Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Condition aggravated, Coronary artery disease, Cough, Dyslipidaemia, Dyspnoea
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on November 17, 2022 08:41 EST   Verified By: MD on November 17, 2022 13:53 EST   Encounter Info: Hospital, Inpatient, 11/17/22 -     * Final Report *        Basic Information  Time Seen:  MD / 11/17/2022 08:38  Chief Complaint  Shortness of breath (Complaint of)  History of Present Illness     60 year old female with hx of COPD presents to the emergency department via private vehicle with shortness of breath onset four days ago. The patient states that she is unable to ambulate more than a few steps at home without feeling dyspneic and fatigued. She reports associated cough and chest pain. Denies n/v/d. She was recently admitted to this facility for similar symptoms. Discharged on 10/21 with doxycycline, prednisone, and oxygen 2L NC as needed. The patient states that she has used her oxygen constantly since her current symptoms began. She completed her discharge course of abx and an additional course prescribed by her PCP. She adds that she has been using her nebulizer at home frequently to minimal relief of symptoms. Patient has an appointment with pulmonology on 12/7.  Review of Systems     Respiratory: +sob, +cough, +fatigue Cardiovascular: +chest pain Gastrointestinal: -nausea, -vomiting, -diarrhea  Additional review of systems information: Except as noted above in the HPI and the ROS, all other systems reviewed and otherwise negative.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS     No qualifying data available.     General: Alert, no acute distress Head: Normocephalic, atraumatic Eye: PERRL, EOMI Cardiovascular: Tachycardic, regular rhythm, no murmur Respiratory: Tachypneic, wheezing GI: Soft, nontender, nondistended Musculoskeletal: Normal ROM Neuro: A/Ox4, No focal neuro deficits Psychiatric: Cooperative, appropriate mood & affect  Medical Decision Making     Vital signs, nursing charting and past history reviewed as pertinent to the case.  I have reviewed all studies ordered by myself and any relevant comparisons.     Differential diagnosis includes but not limited to: COPD exacerbations vs less likely cardiogenic cause vs less likely PE     Will get labs, EKG, CXR and give steroids, breathing tx, and azithromycin.       Likely disposition: admission  11/17/22 10:21:22 Discussed case with Dr., hospitalist. He accepts the patient for admission. Requests BiPAP.          Re-Assessment  11/17/22 09:40:34 Reassessed patient who feels slightly better after breathing tx. Overall, feels worse than her prior COPD exacerbation when she was admitted. Patient is still slightly tachypneic and is requiring 3.5L NC to stay above 90%.  Discussed plan for admission for further evaluation and treatment. Patient agreeable to plan. All questions answered.  Condition     Stable  Disposition: 11/17/22 10:32:24 Admitted, accepted by Dr.   Attestations:   Scribe, 11/17/22 08:44:55    MD, have reviewed this note and attest to its contents.  It was prepared under my direction and at the time of my signature I will have reviewed it in its entirety and edited where appropriate.  Assessment/Plan       Acute respiratory failure with hypoxia and hypercarbia   J96.01    CAD (coronary artery disease)   I25.10    COPD exacerbation   J44.1    Dyslipidemia   E78.5    Tobacco use   Z72.0       Follow Up  No qualifying data available   Chronic Problem List    CAD (coronary artery disease)  COPD (chronic obstructive pulmonary disease)  Current chronic use of inhaled steroid  Current use of steroid medication  Dyslipidemia  Dyspnea  H/O: pneumonia  Long term use of drug  Obesity  Preventive measure  Tobacco use  Procedure/Surgical History  ?Mammogram (08/2008) ?Cardiac catheterization ?Carpal tunnel ?Cervicectomy ?Cholecystectomy ?Colonoscopy ?Partial hysterectomy ?Tonsillectomy    Medications  Home Medications (16) Active albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, 4 Times Daily cefDINIR 300 mg oral capsule 300 mg = 1 Capsule, Orally, Q12H cetirizine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed. fluticasone 50 mCg/inh nasal spray 1 Spray, intraNASAL, BID hydroCODONE-acetaminophen 7.5 mg-325 mg oral tablet 1 Tablet, Orally, TID losartan 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily Misc Supplies See Instructions, Home nebulizerDX: COPDlength of need 99 months nicotine 14 mg/24 hr transdermal film, extended release 1 Patch, Topical, Daily nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min pravastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime predniSONE 20 mg oral tablet See Instructions, 3 tablets daily x4 days, 2 tabs x4 days, 1 tab x4 days, 1/2 tab until gone ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H Symbicort 160 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID traZODONE 50 mg oral tablet 25 mg = 0.5 Tablet, Orally, At Bedtime Trelegy Ellipta 200 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  Medication Administration   Given  albuterol 2.5 mg/0.5mL (0.5%) inhalation solution, 5 mg, Neb Inhal  albuterol 2.5 mg/0.5mL (0.5%) inhalation solution, 2.5 mg, Neb Inhal  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL, 3 mL, Neb Inhal  Ativan, 1 mg, IV Push  Ativan, 1 mg, IV Push  azithromycin, IVPB  losartan, 50 mg, Orally  methylPREDNISolone sodium succinate, 125 mg, IV Push  Allergies   NKA  Social History    Alcohol   Current, Liquor, 1-2 times per month   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description: GM.   Home/Environment   Married, 3 Children, Lives with Spouse.   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. 1.5 packs per day. Started age 16.0 Years. Stopped age 60 Years.  Family History   CHF (congestive heart failure)...: Father.  Diabetes...: Mother and Father.  Throat cancer...: Father.  Lab Results  CO2 retention that is mostly compensated  Diagnostic Results  XR Chest PA or AP Portable    11/17/22 10:05:09  IMPRESSION:   Coarse lung markings suggesting a component of mild and possibly  chronic pulmonary vascular congestion similar to recent studies.   No consolidating infiltrates or other acute findings.   Electronically Signed by:     Signed By: MD  EKG  EKG done at 0845 shows sinus tachycardia rate of 103 bpm, normal intervals, no acute ischemic findings.      Signature Line Electronically Signed on 11/17/22 13:24 EST ________________________________________________________   Electronically Signed on 11/17/22 13:53 EST ________________________________________________________ MD  Reviewed by