Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy, Asthenia
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on May 24, 2023 16:27    Verified By: NP on May 24, 2023 16:28   Encounter Info: Hospital, Inpatient, 05/24/23 -     * Final Report *  Document Has Been Revised And Contains Addenda          History of Present Illness/Subjective     76 year old female with Hx of CHF, GERD, COPD, CAD, OSA, Stage 3 CKD, HTN, PE, HLD, and T2DM, a fib on anticoagulation presents to the ED via EMS c/o weakness. Patient presents from ECF for generalized weakness for the past week and hemoglobin of 5.6. Patient has also gained 17 pounds in the past 2 weeks. Pt states that she had a positive Hemoccult earlier today. Patient was admitted earlier in May for the same issues and received 2 units of blood at that time. FMHx of colon cancer. Pt reports black stools recently, no nausea vomiting or hematemesis.   Upon ER evaluation her temperature was 36.8, respiratory rate was 20, heart rate was 66 she was on 3 L per nasal cannula which is her baseline, nocturnally uses 5 L..  Blood pressure was 151/76 chest x-ray showed central venous access port, coronary vascular congestion with coarse lung markings similar to prior no focal infiltrates.  Lab work revealed a normal white blood cell count of 6.0, hemoglobin was 6.3, sodium was 140, potassium was 4.3, GFR was slightly decreased from baseline at 52, troponin was 9 repeat was 7, BNP was elevated at 479.  In the ER they started 1 unit of packed red blood cells and consulted with Dr. Will bring patient in for further evaluation management of GI bleed and CHF exacerbation.  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  T: 36.7 °C (Oral)  BP: 136/72  HR: 70 (Monitored)  RR: 18  SpO2: 100%  Oxygen Therapy: Nasal Cannula Humidified  Oxygen Flow Rate: 2 (L/min)  WT: 99 kg  BMI: 37.5   Hemodynamics   Neurologic   Patient Weight  Current Daily Weight:    99 kg    05/24/23  Previous Daily Weight:    99 kg    05/24/23  BMI:    37.5    05/24/23    Obese (BMI 30-39.9) Patient Height  Current Height:    162.54 cm    05/24/23        Constitutional:   No acute distress ,   well-nourished Eyes:  PEERL,  EOMI,   normal conjunctiva ,   no scleral icterus ENMT:   Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB cough Cardiovascular:   Regular rate and rhythm Gastrointestinal:  Soft, non-tender,  non-distendedlarge abd hernia Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary: + Bilateral lower extremity edema Neurologic:  Alert & Oriented x 3, no cognitive impairment ,   no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. GI bleed   K92.2   ? Check hemoglobins every 6 hours ? Received 1 unit of packed red blood cells in the ER, transfuse further units for any hemoglobin less than 7 ? GI has been consulted.  -BID protonix  -Hold anticoagulation and ASA  -Will need to wait at least 24 hrs to do EGD last eliquis 5/24. Clr liq for now     2. (HFpEF) heart failure with preserved ejection fraction   I50.30  -acute exacerbation  Resume home meds  -On iv lasix for now, monitor diuresis  -npo for now then advance to low sodium diet  -On BB     3. Acute kidney injury superimposed on chronic kidney disease   N17.9  Noted monitoring daily labs     4. Seizure disorder   G40.909  resume keppra     5. HTN (hypertension)   I10  resume losartan     6. Depression   F32.9  resume prozac, lyrica     Acute respiratory failure   J96.00  on baseline o2 of 3-5L and occasionally uses bipap  -RT will manage   Ordered:   montelukast, 10 mg, Orally, Tablet, At Bedtime, 05/24/23 21:00:00      COPD mixed type   J44.9  Noted continue RT protocol, resume montelukast     Coronary artery disease (CAD)   I25.10  Resume home meds statin, holding ASA     Iron deficiency anemia   D50.9  Resume home meds     OSA on CPAP   G47.33  RT protocol continue home CPAP     Paroxysmal A-fib   I48.0      Type 2 diabetes mellitus   E11.9  Last A1c was 6.3%, n.p.o. for now but will start carb controlled diet when she is able to eat   ???????Code Status: Full code   DVT ppx: SCD since she is here with a GI bleed     Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 05/24/23 16:01:00   albuterol-ipratropium, 3 mL, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, 05/24/23 17:00:00  atorvastatin, 10 mg, Orally, Tablet, At Bedtime, 05/24/23 21:00:00   benzonatate, 100 mg, Orally, Capsule, BID, 05/24/23 21:00:00   calcium carbonate, 750 mg, Orally, Tab, Chewable, 4 Times Daily, PRN, Indigestion, 05/24/23 16:01:00   Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 05/24/23 16:01:00, PRN - See Comments, Clinical Weight  ferrous sulfate, 325 mg, Orally, Tablet, QAM, 05/25/23 9:00:00   FLUoxetine, 40 mg, Orally, Capsule, Daily, 05/25/23 9:00:00  fluticasone-vilanterol, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, BID, 05/24/23 21:00:00   furosemide, 40 mg, IV Push, Injection, BID, 05/24/23 17:00:00   glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 05/24/23 16:01:00   glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 05/24/23 16:01:00   hydroCODONE-acetaminophen, 1 Tablet, Orally, Tablet, Q6H, PRN, Pain, Moderate (4-6 out of 10), 05/24/23 16:01:00   hydrocortisone topical, 1 App, Topical, Ointment, BID, Apply to legs, 05/24/23 21:00:00   insulin glargine, 5 Units, Subcutaneous, Injection, Daily, 05/25/23 9:00:00   insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 05/24/23 16:01:00   labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 05/24/23 16:01:00   leveTIRACetam, 750 mg, Orally, Tablet, BID, 05/24/23 21:00:00   metoPROLOL, 25 mg, Orally, Tablet, BID, 05/24/23 21:00:00   ocular lubricant, 1 App, Eyes, Both, Ophthalmic OINT, Q4H, PRN, Dry Eyes, 05/24/23 16:01:00   ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 05/24/23 16:01:00   pantoprazole, 40 mg, IV Push, Injection, Q12, 05/24/23 21:00:00  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 05/24/23 16:01:00   pregabalin, 50 mg, Orally, Capsule, BID, 05/24/23 21:00:00   Admit to Inpatient   Call (Specify)  Call Blood Glucose  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Hemoglobin  Call Hemoglobin  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Cardiac Rehab Phase II Referral (Outpatient)  Cardiac Rehab Phase III Referral (Outpatient)  Care Management Consult  CBC w/Differential  Comp Metabolic Panel  Emesis Record  Fluid Intake Requirement  Gluc-Strip POC  Heating Pad  Hgb  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Level of Care  Medical Service Consult  Medication Message to Nursing  Message to Nursing  Message to Nursing  Notify Provider  Notify Provider  Notify Provider  NPO  Nutrition Consult  Peripheral IV Insertion  Prepare for Discharge  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Stool Record  Telemetry Class II 48hr Recommendation  Titrate FiO2 to Keep O2 Sat  Vital Signs  Weight  Weight  Code Status   Resuscitation Status - Ordered    -- 05/24/23 16:01:00, Full Code   Chronic Problem List    (HFpEF) heart failure with preserved ejection fraction  Acute kidney injury superimposed on chronic kidney disease  Acute on chronic respiratory failure  Anemia  Back pain  Cellulitis of left leg  Cellulitis of leg  Chronic anemia  Chronic diastolic heart failure  Chronic GERD  Chronic obstructive pulmonary disease  Chronic pain syndrome  Chronic respiratory failure with hypoxia  Chronic venous stasis  COPD mixed type  Coronary artery disease (CAD)  COVID  Depression  Dermatitis associated with moisture  Epiglottic cyst  Falling  Fracture of rib of left side  Generalized weakness  GERD (gastroesophageal reflux disease)  GI bleed  HTN (hypertension)  Hx of pulmonary embolus  Hyperlipidemia  Hyponatremia  Iron deficiency anemia  Left hip pain  Morbid obesity  OSA on CPAP  Paralysis of right vocal cord  Paroxysmal A-fib  Pedal edema  PN (peripheral neuropathy)  Pneumonia  Rib pain on right side  Seizure disorder  Sepsis  Stage III chronic kidney disease  Type 2 diabetes mellitus  UTI (urinary tract infection)  Venous stasis ulcer  Vocal cord nodule  Procedure/Surgical History  ?Mammogram (05/01/2018) ?Cataract surgery (11/2016) ?Eye examination (2016) ?Pelvic examination (10/2015) ?Colonoscopy (05/20/2015) ?Shoulder replacement (03/23/2015) ?Endoscopy and biopsy (04/18/2007) ?bilateral thumbs ?Cholecystectomy Laparoscopic ?Colectomy ?Disc ?gastric banding removal ?Hip Replacement ?Hip replacement ?Hysterectomy ?IVC Filter Placement ?Knee replacement ?Knee replacement ?laparoscopic gastric banding ?lumbar and cervical neck   Surgical History Internal  08/27/2019    Central Line Removal.    DO  07/05/2019    Central Line Insertion.    MD  12/24/2017    Lumbar Laminectomy  (Poss)   MD  11/13/2017    Lumbar Discectomy Posterior  (Bilateral)   MD  11/20/2012    Esophageal Manometry RN Diagnostic Proce      11/05/2012    Gastric Band Revision Lapscpy    MD  10/15/2012    Esophageal Motility      10/15/2012    EGD Bx    MD  Medications   Home Medications (27) Active  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, Q6H  allopurinol 300 mg oral tablet   apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, QAM  Breo Ellipta 100 mCg-25 mCg inhalation powder 1 Puff, Inhalation, BID  cholecalciferol (vitamin D3) 25 mCg (1,000 intl units) oral tablet 1,000 Units = 1 Tablet, Orally, Daily  cloNIDine 0.1 mg oral tablet   cyanocobalamin 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, QAM  FLUoxetine 40 mg oral capsule 40 mg = 1 Capsule, Orally, Daily  hydrocortisone 1% topical ointment 1 App, Topical, BID, apply in a thin film to the affected skin and rub in gently and completely  insulin glargine 100 units/mL subcutaneous solution 5 Units, Subcutaneous, At Bedtime  leveTIRACetam 500 mg oral tablet 750 mg = 1.5 Tablet, Orally, BID  lidocaine 5% topical film   losartan 25 mg oral tablet   Lyrica 50 mg oral capsule 50 mg = 1 Capsule, Orally, BID  metoPROLOL tartrate 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime  NovoLOG (insulin aspart) FlexPen 100 units/mL subcutaneous solution   omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, BID  pantoprazole 40 mg oral delayed release tablet , TAKE 1 TABLET BY MOUTH TWICE DAILY  pramipexole 1 mg oral tablet 1.5 mg = 1.5 Tablet, Orally, At Bedtime, prn  simvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, At Bedtime  torsemide 20 mg oral tablet 40 mg = 2 Tablet, Orally, Daily  traMADOL 50 mg oral tablet   Tylenol 325 mg oral capsule 650 mg = 2 Capsule, PRN, Orally, Q6H  Zanaflex 4 mg oral tablet 4 mg = 1 Tablet, Orally, QHS  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: 05/24/23 19:00:00  allopurinol, Tablet, 300 mg, Orally, Daily, Start: 05/25/23 09:00:00  atorvastatin, Tablet, 10 mg, Orally, At Bedtime, Start: 05/24/23 21:00:00  benzonatate (Tessalon Perles), Capsule, 100 mg, Orally, BID, Start: 05/24/23 21:00:00  ferrous sulfate (iron sulfate), Tablet, 325 mg, Orally, QAM, Start: 05/25/23 09:00:00  FLUoxetine, Capsule, 40 mg, Orally, Daily, Start: 05/25/23 09:00:00  fluticasone-vilanterol (Breo Ellipta 100 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, BID, Start: 05/24/23 21:00:00  furosemide, Injection, 40 mg, IV Push, BID, Start: 05/24/23 17:00:00  hydrocortisone topical (hydrocortisone 1% topical ointment), Ointment, 1 App, Topical, BID, Start: 05/24/23 21:00:00  insulin glargine (insulin glargine 100 units/mL subcutaneous solution), Injection, 5 Units, Subcutaneous, Daily, Start: 05/25/23 09:00:00  leveTIRACetam, Tablet, 750 mg, Orally, BID, Start: 05/24/23 21:00:00  metoPROLOL (metoPROLOL tartrate), Tablet, 25 mg, Orally, BID, Start: 05/24/23 21:00:00  montelukast (montelukast 10 mg oral tablet), Tablet, 10 mg, Orally, At Bedtime, Start: 05/24/23 21:00:00  pantoprazole, Injection, 40 mg, IV Push, Q12, Start: 05/24/23 21:00:00  pregabalin (Lyrica), Capsule, 50 mg, Orally, BID, Start: 05/24/23 21:00:00  Dextrose 10% in Water  500 mL IV  PRN - See Comments       One-Time Medications Given 05/23/23 00:00:00 TO 05/24/23 16:26:44  None Reported  PRN Medications (0600 - 0559) from 05/23 - 05/24  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   calcium carbonate, 750 mg, Orally, 4 Times Daily, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q6H, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   labetalol, 10 mg, IV Push, Q6H, 0  Dose(s)   ocular lubricant, 1 App, Eyes, Both, Q4H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   fosphenytoin (Severe bradycardia and hypotension)  lisinopril (Cough)  dicloxacillin (Tolerated amoxicillin 10/2017, Rash)  gabapentin (Altered mental status)  pneumococcal vaccines (swelling of site)  Demerol. (vomiting)  erythromycin (rash)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Nutrition/Health   Caffeine intake amount: 2-3 cups soda daily.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smokeless tobacco user, quit more than 30 days ago.  Family History   Cancer of colon: Father.  Clotting Disorder: Sister.  Congestive Heart Failure: Mother.  Depression: Sister.  Heart Attack: Brother.  High Blood Pressure: Mother.  Hyperlipidemia: Mother.  Lymphoma: Brother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6 k/cumm (05/24/23 12:14:00)  RBC: 2.14 million/cumm Low (05/24/23 12:14:00)  Hgb: 6.3 GM/dL Low (05/24/23 12:14:00)  Hct: 19.9 % Low (05/24/23 12:14:00)  MCV: 93 fL (05/24/23 12:14:00)  MCH: 29.3 pg (05/24/23 12:14:00)  MCHC: 31.6 GM/dL Low (05/24/23 12:14:00)  RDW: 17.5 % High (05/24/23 12:14:00)  Platelet: 257 k/cumm (05/24/23 12:14:00)  MPV: 7.7 fL (05/24/23 12:14:00)  Neutrophils %: 44 % (05/24/23 12:14:00)  Lymphocytes %: 41 % (05/24/23 12:14:00)  Monocytes %: 9 % (05/24/23 12:14:00)  Eosinophils %: 5 % (05/24/23 12:14:00)  Basophils %: 1 % (05/24/23 12:14:00)  Absolute Neutrophil: 2.6 k/cumm (05/24/23 12:14:00)  Absolute Lymphocyte: 2.4 k/cumm (05/24/23 12:14:00)  Absolute Monocyte: 0.6 k/cumm (05/24/23 12:14:00)  Absolute Eosinophil: 0.3 k/cumm (05/24/23 12:14:00)  Absolute Basophil: 0.1 k/cumm (05/24/23 12:14:00)  Chemistry:  Sodium SerPl QN: 140 mmol/L (05/24/23 12:14:00)  Potassium SerPl QN: 4.3 mmol/L (05/24/23 12:14:00)  Chloride SerPl QN: 105 mmol/L (05/24/23 12:14:00)  Carbon Dioxide SerPl QN: 28 mmol/L (05/24/23 12:14:00)  Anion Gap: 7 mmol/L (05/24/23 12:14:00)  BUN SerPl QN: 63 mg/dL High (05/24/23 12:14:00)  Creatinine SerPl QN: 1.11 mg/dL (05/24/23 12:14:00)  Estimated GFR (CKD-EPI, no race): 52 mL/min/1.73m2 Low (05/24/23 12:14:00)  Estimated CRCL (CG): 50 mL/min Low (05/24/23 12:14:00)  Glucose SerPl QN: 110 mg/dL High (05/24/23 12:14:00)  Calcium Total SerPl QN: 8.7 mg/dL (05/24/23 12:14:00)  Alkaline Phos SerPl QN: 126 Units/L High (05/24/23 12:14:00)  ALT SerPl QN: 19 Units/L (05/24/23 12:14:00)  AST SerPl QN: 30 Units/L (05/24/23 12:14:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (05/24/23 12:14:00)  Total Protein SerPl QN: 6.8 GM/dL (05/24/23 12:14:00)  Albumin SerPl QN: 3.2 GM/dL Low (05/24/23 12:14:00)  Troponin-I High Sensitivity: 7 ng/L (05/24/23 13:40:00)  BNP Pl QN: 479 pg/mL High (05/24/23 12:14:00)  Urine Studies:  Color: Light-Yellow (05/24/23 14:11:00)  Clarity: Clear (05/24/23 14:11:00)  Specific Gravity: 1.01 (05/24/23 14:11:00)  pH: 5 (05/24/23 14:11:00)  Protein: NEGATIVE (05/24/23 14:11:00)  Glucose: Normal (05/24/23 14:11:00)  Ketones: NEGATIVE (05/24/23 14:11:00)  Bilirubin: NEGATIVE (05/24/23 14:11:00)  Hgb Ur: NEGATIVE (05/24/23 14:11:00)  Nitrite: NEGATIVE (05/24/23 14:11:00)  Urobilinogen: Normal (05/24/23 14:11:00)  Leukocyte Esterase Ur: NEGATIVE (05/24/23 14:11:00)  All Other Labs:  ABO Rh: A Pos (05/24/23 12:14:00)  IAT Interp: Neg (05/24/23 12:14:00)  COVID 19 Specimen Source: Nasopharyngeal (05/24/23 13:41:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (05/24/23 13:41:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 05/24/2023 11:48 - XR Chest PA or AP Portable  IMPRESSION:Central venous access port.Coronary vascular congestion with coarse lung markings, similar to5/6/2023.No focal infiltrates.                Signature Line Electronically Signed on 05/24/23 16:28  ________________________________________________________ NP  Electronically Signed on 05/24/23 16:46  ________________________________________________________ NP    Addendum by MD on May 25, 2023 08:49:38 (Verified)    General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple, normal range of motion 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 Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact     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   Hospital Medicine    Patient examined yesterday. Note signed 1 day late.   Signature Line Electronically Signed on 05/25/23 08:50  ________________________________________________________  MD