Age: 60.0
Sex: M
Vaccine: COVID19-2
Symptoms: Aspiration pleural cavity, Asthenia, Atelectasis, Auscultation, Base excess
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on February 12, 2023 00:28   Verified By: DO on February 12, 2023 00:28   Encounter Info: Hospital, Inpatient, 02/11/23 -     * Final Report *  Document Has Been Revised        Chief Complaint   Shortness of Breath  History of Present Illness/Subjective     60-year-old male with a past medical history of chronic HFpEF CAD CVA DVT hypertension and type 2 diabetes presented to ED complaining of dyspnea that started the day prior to his presentation. He is well known to me, this provider admitted him for similar complaints and presentation  Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on February 12, 2023 00:28   Verified By: DO on February 12, 2023 00:28    Encounter Info: Hospital, Inpatient, 02/11/23 -     * Final Report *  Document Has Been Revised        Chief Complaint   Shortness of Breath  History of Present Illness/Subjective     60-year-old male with a past medical history of chronic HFpEF CAD CVA DVT hypertension and type 2 diabetes presented to ED complaining of dyspnea that started the day prior to his presentation. He is well known to me, this provider admitted him for similar complaints and presentation on 01/20/23, he was diuresed, had a therapeutic thoracentesis and was discharged. He returns saying he feels worse than before but labs, imaging suggest his pleural effusion is stable but likely has pulmonary edema. Please see H&P from 01/20/2023 for additional background hx.  Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.4 (36.4-36.4)  Temp (FAHR) 97.5 (97.5-97.5), BP 187/100 (187-187)/(100-100), HR 87 (87-87), RR 18 (18-18), O2Sat 97 (97-97)     Patient Weight  Current Daily Weight:    133.9 kg    02/11/23    Patient Height        Constitutional:  No acute distress,  well-nourished Eyes:  PERRL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB, no crackles, however some decreased breath sounds in left base Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal: 2+ pitting edema in bilateral lower extremities extending to knee, no deformity Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan     1. Hypertensive crisis   I16.9  resume home meds with the exception of amlodipine due to LE edema  2. Respiratory failure with hypoxia   J96.91  likely 2/2 uncontrolled hypertension and recurrent pleural effusion/pulm edema  cont supplemental o2, svns, diuresis  3. Recurrent pleural effusion on left   J90  patient has had multiple thoracentesis this year, will attempt diuresis before obtaining consult for additional thoracentesis  4. (HFpEF) heart failure with preserved ejection fraction   I50.30  cont home meds  recent echo shows normal EF and was otherwise benign  likely not in acute exacerbation given bnp being wnl  cont diuresis  5. Bilateral lower extremity edema   R60.0  possibly 2/2 chronic dvt vs chf  6. Generalized weakness   R53.1 7. Physical deconditioning   R53.81  likely due to pleural effusion, hypertensive crisis, as well as over all physical deconditioning from repeat admissions this month  may need SAR upon discharge, patient is agreeable  8. Coronary artery disease   I25.10  Noted. Cont home meds, control bp. trop negative and patient not experiencing chest pain makes ACS very unlikely  9. Hypertension   I10  see plan above, cont home meds except amlodipine  10. Uncontrolled type 2 diabetes mellitus   E11.65  poc glucose checks  iss  diabetic diet  11. Mixed hyperlipidemia   E78.2  cont home meds, had recent lipid panel  12. History of DVT in adulthood   Z86.718  obtain records from last LE doppler, patient states he had one this month and doesn't want another one if possible  patient is not on anticoagulation and doesn't remember why not, possibility of  obtain d-dimer  13. Proteinuria   R80.9  noted. needs to follow up with nephrologist outpatient.   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/11/23 22:11:00   Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 02/11/23 22:11:00, PRN - See Comments, Clinical Weight  docusate, 100 mg, Orally, Capsule, BID, 02/12/23 9:00:00   furosemide, 40 mg, IV Push, Injection, Q12, 02/12/23 9:00:00   glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 02/11/23 22:11:00   glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 02/11/23 22:11:00   heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 02/11/23 23:00:00   hydroCODONE-acetaminophen, 1 Tablet, Orally, Tablet, Q6H, PRN, Pain, Moderate (4-6 out of 10), 02/11/23 22:48:00   insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 02/11/23 22:11:00   180 gm Carb per day Diet  Admit to Inpatient CAH  Aspiration Precautions  Basic Metabolic Panel  Bladder Scan  BNP Pl QN  Call (Specify)  Call Blood Glucose  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  Care Management Consult  CBC w/Differential  Digoxin SerPl QN  Fall Precautions  Fluid Intake Requirement  Gluc-Strip POC  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Intake + Output Strict  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Magnesium SerPl QN  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  Notify Provider  Notify Provider  Notify Provider  Nutrition Consult  Peripheral IV Insertion  PT Evaluation and Treatment  Reason for Not Ordering Long-acting Insulin  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Sodium Ur Ran QN  Telemetry Class III 24hr Recommendation  Titrate FiO2 to Keep O2 Sat  TSH w FreeT4 reflex  Vital Signs  Weight  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 02/11/23 22:11:00, Full Code   Chronic Problem List    Anxiety and depression  Chronic heart failure with preserved ejection fraction (HFpEF)  Coronary artery disease  Coronary artery disease without angina pectoris  CVA (cerebrovascular accident)  Deep vein thrombosis  Generalized weakness  Hypertension  Long term use of drug  Mixed hyperlipidemia  Neck pain  OSA (obstructive sleep apnea)  Pharyngeal lesion  Physical debility  Pleural effusion  Presence of drug coated stent in LAD coronary artery  Proteinuria  Psoriatic arthritis  S/P gastric bypass  Severe obesity  Staphylococcus aureus septicemia  Uncontrolled type 2 diabetes mellitus  Procedure/Surgical History  ocompound fracture repair R LE (1972) oGastric bypass operation opsa 2011 oRotator cuff repair oRotator cuff repair oUlnar nerve decompression   Surgical History Internal  05/11/2021    Soft Tissue I and D  MD  Medications   Home Medications (11) Active  aspirin 81 mg oral delayed release tablet 81 mg = 1 Tablet, Orally, QAM  atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, At Bedtime  carvedilol 6.25 mg oral tablet 3.125 mg = 0.5 Tablet, Orally, BID  furosemide 40 mg oral tablet 20 mg = 0.5 Tablet, Orally, Daily  gabapentin 800 mg oral tablet 800 mg = 1 Tablet, Orally, 4 Times Daily  hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q6H  Lantus (insulin glargine) SoloStar Pen 100 units/mL subcutaneous solution 60 Units, Subcutaneous, QAM  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, QAM  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, Sublingually, Q5min, not to exceed 3 doses/15 min--if pain persists, seek medical attention  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily  Voltaren Topical 1% topical gel 2 GM, Topical, 4 Times Daily  Active Scheduled Inpatient Medications  docusate (docusate sodium), Capsule, 100 mg, Orally, BID, Start: 02/12/23 09:00:00  furosemide, Injection, 40 mg, IV Push, Q12, Start: 02/12/23 09:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 02/11/23 23:00:00  Dextrose 10% in Water  500 mL IV  PRN - See Comments       One-Time Medications Given 02/11/23 00:00:00 TO 02/12/23 00:28:07  None Reported  PRN Medications (0600 - 0559) from 02/11 - 02/12  acetaminophen, 650 mg, Orally, Q4H, 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, 1  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   Allergies   NKA  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   disability   Home/Environment   Lives with Spouse. Living situation: Home/Independent. Alcohol abuse in household: No. Substance abuse in household: No. Smoker in household: No. Injuries/Abuse/Neglect in household: No.   Nutrition/Health   Diet: Regular. Wants to lose weight: Yes. Sleeping concerns: Yes. Feels highly stressed: No.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Cancer: Mother, Father and Sister.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.1 k/cumm (02/11/23 18:09:00)  RBC: 4.35 million/cumm (02/11/23 18:09:00)  Hgb: 12.2 GM/dL Low (02/11/23 18:09:00)  Hct: 37.1 % Low (02/11/23 18:09:00)  MCV: 85 fL (02/11/23 18:09:00)  MCH: 28 pg (02/11/23 18:09:00)  MCHC: 32.8 GM/dL (02/11/23 18:09:00)  RDW: 14.8 % High (02/11/23 18:09:00)  Platelet: 235 k/cumm (02/11/23 18:09:00)  MPV: 6.5 fL Low (02/11/23 18:09:00)  Neutrophils %: 72 % (02/11/23 18:09:00)  Lymphocytes %: 18 % (02/11/23 18:09:00)  Monocytes %: 5 % (02/11/23 18:09:00)  Eosinophils %: 4 % (02/11/23 18:09:00)  Basophils %: 1 % (02/11/23 18:09:00)  Absolute Neutrophil: 7.3 k/cumm (02/11/23 18:09:00)  Absolute Lymphocyte: 1.8 k/cumm (02/11/23 18:09:00)  Absolute Monocyte: 0.5 k/cumm (02/11/23 18:09:00)  Absolute Eosinophil: 0.4 k/cumm High (02/11/23 18:09:00)  Absolute Basophil: 0.1 k/cumm (02/11/23 18:09:00)  Chemistry:  Sodium SerPl QN: 145 mmol/L (02/11/23 18:09:00)  Potassium SerPl QN: 4 mmol/L (02/11/23 18:09:00)  Chloride SerPl QN: 111 mmol/L High (02/11/23 18:09:00)  Carbon Dioxide SerPl QN: 26 mmol/L (02/11/23 18:09:00)  Anion Gap: 8 mmol/L (02/11/23 18:09:00)  BUN SerPl QN: 31 mg/dL High (02/11/23 18:09:00)  Creatinine SerPl QN: 1.39 mg/dL (02/11/23 18:09:00)  Estimated GFR (CKD-EPI, no race): 58 mL/min/1.73m2 Low (02/11/23 18:09:00)  Estimated CRCL (CG): 71 mL/min (02/11/23 18:09:00)  Glucose SerPl QN: 186 mg/dL High (02/11/23 18:09:00)  Calcium Total SerPl QN: 8 mg/dL Low (02/11/23 18:09:00)  Alkaline Phos SerPl QN: 83 Units/L (02/11/23 18:09:00)  ALT SerPl QN: 9 Units/L (02/11/23 18:09:00)  AST SerPl QN: 14 Units/L (02/11/23 18:09:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (02/11/23 18:09:00)  Total Protein SerPl QN: 5.9 GM/dL Low (02/11/23 18:09:00)  Albumin SerPl QN: 3 GM/dL Low (02/11/23 18:09:00)  Lipase SerPl QN: 19 Units/L (02/11/23 18:09:00)  Troponin-I High Sensitivity: 12 ng/L (02/11/23 19:26:00)  BNP Pl QN: 62 pg/mL (02/11/23 18:09:00)  Gluc-Strip, POC: 111 mg/dL High (02/11/23 22:27:00)  pH Bld Venous QN: 7.41 (02/11/23 18:09:00)  PCO2 Bld Venous QN: 36 mmHg Low (02/11/23 18:09:00)  PO2 Bld Venous QN: 146 mmHg High (02/11/23 18:09:00)  Base Excess Bld Venous: -1 mmol/L (02/11/23 18:09:00)  Bicarb Bld Venous Calc: 23 mmol/L (02/11/23 18:09:00)  O2 Sat Bld Venous Calc: 99 % (02/11/23 18:09:00)  Patient Temperature: 37 DegC (02/11/23 18:09:00)  Coagulation:  D-Dimer Pl QN: 367 ng/mL DDU High (02/11/23 18:09:00)  Toxicology:  Digoxin SerPl QN: <0.2 Low (02/11/23 22:31:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (02/11/23 16:49:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/11/23 16:49:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/11/2023 19:14 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for pulmonary embolism.2.  Small-moderate left pleural effusion, slightly increased from CTcomparison.3.  Bibasilar airspace opacities favored represent atelectasis.4.  Pulmonary mosaic attenuation which is likely related to smallairway disease and air trapping.5.  Noncalcified pulmonary nodules. One along the right major fissureis slightly enlarged and may represent an intrapulmonary lymph node.Another in the right upper lobe is new and is favoredinfectious/inflammatory. Recommend 3 month follow-up CT to documentstability and/or resolution.6.  Mild mediastinal lymphadenopathy, favored reactive.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 02/12/23 00:28  ________________________________________________________ DO  Electronically Signed on 02/12/23 00:30  ________________________________________________________ DO