Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Coagulation test abnormal, Cough, Creatinine renal clearance, Diuretic therapy, Echocardiogram
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on August 19, 2023 18:40   Verified By: MD on August 19, 2023 18:40   Encounter Info: Hospital, Inpatient, 08/19/23 -     * Final Report *          History of Present Illness/Subjective     This is a 72-year-old female with past medical history of lymphedema and obesity presents to the emergency department with complaints of cough weakness sore throat since past 1 week.  The patient's phlegm has now turned yellow and has been feeling febrile.  She also complains of facial swelling on the right side and neck pain.  Denies any chest pain or chest tightness.  Denies any history of smoking, COPD, asthma.  She has never been vaccinated of COVID neither influenza.  She sees a naturopath yearly.  Patient is saturating 97% on 2 L of oxygen meets sepsis criteria, sepsis tachycardic.  Last blood pressures charted at 1447 are elevated.  186/96.  Labs showed normal WBC count, troponins are 6 BNP is 31, lactate is 1.2.  She is influenza positive.  X-ray is suggestive of cardiac enlargement with vascular congestion and central edema.  Her last echo in the system is from 2017 and at that time her ejection fraction was 56 with no obvious valvular abnormality  Review of Systems     13 point review of systems negative except for what is mentioned above  Physical Exam/Objective Vitals & Measurements most recent past 24 hours   Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress,  Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus  ENMT:  Moist oral mucosa  Neck:  Supple, non-tender, intact range of motion  Respiratory: wheezing  Cardiovascular:  Regular rate and rhythm  Gastrointestinal:  Soft, non-tender, non-distended  Musculoskeletal:  No joint swelling, no deformity, intact ROM  Integumentary:  Intact, warm, dry no rashes  Neurologic: Alert & Oriented   Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Acute hypoxemic respiratory failure   J96.01  - Combination of pulmonary edema and influenza  -The patient is symptoms are 10 days old, no utility of Tamiflu  -Concern for bacterial super infection considering the age group I will start ceftriaxone and doxycycline  -Follow pneumonia work-up  -We will start gentle diuresis, she is Lasix naïve, likely trigger was her elevated blood pressures   2. Influenza A   J10.1  - Outside therapeutic window for influenza,  -Symptomatic management  -Respiratory eval  -DuoNebs   3. Pulmonary edema   J81.1  - There is congestion secondary to elevated blood pressures likely  -Echocardiogram  -Lasix IV twice daily   5. Uncontrolled hypertension   I10  - I do not see her to be on any blood pressure medications at home  - awaiting order reconciliation .    Code Status   None Recorded   Chronic Problem List    Fatigue  Lymphedema  Obesity  Procedure/Surgical History  ?Dilation and Curettage (12/2015) ?Cholecystectomy Open (1951) ?appendectomy ?Hysterectomy   Surgical History Internal  03/03/2017    Hysteroscopy W Polypectomy    MD  Medications    Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 08/18/23 00:00:00 TO 08/19/23 18:40:33  None Reported  PRN Medications (0600 - 0559) from 08/18 - 08/19  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   Lives with Spouse.   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Family history is negative  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 8.1 k/cumm (08/19/23 16:42:00)  RBC: 4.85 million/cumm (08/19/23 16:42:00)  Hgb: 13.8 GM/dL (08/19/23 16:42:00)  Hct: 41.4 % (08/19/23 16:42:00)  MCV: 85 fL (08/19/23 16:42:00)  MCH: 28.5 pg (08/19/23 16:42:00)  MCHC: 33.4 GM/dL (08/19/23 16:42:00)  RDW: 14.4 % (08/19/23 16:42:00)  Platelet: 251 k/cumm (08/19/23 16:42:00)  MPV: 7.9 fL (08/19/23 16:42:00)  Neutrophils %: 71 % (08/19/23 16:42:00)  Lymphocytes %: 15 % (08/19/23 16:42:00)  Monocytes %: 13 % (08/19/23 16:42:00)  Eosinophils %: 0 % (08/19/23 16:42:00)  Basophils %: 1 % (08/19/23 16:42:00)  Absolute Neutrophil: 5.7 k/cumm (08/19/23 16:42:00)  Absolute Lymphocyte: 1.2 k/cumm (08/19/23 16:42:00)  Absolute Monocyte: 1 k/cumm (08/19/23 16:42:00)  Absolute Eosinophil: 0 k/cumm (08/19/23 16:42:00)  Absolute Basophil: 0 k/cumm (08/19/23 16:42:00)  Chemistry:  Sodium SerPl QN: 132 mmol/L Low (08/19/23 16:42:00)  Potassium SerPl QN: 3.9 mmol/L (08/19/23 16:42:00)  Chloride SerPl QN: 94 mmol/L Low (08/19/23 16:42:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (08/19/23 16:42:00)  Anion Gap: 8 mmol/L (08/19/23 16:42:00)  BUN SerPl QN: 9 mg/dL (08/19/23 16:42:00)  Creatinine SerPl QN: 0.63 mg/dL (08/19/23 16:42:00)  Estimated GFR (CKD-EPI, no race): >90 (08/19/23 16:42:00)  Estimated CRCL (CG): >120 (08/19/23 16:42:00)  Glucose SerPl QN: 286 mg/dL High (08/19/23 16:42:00)  Calcium Total SerPl QN: 9 mg/dL (08/19/23 16:42:00)  Magnesium SerPl QN: 1.9 mg/dL (08/19/23 16:42:00)  Troponin-I High Sensitivity: 6 ng/L (08/19/23 17:20:00)  BNP Pl QN: 31 pg/mL (08/19/23 17:20:00)  Lactate Venous Pl QN: 1.2 mmol/L (08/19/23 16:42:00)  Influenza A, POC: Positive Abnormal (08/19/23 14:34:00)  Influenza B, POC: Negative (08/19/23 14:34:00)  Coagulation:  PT: 13 seconds (08/19/23 17:20:00)  INR: 1.13 (08/19/23 17:20:00)  aPTT: 33.8 seconds (08/19/23 17:20:00)  Micro - Last 7 days  Coronavirus SARS Ag FIA, POC: Negat (08/19/23 14:33:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 08/19/2023 16:21 - XR Chest PA or AP Portable  IMPRESSION:1.  Severe cardiac enlargement with vascular congestion and centraledema.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 08/19/23 18:40  ________________________________________________________ MD