Age: 29.0
Sex: M
Vaccine: FLUC4
Symptoms: Blood urea normal, Breath sounds abnormal, Carbon dioxide normal, Chest X-ray normal, Coma scale
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on December 11, 2023 11:46  Verified By: MD on December 11, 2023 15:02   Encounter Info: Hospital, Observation, 12/11/23 -     * Final Report *          History of Present Illness/Subjective     Chief complaint shortness of breath  HPI: Patient is a 29-year-old male with history of asthma, kidney transplant, hypertension, hyperlipidemia, cerebral palsy presented to emergency department via private vehicle complaining of shortness of breath that started 2 days ago.  He also states that he has been having congestion as well.  Patient denied fever and stated that his father is also ill for couple of days.  Patient is not wearing any oxygen at home and usually has inhalers for asthma but is out of them currently.  Patient is a smoker have smokes 2 days ago when his symptoms started.  When he was not evaluated in the emergency room patient presented with a white count of 15.2 with tachycardia and tachypnea.  A chest x-ray showed mediastinal contour and heart size are stable and within normal limits radiolucent object projecting over the left midlung favored to represent external paraphernalia.  No focal consolidation no edema no pneumothorax no pleural effusion.  Patient was requiring oxygen in the emergency room 4 L nasal cannula since his dropped his oxygen to 86%.  Despite giving him multiple respiratory treatment patient did not respond it was decided to bring in the patient for influenza treatment which was found to be positive on testing.  Patient also shows mild dehydration.  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 37.1 °C (Oral)  BP: 115/80  HR: 116 (Monitored)  RR: 24  SpO2: 94%  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 4 (L/min)  WT: 115.4 kg    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    115.4 kg    12/11/23  Previous Daily Weight:    115.4 kg    12/11/23    Patient Height  Current Height:    170 cm    12/11/23         General: Alert and oriented Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic Neck: Supple, normal range of motion Oropharynx: mild oropharynx erythema, post nasal drip Respiratory: Lungs are clear to auscultation. decreased air entry bilaterally Cardiovascular: Normal rate, Regular rhythm. Gastrointestinal: Soft, Non-tender. Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect    Assessment/Plan       1. Asthma exacerbation   J45.901   Patient is having asthma exacerbation secondary to influenza A.  -Patient was given methylprednisolone multiple Nedra DuoNebs and a dose of Tamiflu in the emergency room.  -We will continue with the same and monitor patient on medical floor.  -Oxygen as needed.   2. Hypoxia   R09.02   See above   3. Influenza A   J10.1   Patient is positive for influenza A and has been given first dose of Tamiflu in the emergency room.  -We will continue with the same.  -Pharmacy to dose Tamiflu since patient is a renal transplant patient.   4. Kidney transplant   Z94.0   Noted.  Home medications can be started.   5. Cerebral palsy   G80.9   Noted   6. Chronic Kidney Disease, Stage III (Moderate)   N18.30   This appears to have resolved in the past.   7. Hypertension   I10   Resume home medications   8. Hyperlipidemia   E78.5   Resume home meds   9. Hypothyroid   E03.9   Noted.  Resume home medications.  Last TSH checked in August of this year was normal.    Code Status   None Recorded   Chronic Problem List    Aftercare Following Organ Transplant  Anemia  Asthma  Cerebral palsy  Chronic diarrhea  Chronic Kidney Disease, Stage III (Moderate)  Complications of Transplanted Kidney  Dyspepsia  Hyperlipidemia  Hypertension  Hypothyroid  IBS (irritable bowel syndrome)  Kidney transplant  Secondary Hyperparathyroidism (Of Renal Origin)  Severe obesity  Tobacco use  Procedure/Surgical History  ?Repair upper extremity laceration and palmaris longus tendon (06/14/2020) ?EGD and Colonoscopy (01/23/2015) ?kidney transplant (03/25/2009) ?hernia surgery ?left side venticuloperitoneal shunt ?tonsillectomy   Surgical History Internal  06/13/2020    Upper Extremity I and D    MD  05/19/2009    Cystoscopy Stent Removal    MD  03/25/2009    Kidney Transplant    MD  03/16/2009    Hemodialysis Catheter Placement    MD  Medications   Home Medications (22) Active  Advair Diskus 250 mCg-50 mCg inhalation powder 1 Puff, Inhalation, BID  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Inhalation, Q4H  albuterol HFA MDI 90mCg/puff inhalation aerosol 180 mCg = 2 Puff, PRN, Inhalation, Q2H  amantadine 100 mg oral capsule 100 mg = 1 Capsule, Orally, Daily  atenolol 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  cholecalciferol 5000 intl units oral tablet 5,000 Units = 1 Tablet, Orally, Daily  cyanocobalamin 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  Envarsus XR 0.75 mg oral tablet, extended release 1.5 mg = 2 Tablet, Orally, QAM, Dx:  Z94.0increased dose from 1mg to 1.5mg every morning  Envarsus XR 1 mg oral tablet, extended release 1 mg = 1 Tablet, Orally, QAM, Dx: Z94.0  Envarsus XR 1 mg oral tablet, extended release 2 mg = 2 Tablet, Orally, QAM, Dx: Z94.0, T86.10obtain lab asap, 0 refills  levothyroxine 25 mCg (0.025 mg) oral tablet 25 mCg = 1 Tablet, Orally, Daily  Misc Supplies See Instructions, supplies for nebulizer machineJ45.909  mycophenolate mofetil 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID, Dx: Z94  Nebulizer Compressor See Instructions, Use as directed for asthma 493.90 x 99 monthsCROWDER'S  Nebulizer with supplies Not Applicable, Other, Unscheduled, J45.909  Norvasc 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  ondansetron 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q8H  Prevacid 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, Daily  Symbicort 160 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  traZODONE 50 mg oral tablet 50 mg = 1 Tablet, PRN, Orally, At Bedtime  Welchol 625 mg oral tablet 625 mg = 1 Tablet, Orally, BID  Zyrtec 10 mg oral tablet 10 mg = 1 Tablet, PRN, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 12/10/23 00:00:00 TO 12/11/23 11:46:49  albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 10 mg, Neb Inhal, ONCE, (1 DOSE 12/11/23 08:36:00)  methylPREDNISolone (methylPREDNISolone sodium succinate), Injection, 125 mg, IV Push, ONCE, (1 DOSE 12/11/23 09:22:00)  oseltamivir (Tamiflu), Capsule, 75 mg, Orally, ONCE, (1 DOSE 12/11/23 10:55:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 12/11/23 09:22:00)  PRN Medications (0600 - 0559) from 12/10 - 12/11  albuterol, 2.5 mg, Neb Inhal, Q4H, 0  Dose(s)   Allergies   statins (Muscle pain, Unknown)  Augmentin (Hives)  Bactrim (hives)  Ceftin  Lorabid  Tequin (Hives)  Zithromax (critical)  penicillin (Hives)  Social History    Alcohol   Current, Beer, 1-2 times per month   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Unemployed, States "I only got about a 5th grade education because of my health." Hx of CP and kidney transplant.   Home/Environment   Lives with Parents. Living situation: Home/Independent. Smoker in household: Yes. Feels unsafe at home: Yes.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   Anxiety: Mother.  Arthritis...: Son.  Breast cancer: Aunt and Grandmother (M).  Cancer of colon: Uncle.Negative: Aunt.  Depression: Mother.  Diabetes mellitus type 2: Mother.  Drug abuse: Son.  Hypertension..: Mother and Father.  Oral cancer...: Negative: Aunt.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 15.2 k/cumm High (12/11/23 08:45:00)  RBC: 5.83 million/cumm High (12/11/23 08:45:00)  Hgb: 17 GM/dL (12/11/23 08:45:00)  Hct: 49.8 % (12/11/23 08:45:00)  MCV: 85 fL (12/11/23 08:45:00)  MCH: 29.2 pg (12/11/23 08:45:00)  MCHC: 34.1 GM/dL (12/11/23 08:45:00)  RDW: 13.8 % (12/11/23 08:45:00)  Platelet: 145 k/cumm Low (12/11/23 08:45:00)  MPV: 10.2 fL (12/11/23 08:45:00)  Neutrophils %: 83 % (12/11/23 08:45:00)  Lymphocytes %: 8 % (12/11/23 08:45:00)  Monocytes %: 9 % (12/11/23 08:45:00)  Eosinophils %: 0 % (12/11/23 08:45:00)  Basophils %: 0 % (12/11/23 08:45:00)  Absolute Neutrophil: 12.6 k/cumm High (12/11/23 08:45:00)  Absolute Lymphocyte: 1.3 k/cumm (12/11/23 08:45:00)  Absolute Monocyte: 1.4 k/cumm High (12/11/23 08:45:00)  Absolute Eosinophil: 0 k/cumm (12/11/23 08:45:00)  Absolute Basophil: 0 k/cumm (12/11/23 08:45:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (12/11/23 08:45:00)  Potassium SerPl QN: 3.9 mmol/L (12/11/23 08:45:00)  Chloride SerPl QN: 106 mmol/L (12/11/23 08:45:00)  Carbon Dioxide SerPl QN: 23 mmol/L (12/11/23 08:45:00)  Anion Gap: 9 mmol/L (12/11/23 08:45:00)  BUN SerPl QN: 20 mg/dL (12/11/23 08:45:00)  Creatinine SerPl QN: 1.7 mg/dL High (12/11/23 08:45:00)  Estimated GFR (CKD-EPI, no race): 55 mL/min/1.73m2 Low (12/11/23 08:45:00)  Estimated CRCL (CG): 78 mL/min (12/11/23 08:45:00)  Glucose SerPl QN: 124 mg/dL High (12/11/23 08:45:00)  Calcium Total SerPl QN: 8.8 mg/dL (12/11/23 08:45:00)  Lactate Venous Pl QN: 1 mmol/L (12/11/23 08:45:00)  pH Bld Venous QN: 7.35 (12/11/23 08:45:00)  PCO2 Bld Venous QN: 42 mmHg (12/11/23 08:45:00)  PO2 Bld Venous QN: 71 mmHg High (12/11/23 08:45:00)  Base Excess Bld Venous: -2 mmol/L (12/11/23 08:45:00)  Bicarb Bld Venous Calc: 23 mmol/L (12/11/23 08:45:00)  O2 Sat Bld Venous Calc: 93 % (12/11/23 08:45:00)  Patient Temperature: 37 DegC (12/11/23 08:45:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (12/11/23 08:47:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (12/11/23 08:47:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/11/23 09:25:00)  Rapid Influenza A PCR: Detected Abnormal (12/11/23 09:25:00)  Rapid Influenza B PCR: Not Detected (12/11/23 09:25:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/11/2023 09:20 - XR Chest PA or AP  IMPRESSION:  Mediastinal contour and heart size are stable and within normallimits. Radiolucent object projecting over left midlung favored torepresent external paraphernalia. No focal consolidation, pulmonaryedema, pneumothorax, or pleural effusion.  No new acutecardiopulmonary abnormalities since the previous examination.  Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the EmergencyRadiology reading room.                Signature Line Electronically Signed on 12/11/23 15:02  MD