38:00)  Eosinophils %: 0 % (11/05/23 01:38:00)  Basophils %: 1 % (11/05/23 01:38:00)  Absolute Neutrophil: 17.7 k/cumm High (11/05/23 01:38:00)  Absolute Lymphocyte: 2.5 k/cumm (11/05/23 01:38:00)  Absolute Monocyte: 0.4 k/cumm (11/05/23 01:38:00)  Absolute Eosinophil: 0.1 k/cumm (11/05/23 01:38:00)  Absolute Basophil: 0.2 k/cumm (11/05/23 01:38:00)  Chemistry:  Sodium SerPl QN: 141 mmol/L (11/05/23 01:38:00)  Potassium SerPl QN: 4 mmol/L (11/05/23 01:38:00)  Chloride SerPl QN: 96 mmol/L Low (11/05/23 01:38:00)  Carbon Dioxide SerPl QN: 36 mmol/L High (11/05/23 01:38:00)  Anion Gap: 9 mmol/L (11/05/23 01:38:00)  BUN SerPl QN: 31 mg/dL High (11/05/23 01:38:00)  Creatinine SerPl QN: 1.04 mg/dL (11/05/23 01:38:00)  Estimated GFR (CKD-EPI, no race): 52 mL/min/1.73m2 Low (11/05/23 01:38:00)  Estimated CRCL (CG): 47 mL/min Low (11/05/23 01:38:00)  Glucose SerPl QN: 134 mg/dL High (11/05/23 01:38:00)  Calcium Total SerPl QN: 9.6 mg/dL (11/05/23 01:38:00)  Alkaline Phos SerPl QN: 95 Units/L (11/05/23 01:38:00)  ALT SerPl QN: 26 Units/L (11/05/23 01:38:00)  AST SerPl QN: 34 Units/L (11/05/23 01:38:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (11/05/23 01:38:00)  Total Protein SerPl QN: 7.1 GM/dL (11/05/23 01:38:00)  Albumin SerPl QN: 3.6 GM/dL (11/05/23 01:38:00)  Troponin-I High Sensitivity: 9 ng/L (11/05/23 02:50:00)  BNP Pl QN: 29 pg/mL (11/05/23 01:38:00)  Lactate Venous Pl QN: 2.1 mmol/L (11/05/23 04:50:00)  pH Bld Venous QN: 7.43 (11/05/23 01:38:00)  PCO2 Bld Venous QN: 61 mmHg Critical (11/05/23 01:38:00)  PO2 Bld Venous QN: <34 Low (11/05/23 01:38:00)  Base Excess Bld Venous: 13 mmol/L High (11/05/23 01:38:00)  Bicarb Bld Venous Calc: 40 mmol/L High (11/05/23 01:38:00)  O2 Sat Bld Venous Calc: 57 % (11/05/23 01:38:00)  Patient Temperature: 37 DegC (11/05/23 01:38:00)  Urine Studies:  Color: Yellow (11/05/23 05:00:00)  Clarity: Slightly Cloudy (11/05/23 05:00:00)  Specific Gravity: 1.035 High (11/05/23 05:00:00)  pH: 6.5 (11/05/23 05:00:00)  Protein: 30 Abnormal (11/05/23 05:00:00)  Glucose: Normal (11/05/23 05:00:00)  Ketones: TRACE. Abnormal (11/05/23 05:00:00)  Bilirubin: NEGATIVE (11/05/23 05:00:00)  Hgb Ur: NEGATIVE (11/05/23 05:00:00)  Nitrite: NEGATIVE (11/05/23 05:00:00)  Urobilinogen: 2.0 2 Abnormal (11/05/23 05:00:00)  Leukocyte Esterase Ur: Trace25 Abnormal (11/05/23 05:00:00)  WBC: 0-5 (11/05/23 05:00:00)  RBC: 3-5 Abnormal (11/05/23 05:00:00)  Bacteria: TRACE. (11/05/23 05:00:00)  Squamous Epithelial: Moderate (11/05/23 05:00:00)  Amorphous Crys Ur: PRESENT. (11/05/23 05:00:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/05/23 01:38:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/05/23 01:38:00)  Micro - Last 7 days  Rapid Influenza Method: FIA (11/05/23 02:22:00)  Rapid Influenza A: Negative (11/05/23 02:22:00)  Rapid Influenza B: Negative (11/05/23 02:22:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/05/2023 03:09 - XR Chest PA or AP Portable  IMPRESSION: 1.  Small left pleural effusion and probable left basilaratelectasis, infiltrate and/or parenchymal scarring.Template Version: Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 11/05/23 12:40  ________________________________________________________ MD