Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on November 16, 2022 18:50 EST   Verified By: MD on November 16, 2022 22:34 EST   Encounter Info: Hospital, Inpatient, 11/16/22 -     * Final Report *        Basic Information  Time Seen:  MD / 11/16/2022 18:46  Chief Complaint  Dyspnea (Complaint of)  History of Present Illness     Patient seen: 11/16/22 18:50:00 A 60 year old female with Hx of Asthma and GERD, presents to the ED via private vehicle c/o shortness of breath. Patient reports worsening dyspnea, cough, and fever over the past 4 days. Pt pulse ox was 88% on arrival here. Husband states that patient's pulse ox was 80% at home. She received a breathing treatment at 18:00 and pulse ox improved to 88%. Patient is a smoker.  Review of Systems     Constitutional: +fever Skin: Negative except HPI ENMT: Negative except HPI Respiratory: +shortness of breath, +cough Cardiovascular: Negative except HPI Gastrointestinal: Negative except HPI Genitourinary: Negative except HPI Musculoskeletal: Negative except HPI Neurologic: Negative except HPI Psychiatric: Negative except HPI Heme/Lymph: Negative except HPI Allergy/Immunologic: Negative except HPI  Additional ROS info: Except as noted in the above Review of Systems and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.4 DegC  Heart Rate:       115 bpm  Resp Rate:       24 br/min  BP:       152 / 99 mmHg  SpO2 (%):       88 %  O2 Device:       Room air     Height CM: 160 cm  Weight KG: 45 kg  Ideal Body Weight: 52.38 kg     General: Alert, thin, generally unwell patient Skin: Warm, dry Head: Normocephalic, atraumatic Eyes: Extraocular movements are intact ENMT: Tympanic membranes clear bilaterally, oral mucosa moist, no pharyngeal erythema or exudate Neck: Supple Cardiovascular: Regular rate and rhythm, normal peripheral perfusion, no edema Respiratory: coarse and somewhat diminished breath sounds, increased work of breathing, speaking in shorter sentences Chest wall: No tenderness Gastrointestinal: Soft, nontender, non-distended, normal bowel sounds Musculoskeletal: Normal strength Neurological: No focal neurological deficits observed Psychiatric: Cooperative, appropriate mood and affect  Medical Decision Making     11/16/22 20:15:00 Patient is still labored breathing on BiPAP, but currently stable. Discussed options for transfer or admission here. Husband wants her to stay here and not transfer out. Patient has not had her Klonopin today. Will add IV Ativan.  11/16/22 20:17:29 Messaged Hospitalist for admission.   11/16/22 22:32:25  CT neg for PE.  Dr. and I discussed the presentation, concerns, and illness of the patient with her husband.  We discussed seeking transfer to a facility with pulmonologist.  After consideration her husband wants her to stay here, so Dr. will admit to ICU.  At this time she is stable on Bipap, resting.               Condition     Stable  Scribe Attestation  I, acting as a scribe for Dr. on 11/16/22 18:50:09. Signed, 11/16/22 18:50:09.  I, attest that the scribe's documentation has been prepared under my direction and personally reviewed by me in its entirety .  I confirm that the note above accurately reflects all work, treatment , procedures , and medical decision-making performed by me.     Assessment/Plan       1. Acute respiratory failure   J96.00    2. Hypoxia   R09.02    3. Atypical pneumonia   J18.9    4. Elevated troponin   R77.8    5. Elevated brain natriuretic peptide (BNP) level   R79.89    Orders:   ampicillin-sulbactam, 3 GM, IVPB, Injection, ONCE, 11/17/22 0:00:00 EST, 11/17/22 0:00:00 EST, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  OXYcodone-acetaminophen, 1 Tablet, Orally, Tablet, ONCE, NOW, 11/16/22 20:27:00 EST, 11/16/22 20:27:00 EST  **Coronavirus SARS-CoV2 Rapid  Basic Metabolic Panel  Bed Request (Decision to Admit)  BIPAP Intermittent  Blood CX  Blood CX  Blood Gas Venous QN  BNP Pl QN  CBC w/Differential  COVID 19 PCR  CTA Chest Pulm Embolism W/IV Contrast  Electrocardiogram  Lactate Pl Venous QN  Lactate Pl Venous QN  Path Review  Peripheral IV Insertion  Potassium SerPl QN  Resp Evaluation or Assessment  Sepsis Tracking  Titrate FiO2 to Keep O2 Sat  Troponin-I High Sensitivity  XR Chest PA or AP Portable     Follow Up  No qualifying data available   Chronic Problem List    Chronic lumbar pain  Encounter for long-term current use of medication  GAD (generalized anxiety disorder)  GERD (gastroesophageal reflux disease)  Hyponatremia  Hypothyroidism  Tobacco use  Procedure/Surgical History  ?Cholecystectomy ?dental sx ?right ankle sx  Surgical History Internal  06/05/2015    Spinal Stimulator Implant Stage 2    MD  05/29/2015    Spinal Stimulator Implant Stage 1    MD  Medications  Home Medications (11) Active albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H albuterol HFA MDI 90mCg/puff inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily calcium carbonate 750mg chewable tablet 750 mg = 1 Tablet, Orally, BID CLonazePAM 0.5 mg oral tablet 0.5 mg = 1 Tablet, Orally, BID Fiorinal 325 mg-50 mg-40 mg oral tablet 2 Tablet, PRN, Orally, Q6H levothyroxine 37.5 mCg, Orally, Daily Neurontin 300 mg oral capsule 600 mg = 2 Capsule, Orally, 4 Times Daily Nexium 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily Percocet 7.5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q6H Prozac 10 mg oral capsule 10 mg = 1 Capsule, Orally, Daily Wixela Inhub 250 mCg-50 mCg inhalation powder , Inhalation, BID  Medication Administration   Given  albuterol 2.5 mg/0.5mL (0.5%) inhalation solution, 5 mg, Neb Inhal  ampicillin-sulbactam, IVPB  azithromycin, IVPB  droperidol, 1.25 mg, IV Push  LORazePAM, 1 mg, IV Push  methylPREDNISolone sodium succinate, 125 mg, IV Push  Allergies   Versed (combative)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days. 1 packs per day. Started age 18.0 Years.  Family History   Diabetes mellitus type 2: Mother.  Lab Results      Hemogram-Platelets-WBC Differential FS  LATEST RESULTS        WBC  11/16/22 19:14  8.5        RBC  11/16/22 19:14  5.68  High        Hgb  11/16/22 19:14  17.8  High        Hct  11/16/22 19:14  53.0  High        MCV  11/16/22 19:14  93        MCH  11/16/22 19:14  31.3        MCHC  11/16/22 19:14  33.5        RDW  11/16/22 19:14  15.1  High        Platelet  11/16/22 19:14  401        MPV  11/16/22 19:14  9.2        # WBC Counted in Diff  11/16/22 19:14  100        Metamyelocyte  11/16/22 19:14  1        Band  11/16/22 19:14  53        Neutrophil  11/16/22 19:14  18        Lymphocyte  11/16/22 19:14  16        Monocyte  11/16/22 19:14  12        Absolute Metamyelocyte  11/16/22 19:14  0.1        Absolute Band  11/16/22 19:14  4.5  High        Absolute Neutrophil  11/16/22 19:14  1.5  Low        Abs Lymphocyte  11/16/22 19:14  1.4        Absolute Monocyte  11/16/22 19:14  1.0        RBC Morphology  11/16/22 19:14  See description        Macrocyte  11/16/22 19:14  Few (1+)        Platelet Estimate  11/16/22 19:14  Adequate        Platelet Morphology  11/16/22 19:14  Normal          Routine Chemistry Tests FS  LATEST RESULTS        Sodium SerPl QN  11/16/22 19:14  129  Low        Potassium SerPl QN  11/16/22 20:30  4.2        Chloride SerPl QN  11/16/22 19:14  93  Low        Carbon Dioxide SerPl QN  11/16/22 19:14  26        Anion Gap  11/16/22 19:14  10        BUN SerPl QN  11/16/22 19:14  23  High        Creatinine SerPl QN  11/16/22 19:14  0.60        Estimated GFR (CKD-EPI, no race)  11/16/22 19:14  >90        Estimated CRCL (CG)  11/16/22 19:14  71        Glucose SerPl QN  11/16/22 19:14  155  High        Calcium Total SerPl QN  11/16/22 19:14  12.6  High        Troponin-I High Sensitivity  11/16/22 19:14  63  High        BNP Pl QN  11/16/22 19:14  513  High        Lactate Venous Pl QN  11/16/22 19:14  3.8  High          Blood Gases FS  LATEST RESULTS        pH Bld Venous QN  11/16/22 19:14  7.29  Low        PCO2 Bld Venous QN  11/16/22 19:14  54        PO2 Bld Venous QN  11/16/22 19:14  62  High        Base Excess Bld Venous  11/16/22 19:14  -2        Bicarb Bld Venous Calc  11/16/22 19:14  26        O2 Sat Bld Venous Calc  11/16/22 19:14  88        Patient Temperature  11/16/22 19:14  37.0          Molecular Diagnostic Tests  LATEST RESULTS        COVID 19 Specimen Source  11/16/22 19:14  Nasal        Coronavirus SARS-CoV2 Rapid  11/16/22 19:14  Not Detected      Diagnostic Results  XR Chest PA or AP Portable    11/16/22 20:44:13  IMPRESSION:  1. No acute radiographic cardiopulmonary process.   Template Version:    Thank you for consulting with Radiology. For Healthcare  Providers, if you would like to discuss this case further, please  contact the Emergency Radiology reading room.   Electronically Signed by:     Signed By: MD  EKG  Time: 11/16/2022 19:01 Rate: 113 bpm Rhythm: sinus tachycardia Axis: normal ST-T segments: no changes T waves: normal Ectopy: none P waves and PR interval: within normal limits QT interval:within normal limits QRS interval: within normal limits Previous EKG:none available EP Interpretation: Poor quality, no STEMI      Signature Line Electronically Signed on 11/16/22 21:11 EST ________________________________________________________   Electronically Signed on 11/16/22 22:34 EST ________________________________________________________ MD  Reviewed by