Age: 69.0
Sex: F
Vaccine: FLU3
Symptoms: Blood magnesium normal, Blood pH, Blood potassium normal, Blood sodium normal, Blood urea normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on December 05, 2024 16:47 EST   Verified By: MD on December 05, 2024 16:47 EST   Encounter Info: Hospital, Inpatient, 12/05/24 -     * Final Report *        Chief Complaint   Cough  History of Present Illness/Subjective     Patient is a 69 year old woman w/ COPD who presents w/ cough and dyspnea. Patient was admitted w/ PNA and had a positive sputum cx growing Pseudomonas. She completed a course of treatment for her PNA however has been feeling "puny" for the last 4-5 days. She is very weak and short of breath. She is coughing up green sputum. Denies any fevers. Upon arrival to the ER she was on her baseline home O2. VBG showed hypercarbia but at her baseline. WBC count was normal and Hgb was 8 which is around her baseline. CxR showed a cavitary lung lesion similar to prior. Patient's case was discussed w/ pulmonology who recommended admission for Zosyn and steroids. Patient was admitted to the medicine service for further management.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours      Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  crackles bilaterally Cardiovascular:  Regular rate and rhythm, no MGR Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan      1. Cavitary pneumonia   J18.9  -Discussed case w/ pulm  -Zosyn for now  -IV steroids      2. Pseudomonas pneumonia   J15.1  -See problem #1      3. Emphysema/COPD   J43.9  -Duonebs      4. Hyperlipidemia   E78.5  -Continue statin       5. Fibromyalgia   M79.7  -Continue home pain regimen      6. Anxiety and depression   F41.9  -Continue home psych regimen      7. Anemia   D64.9  -The patient presents with anemia chronic and normocytic due to other chronic disease at present is stable.  Continue to trend serial analysis as appropriate with nutritional or blood product supplementation as required.      8. Hypothyroidism   E03.9  -Continue home levothyroxine       Code Status  Full Code   Chronic Problem List    Anemia  Anxiety and depression  B12 deficiency  Back pain  Benign positional vertigo  Chronic cough  Chronic pain syndrome  Emphysema/COPD  Fibromyalgia  Hyperlipidemia  Hypertriglyceridemia  Hypokalemia  Hypothyroidism  Lip ulcer  Myalgia & Myositis  Nasal septal deviation  Non-small cell cancer of right lung  Olecranon bursitis, left elbow  Olecranon bursitis, left elbow  Osteoarthritis  Osteopenia  Peripheral neuropathy  Polyp of labia and vulva  S/P radiation therapy  Sebaceous cyst  Vaginal prolapse  Vitamin D deficiency  Procedure/Surgical History  ?Biopsy of lung (07/12/2024) ?Colonoscopy (10/18/2023) ?Ventral hernia repair (03/11/2020) ?Colonoscopy (01/14/2020) ?Endoscopy (01/14/2020) ?Mammogram (03/18/2014) ?Left shoulder replacement (2010) ?Appendectomy ?Arthroscopy ?BACK SURGERY ?Gallbladder ?Hip replacement ?Hysterectomy ?Tonsillectomy   Surgical History Internal  07/12/2024    Bronchoscopy Ultrasound Guided Fine Need   MD  10/18/2023    Colonoscopy Diagnostic/Screen    MD  03/11/2020    Hernia Repair Abdominal Laparoscopic    MD  01/14/2020    Colonoscopy Diagnostic/Screen    MD  Medications   Home Medications (25) Active  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, 4 Times Daily  ALprazoLAM 0.5 mg oral tablet 0.5 mg = 1 Tablet, Orally, BID  atorvastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime  Carafate 1 g oral tablet 1 GM = 1 Tablet, Orally, 4 Times Daily, Take 30 minutes before meals and bedtime  cetirizine 10 mg oral tablet 1 Tablet, Orally, Daily  DME (Vendor) BiPAP and Supplies See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DULOXetine 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, Daily  ferrous sulfate 324 mg (65 mg elemental iron) oral delayed release tablet 324 mg = 1 Tablet, Orally, Daily  folic acid 1 mg oral tablet 1 mg = 1 Tablet, Orally, Daily  furosemide 40 mg oral tablet 1 Tablet, Orally, Daily  gabapentin 600 mg oral tablet 600 mg = 1 Tablet, Orally, TID  Lidoderm 5% topical film 1 Patch, Topical, Daily  meclizine 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, TID  metoPROLOL tartrate 50 mg oral tablet 100 mg = 2 Tablet, Orally, BID  olanzapine 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  pantoprazole 40 mg oral delayed release tablet 1 Tablet, Orally, Daily  Phenergan 25 mg oral tablet 25 mg = 1 Tablet, Orally, TID  Potassium Chloride (Eqv-K-Tab) 20 mEq oral tablet, extended release 20 mEq = 1 Tablet, Orally, BID  primidone 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID  Senna-Time 8.6 mg oral tablet 4 tablets, Orally, At Bedtime  sertraline 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Synthroid 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Daily  Trelegy Ellipta 100 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 12/04/24 00:00:00 TO 12/05/24 16:42:38  None Reported  PRN Medications (0600 - 0559) from 12/04 - 12/05  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Work/School description: CNA.   Home/Environment   daughter with special needs lives with, Lives with Children, Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. 1.5 packs per day. 55 year(s).  Family History   Cancer of colon: Father.   Deceased Family Member(s)  Relationship: Father, Age: Unknown, Cause: COLON CANCER  Relationship: Mother, Age: Unknown, Cause: ABDOMINAL BLOCKAGE  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.1 k/cumm (12/05/24 14:30:00)  RBC: 3.12 million/cumm Low (12/05/24 14:30:00)  Hgb: 8.6 GM/dL Low (12/05/24 14:30:00)  Hct: 26.2 % Low (12/05/24 14:30:00)  MCV: 84 fL (12/05/24 14:30:00)  MCH: 27.5 pg (12/05/24 14:30:00)  MCHC: 32.7 GM/dL (12/05/24 14:30:00)  RDW: 17.1 % High (12/05/24 14:30:00)  Platelet: 320 k/cumm (12/05/24 14:30:00)  MPV: 7.9 fL (12/05/24 14:30:00)  Neutrophils %: 80 % (12/05/24 14:30:00)  Lymphocytes %: 8 % (12/05/24 14:30:00)  Monocytes %: 9 % (12/05/24 14:30:00)  Eosinophils %: 2 % (12/05/24 14:30:00)  Basophils %: 1 % (12/05/24 14:30:00)  Absolute Neutrophil: 4.9 k/cumm (12/05/24 14:30:00)  Absolute Lymphocyte: 0.5 k/cumm Low (12/05/24 14:30:00)  Absolute Monocyte: 0.6 k/cumm (12/05/24 14:30:00)  Absolute Eosinophil: 0.1 k/cumm (12/05/24 14:30:00)  Absolute Basophil: 0 k/cumm (12/05/24 14:30:00)  Chemistry:  Sodium SerPl QN: 142 mmol/L (12/05/24 14:30:00)  Potassium SerPl QN: 3.5 mmol/L (12/05/24 14:30:00)  Chloride SerPl QN: 104 mmol/L (12/05/24 14:30:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (12/05/24 14:30:00)  Anion Gap: 8 mmol/L (12/05/24 14:30:00)  BUN SerPl QN: 14 mg/dL (12/05/24 14:30:00)  Creatinine SerPl QN: 0.77 mg/dL (12/05/24 14:30:00)  Estimated GFR (CKD-EPI, no race): 83 mL/min/1.73m2 (12/05/24 14:30:00)  Estimated CRCL (CG): 74 mL/min (12/05/24 14:30:00)  Glucose SerPl QN: 79 mg/dL (12/05/24 14:30:00)  Calcium Total SerPl QN: 8.9 mg/dL (12/05/24 14:30:00)  Alkaline Phos SerPl QN: 119 Units/L (12/05/24 14:30:00)  ALT SerPl QN: 7 Units/L (12/05/24 14:30:00)  AST SerPl QN: 11 Units/L Low (12/05/24 14:30:00)  Bilirubin Total SerPl QN: 0.2 mg/dL (12/05/24 14:30:00)  Total Protein SerPl QN: 6.7 GM/dL (12/05/24 14:30:00)  Albumin SerPl QN: 3.8 GM/dL (12/05/24 14:30:00)  Magnesium SerPl QN: 1.6 mg/dL (12/05/24 15:36:00)  Troponin-I High Sensitivity: 5 ng/L (12/05/24 14:30:00)  BNP Pl QN: 91 pg/mL (12/05/24 14:30:00)  pH Bld Venous QN: 7.31 Low (12/05/24 14:30:00)  PCO2 Bld Venous QN: 58 mmHg High (12/05/24 14:30:00)  PO2 Bld Venous QN: <35 Low (12/05/24 14:30:00)  Base Excess Bld Venous: 2 mmol/L (12/05/24 14:30:00)  Bicarb Bld Venous Calc: 29 mmol/L (12/05/24 14:30:00)  Patient Temperature: 37 DegC (12/05/24 14:30:00)  Urine Studies:  Color: Yellow (12/05/24 14:50:00)  Clarity: Clear (12/05/24 14:50:00)  Specific Gravity: 1.015 (12/05/24 14:50:00)  pH: 6 (12/05/24 14:50:00)  Protein: NEGATIVE (12/05/24 14:50:00)  Glucose: NEGATIVE (12/05/24 14:50:00)  Ketones: NEGATIVE (12/05/24 14:50:00)  Bilirubin: NEGATIVE (12/05/24 14:50:00)  Hgb Ur: NEGATIVE (12/05/24 14:50:00)  Nitrite: NEGATIVE (12/05/24 14:50:00)  Urobilinogen: NormalUro (12/05/24 14:50:00)  Leukocyte Esterase Ur: NEGATIVE (12/05/24 14:50:00)  WBC: 0-5 (12/05/24 14:50:00)  RBC: 0-2 (12/05/24 14:50:00)  Bacteria: TRACE. (12/05/24 14:50:00)  Squamous Epithelial: NONE (12/05/24 14:50:00)  Hyaline Casts: 3-5 (12/05/24 14:50:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/05/2024 15:27 - XR Chest PA or AP Portable  IMPRESSION: 1.  Bibasilar airspace disease, similar to prior CTA chest.2.  Streaky right apical airspace opacity likely corresponds topartial cavitary lesion on prior CTA chest.Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the ER Reading.             Signature Line Electronically Signed on 12/05/24 16:47 EST ________________________________________________________  MD