Age: 70.0
Sex: M
Vaccine: UNK
Symptoms: Pain, Platelet count decreased, Pneumonia, Positive airway pressure therapy, Protein total normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: on December 12, 2022 06:51  Verified By: on December 12, 2022 06:51  Encounter Info: Inpatient, 12/12/22 -     * Final Report *        Chief Complaint   Dyspnea  History of Present Illness/Subjective     70-year-old male with past medical history of CAD, CHF, COPD on 2 L nasal cannula at home, and history of DVT presented to ED complaining of worsening shortness of breath over the past day. He does daily breathing treatments 4 times a day at baseline.  He does wear 3 L of nasal cannula at baseline as well.  He has a new cough.  He is felt hot.  He has had nausea vomiting diarrhea.  He notes diffuse body aches.  Denies any focal pain.  Denies any specific chest or abdominal pain. Denies any fever.  He has been taking Tylenol and took a dose prior to arrival.  Denies any change in urination.   In the ED he was noted to have increased work of breathing and was placed on BiPAP.  He had an AKI.  His chest x-ray noted possible pneumonia versus pulmonary edema, but given that patient had elicited fevers at home and there is no lower extremity edema or significant crackles in the bases He was given 2 L of fluid.    When patient arrived he stated that he was feeling better though he remains on BiPAP and appeared to have significant respiratory distress patient confirmed his CODE STATUS is DNR/DNI comprehensive care.  This patient is critically ill due to metabolic, hemodynamic and/or respiratory instability. They require high complexity evaluation, decision making, and care. They require ICU level of care and monitoring due to high risk of clinical decompensation with high risk of morbidity and mortality. Critical care time includes, but is not limited to, bedside assessment, review of medical record, radiographic and laboratory results, ventilator and/or respiratory management, review of ekg and/or cardiac monitoring, critical decision making, coordination of care with consultants and/or care team, and documentation of critical intervention/plans, and consultation with patient and/or family. Time excludes any procedural time.  I spent greater than 65 minutes in the evaluation and management of this patient with more than 50% of the time spent counseling and/or coordinating care.  I counseled the patient and/or family about the findings, differential diagnoses, my assessment, recommendations, and plan.  I coordinated care with the multidisciplinary healthcare team.  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) 36.3 (36.2-36.3)  Temp (FAHR) 97.3 (97.2-97.3), BP 80/51 (72-115)/(50-78), HR 60 (60-90), RR 25 (25-36), O2Sat 96 (92-96) Neurologic (most recent and range for last 24 hours)  GCS 14(14-14)     Patient Weight  Current Daily Weight:    57.7 kg    12/12/22    Patient Height  Current Height:    152.4 cm    12/12/22        Constitutional:  + Severe distress,  + malnourished, elderly appearing ill appearing male Eyes:  PERRL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory: Patient has significant inspiratory wheeze with inspiratory phase greater than expiratory, few crackles scattered Cardiovascular:  Regular rate and rhythm no murmur Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, there is a medial surgical scar extending distally in both thighs and legs, unable to test range of motion 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     Admit to ICU   1. Acute on chronic respiratory failure with hypoxia and hypercapnia   J96.21  Continue BiPAP, serial ABGs, patient is DNR/DNI, while patient is on BiPAP we will make him n.p.o. except meds   2. Pneumonia   J18.9  No white count but given that patient complained of fevers is experiencing diaphoresis here will cover for CAP with Rocephin and Doxy  Repeat chest x-ray   3. COPD with exacerbation   J44.1  Every 2 hours DuoNebs as needed  Was given 125mg soluMedrol IV in ED will give an additional 40 now and continue 40 twice daily to titrate as needed   4. Chronic CHF   I50.9  Possibility of acute CHF exists however on my exam patient does not have wet sounding lungs and said I hear significant inspiratory wheeze which makes me suspect the pathology of his illness lies more within the airways   Upon arrival to ICU patient was given one-time dose of 40 mg Lasix however almost no urine output was produced subsequently confirming my original suspicion that patient acute kidney injury was driven by dehydration and therefore pulmonary edema is much less likely an infectious and inflammatory source of COPD exacerbation  Continue home meds as able to  Obtain stat echo   5. Hyponatremia   E87.1  Resolved with IV fluid administration    6. Acute kidney injury   N17.9  Improved with fluid administration after dose of Lasix can expect a mild bump in renal function will give IV fluids and continue to monitor   7. Thrombocytopenia   D69.6  If platelets drop less than 100,000 we will stop chemical DVT prophylaxis and use mechanical only continue to monitor platelet count unclear etiology possibly reactive   8. Elevated troponin   R77.8  Continue to monitor possibly secondary to AKI versus demand ischemia, patient denies any chest pain at this less likely  Maintain telemetry   9. Elevated lactic acid level   R79.89  Improving after IV fluid administration we will continue to trend until normalized   10. Coronary artery disease   I25.10  Noted.  Continue statin, medications as to   11. History of DVT in adulthood   Z86.718  No evidence of acute DVT currently, patient is not on any anticoagulation at home   12. Hyperlipidemia, mixed   E78.2  Continue home meds as able to   13. DVT prophylaxis   Z29.9    Prognosis is guarded   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 12/12/22 3:13:00  albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q2H, PRN, Dyspnea, 12/12/22 4:18:00, RT Care Assessment and Protocol per Policy  albuterol-ipratropium, 3 mL, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, 12/12/22 4:00:00  albuterol-ipratropium, 3 mL, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, PRN, Shortness of Breath/Wheezing, 12/12/22 3:13:00  ceftRIAXone, 1 GM, IVPB, Injection, Q24H, 12/13/22 23:00:00, for 4 Doses, 12/16/22 23:00:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  dexmedetomidine 400 mCg + Sodium Chloride 0.9% 100 mL, Total Volume (mL) = 100, IV, 12/12/22 3:25:00, Titrate - See Comments  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 12/12/22 3:13:00, PRN - See Comments, Clinical Weight  doxycycline, 100 mg, IVPB, Injection, Q12H, 12/12/22 11:00:00, for 9 Doses, 12/16/22 11:00:00, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 12/12/22 3:13:00  glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 12/12/22 3:13:00  heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 12/12/22 4:00:00  insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 12/12/22 3:13:00  methylPREDNISolone, 40 mg, IV Push, Injection, Q12H, 12/12/22 4:00:00  miconazole topical, 1 App, Topical, Powder, TID, Apply to Groin, 12/12/22 3:41:00  OXYcodone, 2.5 mg, Orally, Tablet, Q4H, PRN, Pain Moderate PO (4-6 out of 10), 12/12/22 3:13:00  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 12/12/22 3:13:00  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV, 12/12/22 3:42:00, Other - See Comments, Clinical Weight  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV, 12/12/22 3:42:00, Other - See Comments, Clinical Weight  180 gm Carb per day Diet  Admit to Inpatient  Aspiration Precautions  Auto Diff  Basic Metabolic Panel  Bed Request (Decision to Admit)  BIPAP Intermittent  Bladder Scan  Blood Gas Arterial 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  CBC w/Differential  CBC w/Differential  Comp Metabolic Panel  Comp Metabolic Panel  COPD Education per Respiratory Care  D-Dimer Pl QN  Echocardiogram with Cardiac Doppler PW/CW/Color  Electrocardiogram  Fall Precautions  Fluid Intake Requirement  Gluc-Strip POC  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  Lactate Pl Venous QN  Lactate Pl Venous QN  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Medication Message to Nursing  Message to Nursing  Message to Nursing  Notify Provider  Notify Provider  Notify Provider  Peripheral IV Insertion  Phosphorus SerPl QN  PT Evaluation and Treatment  Pulmonary Rehab Inpatient Evaluation  Reason for Not Ordering Long-acting Insulin  Resp Evaluation or Assessment  Resuscitation Status  Strep pneumoniae Ag Urine  Telemetry Class III 24hr Recommendation  Titrate FiO2 to Keep O2 Sat  Troponin-I High Sensitivity  TSH w FreeT4 reflex  UA Microscopic  Urinalysis  Urinary Catheter Insertion  Urinary Catheter to Dependent Drainage  Urine CX  Vital Signs  Weight  Weight  XR Chest PA or AP Portable   Code Status   Resuscitation Status - Ordered    -- 12/12/22 3:42:00, DNR/DNI/Comprehensive Care   Chronic Problem List    Acute on chronic heart failure  Anemia  Atherosclerosis of native arteries of extremity with intermittent claudication  CAD (coronary artery disease), native coronary artery  Cardiomyopathy, ischemic  Carotid artery stenosis  Chronic CHF  COPD with exacerbation  DVT of proximal lower limb  Dysphagia  Gastric hemorrhage due to angiodysplasia of stomach  Heart failure with reduced ejection fraction  History of GI bleed  Hyperlipidemia, mixed  Hyponatremia  Melena  Mitral regurgitation  Pacemaker  Presence of single chamber implantable cardioverter-defibrillator (ICD)  Respiratory tract infection due to COVID-19 virus  Systolic CHF, chronic  TIA (transient ischemic attack)  Tobacco use  Ventricular tachycardia  Procedure/Surgical History  ?SBC (04/12/2022) ?Colonoscopy (03/21/2022) ?EGD - Esophagogastroduodenoscopy (03/21/2022) ?vt ablation (03/02/2017) ?Angioplasty ?bone graft ?cardiac bypass ?defibulator ?left heart cath   Surgical History Internal  03/21/2022    Colonscpy Bx   Medications   Home Medications (12) Active  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL , USE 1 VIAL FOUR TIMES DAILY  atorvastatin 40 mg oral tablet See Instructions, TAKE ONE TABLET BY MOUTH EVERY DAY  escitalopram 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  furosemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  hydroCHLOROthiazide 12.5 mg oral capsule See Instructions, TAKE ONE CAPSULE BY MOUTH EVERY DAY  magnesium chloride   magnesium oxide 400 mg oral tablet 400 mg = 1 Tablet, Orally, BID  metoPROLOL tartrate 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID  pantoprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, Daily, for one month due to hx of recent GI bleed. Eval pending.   Cancel pepcid  Prilosec 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  ProAir HFA 90 mcg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily, yours may be blue ( Ventolin) you already have at home.  spironolactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  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: 12/12/22 04:00:00  ceftRIAXone, Injection, 1 GM, IVPB, Q24H, Start: 12/13/22 23:00:00  doxycycline, Injection, 100 mg, IVPB, Q12H, Start: 12/12/22 11:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 12/12/22 04:00:00  methylPREDNISolone (methylPREDNISolone sodium succinate), Injection, 40 mg, IV Push, Q12H, Start: 12/12/22 04:00:00  miconazole topical (miconazole 2% topical powder), Powder, 1 App, Topical, TID, Start: 12/12/22 03:41:00  Dexmedetomidine PREMIX + Sodium Chloride 0.9% PREMIX IV Titrate - See Comments 0 mCg/kg/hr  12/12/22  Dextrose 10% in Water PREMIX  500 mL IV  PRN - See Comments     Sodium Chloride 0.9%  500 mL IV  Other - See Comments     Sodium Chloride 0.9%  500 mL IV  Other - See Comments       One-Time Medications Given 12/11/22 00:00:00 TO 12/12/22 06:50:44  furosemide (Lasix), Injection, 40 mg, IV Push, ONCE, (1 DOSE 12/12/22 04:05:00)  Sodium Chloride 0.9% (NS Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 12/12/22 06:16:00)  PRN Medications (0600 - 0559) from 12/11 - 12/12  OXYcodone, 2.5 mg, Orally, Q4H, 0  Dose(s)   acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 2.5 mg, Neb Inhal, Q2H, 0  Dose(s)   albuterol-ipratropium, 3 mL, Neb Inhal, Q6H, 1  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   penicillins (Swelling Pharyngeal, Hives)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with ex wife.   Nutrition/Health   Diet: Regular.   Other   RHD   Substance Abuse   Denies   Tobacco   Tobacco Use: 5-9 cigarettes (between 1/4 to 1/2 pack)/day in last 30 days. 1 packs per day. 55 year(s). Total pack years: 55. Started age 15.0 Years. Ready to change: No. Smoking cessation information given: Yes.  Family History   Chest pain..: Father.  Heart attack..: Negative: Sister.  Heart disease..: Negative: Sister.  Stroke: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 8.2 k/cumm (12/12/22 03:38:00)  RBC: 3.68 million/cumm Low (12/12/22 03:38:00)  Hgb: 11.5 GM/dL Low (12/12/22 03:38:00)  Hct: 34.8 % Low (12/12/22 03:38:00)  MCV: 95 fL (12/12/22 03:38:00)  MCH: 31.2 pg (12/12/22 03:38:00)  MCHC: 33 GM/dL (12/12/22 03:38:00)  RDW: 16.2 % High (12/12/22 03:38:00)  Platelet: 104 k/cumm Low (12/12/22 03:38:00)  MPV: 11.1 fL (12/12/22 03:38:00)  Neutrophils %: 77 % (12/12/22 03:38:00)  Lymphocytes %: 17 % (12/12/22 03:38:00)  Monocytes %: 5 % (12/12/22 03:38:00)  Eosinophils %: 0 % (12/12/22 03:38:00)  Basophils %: 1 % (12/12/22 03:38:00)  Absolute Neutrophil: 6.3 k/cumm (12/12/22 03:38:00)  Absolute Lymphocyte: 1.4 k/cumm (12/12/22 03:38:00)  Absolute Monocyte: 0.4 k/cumm (12/12/22 03:38:00)  Absolute Eosinophil: 0 k/cumm (12/12/22 03:38:00)  Absolute Basophil: 0.1 k/cumm (12/12/22 03:38:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (12/12/22 03:38:00)  Potassium SerPl QN: 4.7 mmol/L (12/12/22 03:38:00)  Chloride SerPl QN: 100 mmol/L (12/12/22 03:38:00)  Carbon Dioxide SerPl QN: 23 mmol/L (12/12/22 03:38:00)  Anion Gap: 12 mmol/L High (12/12/22 03:38:00)  BUN SerPl QN: 52 mg/dL High (12/12/22 03:38:00)  Creatinine SerPl QN: 1.81 mg/dL High (12/12/22 03:38:00)  Estimated GFR (CKD-EPI, no race): 40 mL/min/1.73m2 Low (12/12/22 03:38:00)  Estimated CRCL (CG): 30 mL/min Low (12/12/22 03:38:00)  Glucose SerPl QN: 166 mg/dL High (12/12/22 03:38:00)  Calcium Total SerPl QN: 7.9 mg/dL Low (12/12/22 03:38:00)  Alkaline Phos SerPl QN: 76 Units/L (12/12/22 03:38:00)  ALT SerPl QN: 23 Units/L (12/12/22 03:38:00)  AST SerPl QN: 50 Units/L High (12/12/22 03:38:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (12/12/22 03:38:00)  Total Protein SerPl QN: 7.2 GM/dL (12/12/22 03:38:00)  Albumin SerPl QN: 3.3 GM/dL Low (12/12/22 03:38:00)  Lipase SerPl QN: 20 Units/L (12/11/22 22:01:00)  Troponin-I High Sensitivity: 72 ng/L High (12/12/22 03:38:00)  BNP Pl QN: 285 pg/mL High (12/11/22 22:01:00)  Lactate Venous Pl QN: 1.8 mmol/L (12/12/22 03:38:00)  Gluc-Strip, POC: 159 mg/dL High (12/12/22 03:25:00)  pH Bld Arterial QN: 7.25 Low (12/12/22 03:43:00)  PCO2 Bld Arterial QN: 50 mmHg High (12/12/22 03:43:00)  PO2 Bld Arterial QN: 85 mmHg (12/12/22 03:43:00)  Base Excess Bld Arterial: -6 mmol/L Low (12/12/22 03:43:00)  Bicarb Bld Arterial Calc: 22 mmol/L (12/12/22 03:43:00)  O2 Sat Bld Arterial Calc: 95 % (12/12/22 03:43:00)  pH Bld Venous QN: 7.37 (12/11/22 22:01:00)  PCO2 Bld Venous QN: 41 mmHg (12/11/22 22:01:00)  PO2 Bld Venous QN: 39 mmHg (12/11/22 22:01:00)  Base Excess Bld Venous: -2 mmol/L (12/11/22 22:01:00)  Bicarb Bld Venous Calc: 24 mmol/L (12/11/22 22:01:00)  O2 Sat Bld Venous Calc: 72 % (12/11/22 22:01:00)  FIO2: 30% BiPap (12/12/22 03:43:00)  FiO2: 32 % (12/11/22 23:30:00)  Patient Temperature: 37 DegC (12/12/22 03:43:00)  Sample Type: Arterial (12/12/22 03:53:00)  TSH 3rd Gen SerPl QN: 1.73 mcU/mL (12/12/22 03:38:00)  Coagulation:  D-Dimer Pl QN: 501 ng/mL DDU High (12/12/22 03:38:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (12/11/22 22:06:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (12/11/22 22:06:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/11/22 22:06:00)  Rapid Influenza A PCR: Not Detected (12/11/22 22:06:00)  Rapid Influenza B PCR: Not Detected (12/11/22 22:06:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/11/2022 22:22 - XR Chest PA or AP Portable  IMPRESSION:1.  Bibasilar interstitial opacities, greater on the left. This couldreflect underlying pneumonia versus pulmonary vascular congestionwith interstitial edema.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact. For after-hours or emergency department cases, pleasecall.                Signature Line Electronically Signed on 12/12/22 06:51 ________________________________________________________