Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Rales, Red blood cell count decreased, Red cell distribution width increased, SARS-CoV-2 test, SARS-CoV-2 test negative
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on March 21, 2023 16:38 EDT   Verified By: MD on March 21, 2023 16:38 EDT   Encounter Info: Hospital, Inpatient, 03/21/23 -     * Final Report *          History of Present Illness/Subjective     68-year-old full code woman with a past medical history of hypertension, COVID complicated with lung fibrosis, lung nodule, chronic GERD, hypothyroidism presents to of 1 day duration emergency room with complaints of heart palpitations.  Patient was apparently well until 1 day ago when she noticed fluttering in her chest during the women's football game.  The fluttering was on and off but very frequent. There was no associated chest pain, shortness of breath, headache, nausea or vomiting, abdominal pain, no dysuria. No prior fever or ill health before episode. It was first episode.  No history of A-fib.  Patient follows up with cardiologist for unknown specific reason.  Positive family history of significant heart disease.   Patient is full code.   In the ER,  Blood pressure is 134/71, heart rates initially ranged from 1 33-1 36, temperature was normal, she is on 2 L of nasal cannula  On evaluation in the ICU patient was awake and alert, AAOx3, on 2 L of nasal cannula saturating well, with diffuse crackles heard over lung zones.  Pt has already converted back to sinus rhythm on evaluation with well controlled HR    labs  WBC 3.2, hemoglobin 9.8, platelets 113,  Sodium 144, potassium 3.2, anion gap 15, alkaline phosphatase 159 other LFTs within normal limits, glucose 93  BNP 98  COVID-negative  CXR- pulmonary congestion  ECHO pending   Pt is admitted for acute respiratory failure 2/2 new onset afib with flash pulmonary edema  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 last 24 hours  T: 36.5 °C (Oral)  HR: 71 (Peripheral)  HR: 72 (Monitored)  RR: 18  BP: 100/89  SpO2: 93%  WT: 108.50 kg (WFC)  BMI: 37.5  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 2 (L/min)   Hemodynamics (most recent and range for last 24 hours)  Left Ventricular Ejection Fraction: 55  Neurologic (most recent and range for last 24 hours)  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    108.5 kg    03/21/23  BMI:    37.5    03/21/23    Obese (BMI 30-39.9) Patient Height  Current Height:    170.15 cm    03/21/23        General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: diffuse crackles, Respirations are non-labored. on 2L; of INC Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: bilateral leg swelling,     Assessment/Plan     68-year-old full code woman with a past medical history of hypertension, COVID complicated with lung fibrosis, lung nodule, chronic GERD, hypothyroidism presents to of 1 day duration emergency room with complaints of heart palpitations  Pt is admitted for acute respiratory failure 2/2 new onset afib with flash pulmonary edema   1. Atrial fibrillation with RVR   I48.91  Presented with A-fib with RVR with heart rates in the 130s.  Unknown trigger,  Likely due to involvement in anxiety provoking activity.  Heart rate is currently controlled and rhythm is back to sinus.  Other vital signs are stable.    -We will continue rate control with metoprolol 25 mg daily  -We will hold off on anticoagulation for now.  Already discussed with patient the need for anticoagulation if atrial fibrillation recurs.  -Continue telemetry monitoring  -Follow-up TSH level     2. Pulmonary edema   J81.1  Evidence on chest x-ray. Likely flash pulmonary edema from rapid afib. No evidence of sepsis on labs noted on pneumonia  We will continue diuresis-strict input and output and document  -Wean off oxygen as tolerated     3. Pancytopenia   D61.818  Noted on labs.  Symptomatic  We will continue to trend, if continues to downtrend we will get hematology involved     4. Hypokalemia   E87.6  Noted  Replete according to protocol     5. CHF exacerbation   I50.9  -continue to diurese with IV Lasix 40 mg twice daily.  -Monitor blood pressure closely  -Telemetry monitoring  -Strict I's and O's  -Daily weight  -2 g sodium diet  -Trend troponin to peak  -low dose beta blocker  -Will ACE or ARB's for Entresto if BP tolerates  -Cardiac echo for cardiac function and ejection fraction     Fatigue   R53.83  chronic     Post-COVID chronic cough   R05.3  noted   Ordered:   albuterol, 2 Puff, Inhalation, Aerosol, MDI/DPI Inhaler Treatment, Q4H, PRN, Wheezing, 03/21/23 14:02:00 EDT     Seasonal rhinitis   J30.2      Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 03/21/23 13:56:00 EDT  aripiprazole, 20 mg, Orally, Tablet, Daily, 03/22/23 9:00:00 EDT  atorvastatin, 20 mg, Orally, Tablet, Daily, 03/22/23 9:00:00 EDT  azelastine nasal, 1 Spray, intraNASAL, Spray, BID, 03/21/23 21:00:00 EDT  cholecalciferol, 50 mCg, Orally, Tablet, Daily, 03/22/23 9:00:00 EDT  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 03/21/23 14:04:00 EDT, PRN - See Comments, Clinical Weight  enoxaparin, 40 mg, Subcutaneous, Injection, Daily, 03/22/23 9:00:00 EDT  fluticasone-vilanterol, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 03/22/23 9:00:00 EDT  furosemide, 40 mg, IV Push, Injection, Q12, 03/21/23 21:00:00 EDT  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 03/21/23 14:04:00 EDT  glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 03/21/23 14:04:00 EDT  hydrALAZINE, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 03/21/23 13:56:00 EDT  insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 03/21/23 14:04:00 EDT  lamoTRIgine, 100 mg, Orally, Tablet, BID, 03/21/23 21:00:00 EDT  levothyroxine, 100 mCg, Orally, Tablet, Daily, 03/22/23 6:00:00 EDT  loratadine, 10 mg, Orally, Tablet, Daily, 03/22/23 9:00:00 EDT  magnesium sulfate, 4 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 03/21/23 13:57:00 EDT, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  multivitamin, 1 Tablet, Orally, Tablet, Daily, 03/22/23 9:00:00 EDT  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 03/21/23 13:56:00 EDT  pantoprazole, 20 mg, Orally, Tab, Delayed Rel, Daily, 03/22/23 9:00:00 EDT  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 03/21/23 13:56:00 EDT  potassium chloride, 30 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 03/21/23 13:57:00 EDT  potassium chloride, 40 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 03/21/23 13:57:00 EDT  potassium phosphate, 21 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 03/21/23 13:57:00 EDT, 33.33 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 100  potassium phosphate, 14 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 03/21/23 13:57:00 EDT, 33.33 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 100  potassium phosphate, 21 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 03/21/23 13:57:00 EDT, 33.33 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 100  vitamin E, 800 Units, Orally, Capsule, Daily, 03/22/23 9:00:00 EDT  2000 mg Sodium, 20 gm Saturated Fat Diet  Admit to Inpatient   Basic Metabolic Panel  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  Cardiac Rehab Phase II Referral (Outpatient)  Cardiac Rehab Phase III Referral (Outpatient)  Care Management Consult  CBC w/Differential  Collect Specimen  Collect Specimen  Collect Specimen  Echocardiogram with Cardiac Doppler PW/CW/Color  Fluid Intake Requirement  Gluc-Strip POC  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Oxygen Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Intake + Output Strict  Level of Care  Lipid Panel SerPl QN  Medication Message to Nursing  Message to Nursing  Message to Nursing  Message to Nursing  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Nutrition Consult  OT Evaluation and Treatment  Peripheral IV Insertion  PT Evaluation and Treatment  Resuscitation Status  Troponin-I High Sensitivity  TSH w FreeT4 reflex  Vital Signs  Weight  Weight  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 40 minutes of critical care time directly and personally managing the patient. This critical care time included obtaining a history, examining the patient, pulse oximetry, ordering and reviewing the studies, arranging urgent treatment with development of a management plan, evaluation of the patient?s response to treatment, frequent reassessment, and discussions with other clinicians. The 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. Please see the MDM section and the rest of this note for further information on patient assessment and treatment.  Code Status   Resuscitation Status - Ordered    -- 03/21/23 13:56:00 EDT, Full Code   Chronic Problem List    Allergic rhinitis  B12 deficiency  Bipolar disorder  Change in bowel habits  Chronic GERD  Chronic ITP (idiopathic thrombocytopenia)  Chronic left maxillary sinusitis  Concha bullosa  Cough  Dysphagia  Elevated d-dimer  Elevated LFTs  Esophageal reflux  Family hx of colon cancer  Fatty liver  History of colon polyps  Hyperlipidemia  Hypertension  Hypertrophy of both inferior nasal turbinates  Hypomagnesemia  Hypothyroidism  Hypoxia  IDA (iron deficiency anemia)  Irritable bowel syndrome with diarrhea  Morbid obesity  Nasal septal deviation  NASH (nonalcoholic steatohepatitis)  Obstructive sleep apnea on CPAP  Pancytopenia  Pneumonia due to COVID-19 virus  Pre-diabetes  Prediabetes  Schizophrenia  Severe obesity  Solitary pulmonary nodule  Splenomegaly  Procedure/Surgical History  ?Mammogram - screening (06/13/2022) ?Colonoscopy (06/05/2019) ?Colonoscopy (07/21/2017) ?basal skin cell surgery on forehead (04/11/2017) ?Cholecystectomy (07/07/2014) ?Esophagogastroduodenoscopy and biopsy (07/01/2014) ?Diabetic retinal eye exam   Surgical History Internal  06/05/2019    Colonscpy Diagnostic/Screen    MD  07/21/2017    Colonscpy Diagnostic/Screen   MD  Medications   Home Medications (18) Active  amLODIPine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  aripiprazole 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, QHS  azelastine nasal 0.1% spray 2 Spray, intraNASAL, BID  biotin , Orally, Daily  Flonase 50 mCg/inh nasal spray 1 Spray, intraNASAL, QAM  fluticasone-vilanterol 200 mCg-25 mCg inhalation powder 2 puffs, Inhalation, BID  lamoTRIgine 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID  Lasix 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  levothyroxine 0.1 mg (100 mCg) oral tablet 100 mCg = 1 Tablet, Orally, Daily  loratadine 10 mg oral capsule 10 mg = 1 Capsule, Orally, Daily  metFORMIN 850 mg oral tablet 850 mg = 1 Tablet, Orally, BID  Multi-Day Plus Minerals , Orally, Daily  multivitamin with minerals Multiple Vitamins with Minerals oral capsule 1 Capsule, Orally, Daily  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H  Vitamin D3 50 mCg (2,000 intl units) oral capsule 50 mCg = 1 Capsule, Orally, Daily  vitamin E 400 intl units oral capsule 800 Units = 2 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  aripiprazole, Tablet, 20 mg, Orally, Daily, Start: 03/22/23 09:00:00  atorvastatin, Tablet, 20 mg, Orally, Daily, Start: 03/22/23 09:00:00  azelastine nasal, Spray, 1 Spray, intraNASAL, BID, Start: 03/21/23 21:00:00  cholecalciferol (Vitamin D3 (cholecalciferol)), Tablet, 50 mCg, Orally, Daily, Start: 03/22/23 09:00:00  enoxaparin (Lovenox), Injection, 40 mg, Subcutaneous, Daily, Start: 03/22/23 09:00:00  fluticasone-vilanterol (fluticasone-vilanterol 200 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 03/22/23 09:00:00  furosemide, Injection, 40 mg, IV Push, Q12, Start: 03/21/23 21:00:00  lamoTRIgine (lamoTRIgine 100 mg oral tablet), Tablet, 100 mg, Orally, BID, Start: 03/21/23 21:00:00  levothyroxine, Tablet, 100 mCg, Orally, Daily, Start: 03/22/23 06:00:00  loratadine, Tablet, 10 mg, Orally, Daily, Start: 03/22/23 09:00:00  multivitamin (Tab-A-Vite), Tablet, 1 Tablet, Orally, Daily, Start: 03/22/23 09:00:00  pantoprazole, Tab, Delayed Rel, 20 mg, Orally, Daily, Start: 03/22/23 09:00:00  vitamin E, Capsule, 800 Units, Orally, Daily, Start: 03/22/23 09:00:00  Dextrose 10% in Water  500 mL IV  PRN - See Comments       One-Time Medications Given 03/20/23 00:00:00 TO 03/21/23 16:37:21  None Reported  PRN Medications (0600 - 0559) from 03/20 - 03/21  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2 Puff, Inhalation, Q4H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   hydrALAZINE, 10 mg, IV Push, Q6H, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   magnesium sulfate, 4 GM, IVPB, Q12H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   potassium chloride, 30 mEq, Orally, Unscheduled, 0  Dose(s)   potassium chloride, 40 mEq, Orally, Unscheduled, 0  Dose(s)   potassium phosphate, 14 mmol, IVPB, Unscheduled, 0  Dose(s)   potassium phosphate, 21 mmol, IVPB, Unscheduled, 0  Dose(s)   Allergies   NSAIDS (Insomnia)  sulfa drugs (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Highest education level: Some college.   Home/Environment   Lives with Siblings. Home equipment: CPAP/BiPAP.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Alzheimer's disease: Mother.  Anemia: Father.  Aplastic anemia: Father.  Barrett's esophagus...: Mother.  Cardiovascular disease: Father.  Cirrhosis - non-alcoholic: Grandmother (M).  Colon cancer..: Father.  Diabetes mellitus type 2: Mother.  Esophageal cancer: Aunt.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 3.2 k/cumm Low (03/21/23 10:42:00)  RBC: 4.06 million/cumm (03/21/23 10:42:00)  Hgb: 9.8 GM/dL Low (03/21/23 10:42:00)  Hct: 31.8 % Low (03/21/23 10:42:00)  MCV: 79 fL Low (03/21/23 10:42:00)  MCH: 24.1 pg Low (03/21/23 10:42:00)  MCHC: 30.7 GM/dL Low (03/21/23 10:42:00)  RDW: 17.1 % High (03/21/23 10:42:00)  Platelet: 113 k/cumm Low (03/21/23 10:42:00)  MPV: 9.2 fL (03/21/23 10:42:00)  Neutrophils %: 66 % (03/21/23 10:42:00)  Lymphocytes %: 24 % (03/21/23 10:42:00)  Monocytes %: 7 % (03/21/23 10:42:00)  Eosinophils %: 1 % (03/21/23 10:42:00)  Basophils %: 2 % (03/21/23 10:42:00)  Absolute Neutrophil: 2.1 k/cumm (03/21/23 10:42:00)  Absolute Lymphocyte: 0.8 k/cumm Low (03/21/23 10:42:00)  Absolute Monocyte: 0.2 k/cumm (03/21/23 10:42:00)  Absolute Eosinophil: 0 k/cumm (03/21/23 10:42:00)  Absolute Basophil: 0 k/cumm (03/21/23 10:42:00)  Chemistry:  Sodium SerPl QN: 144 mmol/L (03/21/23 10:42:00)  Potassium SerPl QN: 3.2 mmol/L Low (03/21/23 10:42:00)  Chloride SerPl QN: 104 mmol/L (03/21/23 10:42:00)  Carbon Dioxide SerPl QN: 25 mmol/L (03/21/23 10:42:00)  Anion Gap: 15 mmol/L High (03/21/23 10:42:00)  BUN SerPl QN: 10 mg/dL (03/21/23 10:42:00)  Creatinine SerPl QN: 0.92 mg/dL (03/21/23 10:42:00)  Estimated GFR (CKD-EPI, no race): 68 mL/min/1.73m2 (03/21/23 10:42:00)  Estimated CRCL (CG): 74 mL/min (03/21/23 10:42:00)  Glucose SerPl QN: 93 mg/dL (03/21/23 10:42:00)  Calcium Total SerPl QN: 8.9 mg/dL (03/21/23 10:42:00)  Alkaline Phos SerPl QN: 159 Units/L High (03/21/23 10:42:00)  ALT SerPl QN: 11 Units/L (03/21/23 10:42:00)  AST SerPl QN: 25 Units/L (03/21/23 10:42:00)  Bilirubin Total SerPl QN: 0.9 mg/dL (03/21/23 10:42:00)  Total Protein SerPl QN: 6.7 GM/dL (03/21/23 10:42:00)  Albumin SerPl QN: 3.6 GM/dL (03/21/23 10:42:00)  Troponin-I High Sensitivity: 7 ng/L (03/21/23 13:56:00)  BNP Pl QN: 69 pg/mL (03/21/23 13:58:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (03/21/23 12:46:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (03/21/23 12:46:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 03/21/2023 10:34 - XR Chest PA or AP Portable  IMPRESSION:Pulmonary vascular congestion with increased interstitial prominencesuggesting mild/early congestive heart failure.Increasing bibasilar subsegmental atelectasis.                Signature Line Electronically Signed on 03/21/23 16:38 EDT ________________________________________________________ MD