Age: 82.0
Sex: F
Vaccine: FLU4
Symptoms: Acute kidney injury, Anion gap, Asthenia, Asthma, Atelectasis
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on November 17, 2023 21:03   Verified By: DO on November 17, 2023 21:03   Encounter Info: Hospital, Inpatient, 11/17/23 -     * Final Report *  Document Has Been Revised        Chief Complaint   Dyspnea  History of Present Illness/Subjective     Patient is a 82-year-old female with past medical history of CHF, COPD, asthma, chronic constipation, CAD, narcolepsy, OSA, osteoarthritis, paroxysmal A-fib, pulmonary hypertension, Raynaud's disease, restless leg syndrome, mitral stenosis status post mitral valve repair in 2017, supraventricular tachycardia, and tricuspid regurgitation who presented to the ED with dyspnea.   Patient reports that she has been progressively short of breath for the last 2 days.  She reports waking up yesterday morning feeling short of breath.  She currently has to sleep with 2 pillows propped up at night and feels significantly short of breath with laying flat.  She reports her shortness of breath is worse with exertion and relieved by rest.  Denies any lower extremity edema.  She denies any fevers chills or recent illness.  She takes her medications as prescribed.  She does also endorse chest pain that resolves with rest.  She is not currently having any chest pain.  She reports that the chest pain feels like when she had her episode of A-fib and was hospitalized in the ICU.  She does report intermittent palpitations although when she has checked her heart rate at home and has remained normal and usually tells her when it is irregular which has not done that. She also feels weak and has been having episodes of dizziness. The only change to her medications has been her amiodarone although when she saw her PCP he reported that she was post be taking several of her medications differently after her recent pacemaker procedure.  She did have a pacemaker placed on 11/3/2023.  She reports that the procedure was slightly complicated due to her dextrocardia.  They initially tried to going on the left side but had to move placement to the right side.  She reports that the surgical site is healing well without any drainage or discharge or pain.  She denies any nausea, abdominal pain, vomiting, diarrhea.  She is taking her torsemide as prescribed and is urinating frequently without any dysuria or changes in the color of her urine.  She takes her Eliquis for A-fib and is without any bleeding but frequently bruises.  She adheres to a low-salt diet and fluid restrictions.   On arrival to the ER initial blood pressure 167/79, afebrile heart rate 91 respiratory rate 22 saturating 98% on room air.  Hemoglobin of 10.4 baseline of appears to be around 10.5, creatinine of 1.47 of note baseline appears to be around 1.17, glucose 113 high-sensitivity troponin initially elevated to 55 increased to 69 and BNP 848 BNP checked in October was 551, UA unremarkable.  EKG with ventricular paced rhythm without any acute ST or T wave changes.  Chest x-ray with findings of prior sternotomy and dextrocardia with pacer leads in stable position.  Some streaky opacities in the left lung possible vascular crowding versus atelectasis with some vascular congestion.  Patient admitted to Hospital for further management.  Review of Systems     Constitutional:  No fevers,  no chills,  no sweats Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No ear pain,  no nasal congestion,  no sore throat Respiratory:  No shortness of breath,  no cough,  no wheeze Cardiovascular:  + Chest pain,  + palpitations,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea,  no constipation Genitourinary:  No frequency,  no urgency,  no dysuria,  no hematuria Hematologic/Lymphatic:  No bruising,  no enlarged lymph nodes Allergic/Immunologic:  No hives Endocrine:  No cold intolerance,  no heat intolerance,  no polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash,  no pruritus Neurological:  No headache,  no focal weakness,  no numbness Psychiatric:  No anxiety,  no depression  Physical Exam/Objective Vitals & Measurements most recent past 24 hours    Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported      Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Bilateral surgical sites chest wall without any erythema or discharge, healing well  Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Elevated troponin   R77.8   Patient with elevated troponin elevated at 55 increased to 69.  EKG without any acute findings but patient with worsening dyspnea, PND and orthopnea in light of elevated BNP with vascular congestion on chest x-ray.  Most likely elevated troponin secondary to demand due to CHF exacerbation as mentioned below. HEART score 6, TIMI score 4.   - Trend troponin to peak   - Telemetry monitoring   - TTE  - Keep K > 4 Mg > 2    2. CHF exacerbation   I50.9   Patient with elevated BNP, orthopnea and PND along with dyspnea with exertion and some vascular congestion on chest x-ray and AKI.  BNP 800. We will treat for mild CHF exacerbation and get a repeat echo.  Patient is on torsemide at home will start Bumex.   - Bumex 2 mg BID IV   - Strict I/O's; Daily weights   - Low salt diet, fluid restrictions     3. Chest pain   R07.9   Patient with intermittent atypical chest pain that is sometimes associated with exertion but also happens at rest.  We will continue to trend troponin.  EKG without any acute findings and patient is currently without chest pain.  Consider Lexiscan Monday.   - Consider Lexiscan Monday    4. Dyspnea   R06.00   Dyspnea most likely due to a combination of CHF exacerbation and A-fib.  We will continue with telemetry monitoring and diuresis as mentioned above.   5. Dizziness   R42   Patient with intermittent dizziness which is most likely multifactorial in nature due to above CHF and A-fib.  Continue with telemetry monitoring.   6. Dextrocardia   Q24.0   Patient is known to have dextrocardia.   7. Cardiac pacemaker recipient   Z95.0   Patient recently received cardiac pacemaker placement on 11/3/2023.  Procedure was moderately complicated but surgical sites appear to be healing well.   8. AKI (acute kidney injury)   N17.9  Patient with AKI most likely due to CHF exacerbation.  Will repeat BMP in the morning suspect renal function improved with diuresis.   9. Normocytic anemia   D64.9   Globin stable patient without any bleeding.   10. Hyperglycemia   R73.9   No known diabetes we will check A1c in the a.m.   11. Asthma   J45.909  Nebs as needed.  Patient currently without any wheezing physical exam.   12. Chronic constipation   K59.09   Continue with MiraLAX and senna daily.   13. COPD type A   J43.9   Currently no wheezing on exam.  DuoNebs as needed.   14. Coronary arteriosclerosis   I25.10   Continue with home medications.   15. Obstructive sleep apnea   G47.33   Continue with CPAP at night and with naps.  RT to eval.   16. Osteoarthritis   M19.90   Tylenol as needed for pain.   17. Paroxysmal atrial fibrillation   I48.0   Patient with a history of paroxysmal A-fib.  Was supposed to undergo ablation along with pacemaker placement on 11/3/2023 but ablation was unable to be performed at that time.  We will continue with telemetry monitoring and continue with home anticoagulation.   18. Pulmonary HTN   I27.29   C/w home sildenafil.   19. S/P mitral valve repair   Z98.890   Had mitral valve repair in 2017.  We will follow-up with echo.   20. Supraventricular tachycardia   I47.10   History of SVT.  Was supposed to undergo ablation on 11/3/2023 but was unable to receive ablation.   21. Tricuspid regurgitation   I07.1   History of known tricuspid recharge.  We will follow-up with echo.   22. Raynaud disease   I73.00   Continue with home medications.   23. Restless legs syndrome   G25.81   Continue with home medication   24. Narcolepsy   G47.419  Continue with home medications   Orders:   potassium chloride, 20 mEq, IVPB, Injection, Q2H, 11/17/23 22:00:00 EST, for 2 Doses, 11/18/23 0:00:00 EST, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100  Magnesium SerPl QN   Code Status   FULL code   Chronic Problem List    Asthma  Bilateral shoulder pain  CHF (congestive heart failure)  Cholelithiases  Chronic constipation  COPD type A  Coronary arteriosclerosis  Dextrocardia  Diarrhea  Dysphagia  Epigastric pain  Hernia of abdominal wall  History of esophageal stricture  Left shoulder pain  Lumbar and sacral osteoarthritis  Narcolepsy  Obstructive sleep apnea  Osteoarthritis  Osteoarthritis of left shoulder  Osteoarthritis of right shoulder  Other parasomnia  Paroxysmal atrial fibrillation  Primary osteoarthritis of left knee  Pulmonary HTN  Raynaud disease  Restless legs syndrome  Right calf pain  S/P mitral valve repair  Supraventricular tachycardia  Tricuspid regurgitation  Procedure/Surgical History  ?Pacemaker insertion (11/03/2023) ?Reversal of colostomy with colo-colonic anastomosis (06/26/2019) ?Colonoscopy (06/25/2019) ?Exploratory laparotomy, sigmoid colectomy, peritoneal lavage, and end (03/16/2019) ?cardiac ablation (11/02/2018) ?TEE (09/13/2018) ?full heart cath (08/29/2018) ?EGD (07/24/2018) ?bronchoscopy (07/18/2018) ?bilateral cataract with IOL ?bilateral upper eyelid lift ?blader interstim ?Hysterectomy ?mitral value repair ?right hip replacement ?right knee replacement ?Thoracentesis ?Tonsillectomy ?Tubal ligation   Surgical History Internal  02/17/2020    EGD Dilate Unguided Maloney    MD  06/26/2019    Bowel Resection    MD  06/25/2019    Colonscpy Bx    MD  03/16/2019    Bowel Resection    MD  07/24/2018    EGD Diagnostic    MD  07/18/2018    Bronchoscopy Diagnostic    MD  Medications   Home Medications (18) Active  albuterol (Eqv-ProAir HFA) 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H  amiodarone 200 mg oral tablet 200 mg = 1 Tablet, Orally, BID  apixaban 5 mg oral tablet 2.5 mg = 0.5 Tablet, Orally, BID  Breo Ellipta 100 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  Centrum Silver oral tablet 1 Tablet, Orally, Daily  cyanocobalamin 1000 mCg/mL injectable solution , INJECT 1ML EVERY 2 WEEKS FOR 8WEEKS THEN INJECT 1 TIME MONTHLY FOR 3 MONTHS  Cymbalta 60 mg oral delayed release capsule 60 mg = 1 Capsule, Orally, QAM  fluticasone 50 mCg/inh nasal spray 1 Spray, intraNASAL, QAM  gabapentin 100 mg oral capsule 100 mg = 1 Capsule, Orally, At Bedtime  Klor-Con M20 oral tablet, extended release 20 mEq = 1 Tablet, Orally, Daily  lidocaine 5% topical film 1-2 Patch, Topical, Daily, Application site: back  metoPROLOL succinate 50 mg oral tablet, extended release 50 mg = 1 Tablet, Orally, Daily  Misc Med 3 L, oxygen, 3L NOC in CPAP  modafinil 200 mg oral tablet 200 mg = 1 Tablet, Orally, QAM  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  sildenafil 20 mg oral tablet 20 mg = 1 Tablet, Orally, TID  torsemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily, May an extra 10mg for weight gain over 2 pounds in 24 hours, 5 pounds in 1 week  Vitamin D3 25 mCg (1,000 intl units) oral capsule 25 mCg = 1 Capsule, Orally, Daily, OTC  Active Scheduled Inpatient Medications  potassium chloride IVPB, Injection, 20 mEq, IVPB, Q2H, Start: 11/17/23 22:00:00    One-Time Medications Given 11/16/23 00:00:00 TO 11/17/23 21:02:36  None Reported  PRN Medications (0600 - 0559) from 11/16 - 11/17  None Reported  Allergies   levoFLOXacin  traZODone (Hives)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Work/School description: former school bus driver.   Exercise   Home/Environment   Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Patient was adopted  Autoimmune disease..: Negative: Mother and Father.  Diabetes insipidus..: Mother.Negative: Father.  Diabetes mellitus type 2: Negative: Mother and Father.  Heart disease..: Negative: Mother and Father.  Insomnia: Negative: Mother and Father.  Lung cancer..: Negative: Mother and Father.  Lung disease..: Negative: Mother and Father.  Narcolepsy: Negative: Mother and Father.  Obstructive sleep apnea: Negative: Mother and Father.  Restless legs: Negative: Mother and Father.  Sleep apnea: Negative: Mother and Father.  Sleep problem: Negative: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.5 k/cumm (11/17/23 15:36:00)  RBC: 3.62 million/cumm Low (11/17/23 15:36:00)  Hgb: 10.4 GM/dL Low (11/17/23 15:36:00)  Hct: 31.5 % Low (11/17/23 15:36:00)  MCV: 87 fL (11/17/23 15:36:00)  MCH: 28.7 pg (11/17/23 15:36:00)  MCHC: 33.1 GM/dL (11/17/23 15:36:00)  RDW: 15.6 % High (11/17/23 15:36:00)  Platelet: 164 k/cumm (11/17/23 15:36:00)  MPV: 8.1 fL (11/17/23 15:36:00)  Neutrophils %: 78 % (11/17/23 15:36:00)  Lymphocytes %: 15 % (11/17/23 15:36:00)  Monocytes %: 5 % (11/17/23 15:36:00)  Eosinophils %: 1 % (11/17/23 15:36:00)  Basophils %: 1 % (11/17/23 15:36:00)  Absolute Neutrophil: 5.9 k/cumm (11/17/23 15:36:00)  Absolute Lymphocyte: 1.1 k/cumm (11/17/23 15:36:00)  Absolute Monocyte: 0.4 k/cumm (11/17/23 15:36:00)  Absolute Eosinophil: 0.1 k/cumm (11/17/23 15:36:00)  Absolute Basophil: 0 k/cumm (11/17/23 15:36:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (11/17/23 15:36:00)  Potassium SerPl QN: 3.6 mmol/L (11/17/23 15:36:00)  Chloride SerPl QN: 107 mmol/L (11/17/23 15:36:00)  Carbon Dioxide SerPl QN: 27 mmol/L (11/17/23 15:36:00)  Anion Gap: 5 mmol/L (11/17/23 15:36:00)  BUN SerPl QN: 28 mg/dL High (11/17/23 15:36:00)  Creatinine SerPl QN: 1.47 mg/dL High (11/17/23 15:36:00)  Estimated GFR (CKD-EPI, no race): 35 mL/min/1.73m2 Low (11/17/23 15:36:00)  Estimated CRCL (CG): 27 mL/min Low (11/17/23 15:36:00)  Glucose SerPl QN: 113 mg/dL High (11/17/23 15:36:00)  Calcium Total SerPl QN: 8.7 mg/dL (11/17/23 15:36:00)  Troponin-I High Sensitivity: 69 ng/L High (11/17/23 16:37:00)  BNP Pl QN: 848 pg/mL High (11/17/23 15:36:00)  Urine Studies:  Color: Colorless (11/17/23 16:10:00)  Clarity: Clear (11/17/23 16:10:00)  Specific Gravity: 1.007 (11/17/23 16:10:00)  pH: 6.5 (11/17/23 16:10:00)  Protein: NEGATIVE (11/17/23 16:10:00)  Glucose: Normal (11/17/23 16:10:00)  Ketones: NEGATIVE (11/17/23 16:10:00)  Bilirubin: NEGATIVE (11/17/23 16:10:00)  Hgb Ur: NEGATIVE (11/17/23 16:10:00)  Nitrite: NEGATIVE (11/17/23 16:10:00)  Urobilinogen: Normal (11/17/23 16:10:00)  Leukocyte Esterase Ur: NEGATIVE (11/17/23 16:10:00)  WBC: 0-5 (11/17/23 16:10:00)  RBC: 0-2 (11/17/23 16:10:00)  Bacteria: NONE (11/17/23 16:10:00)  Squamous Epithelial: NONE (11/17/23 16:10:00)  Hyaline Casts: 3-5 (11/17/23 16:10:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (11/17/23 20:32:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/17/23 20:32:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/17/2023 16:02 - XR Chest PA or AP Portable  IMPRESSION:  Median sternotomy. Redemonstration of dextrocardia. Mediastinalcontour and heart size are stable. Transvenous pacer leads project instable position. Streaky opacities left lung base suggestive ofbronchial vascular crowding and subsegmental atelectasis. No overtconsolidation, significant pleural effusion, pulmonary edema, orpneumothorax.Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the EmergencyRadiology reading room.                Signature Line Electronically Signed on 11/17/23 21:03  ________________________________________________________ DO  Electronically Signed on 11/17/23 22:08  ________________________________________________________ DO  Electronically Signed on 11/17/23 22:36  ________________________________________________________ DO