Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on January 22, 2023 18:37 EST   Verified By: MD on January 22, 2023 18:37 EST   Encounter Info: Hospital, Inpatient, 01/22/23 -     * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     She is significantly dyspneic unable to speak in long sentences   this is an 84-year-old female past medical history of COPD, and DVT presents with sudden onset of shortness of breath since morning, besides that the patient was in her usual state of health.  Denies any complaints of chest pain cough or sputum.  Upon arrival to the ED she was noted to be 68% on 2 L  The patient was noted to have elevated blood pressures upon arrival   Blood gas showed hypercapnic respiratory acidosis, leukocytosis, dimers were 207, lactate normal.  She is COVID-negative x-ray showed patchy infiltrate on the right upper lobe due to pneumonia.  She was placed on BiPAP  Review of Systems     13 point review system was not taken due to patient's condition  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  None reported this timeframe     Patient Weight    Patient Height  None Reported     Constitutional:  dyspneic  Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus  ENMT:  Moist oral mucosa  Neck:  Supple, non-tender, intact range of motion  Respiratory:  decreased air movement b/l, using accessory muscles  Cardiovascular:  sinus tachy  Gastrointestinal:  Soft, non-tender, non-distended  Musculoskeletal:  No joint swelling, no deformity, intact ROM  Integumentary:  toes erythematous b/ l  Neurologic: Alert & Oriented   Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan     #Acute respiratory failure   1. Hypertensive urgency   I16.0  - Initial presentation the blood pressures were 189/108  -The patient's blood pressures were controlled in the ED  -Resume blood pressure medications  -Monitor for chest pain headache or visual changes   2. COPD exacerbation   J44.1  - methypred Q8,   -DUONEBS   - RT to evaluate   - azithromycin for 3 days  - follow blood gas   3. PNA (pneumonia)   J18.9  -Right upper lobe pneumonia  -Given history of COPD will cover broadly  -Cefepime and doxycycline  -Follow pneumonia work-up   4. History of DVT in adulthood   Z86.718  - resume meds on reconciliation   CAD (coronary artery disease)   I25.10  -Noted  -Resume core measures upon medical reconciliation   Hypertension   I10  -Resume home medications once bp is stable      Orders:   azithromycin, 500 mg, Orally, Tablet, Daily, Indication: Pneumonia - CAP, 01/23/23 9:00:00 EST  Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent  70 minutes of critical care time directly and personally managing the patient. This critical care time included obtaining a history, examining the patient, pulse oximetry, ordering and reviewing the studies, arranging urgent treatment with development of a management plan, evaluation of the patient?s response to treatment, frequent reassessment, and discussions with other clinicians. The critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see the MDM section and the rest of this note for further information on patient assessment and treatment.  Code Status   None Recorded   Chronic Problem List    Ambulatory dysfunction  CAD (coronary artery disease)  COPD exacerbation  Dislocation of jaw, closed  Dyspnea  History of COPD  Hypercarbia  Hypertension  Hypoxia  Pain, dental  Pneumonia  Severe obesity  Procedure/Surgical History  ?Breast Lumps ?Cataracts ?Right wrist ?Tonsillectomy     Medications   Home Medications (17) Active  acetaminophen   albuterol (Eqv-ProAir HFA) 90 mCg/inh inhalation aerosol   azelastine nasal 0.1% spray   Breo Ellipta 100 mCg-25 mCg inhalation powder   carvedilol 3.125 mg oral tablet   docusate sodium 100 mg oral capsule   Eliquis 5 mg oral tablet   gabapentin 300 mg oral capsule   loratadine   omeprazole 40 mg oral delayed release capsule   ondansetron 4 mg oral tablet   simethicone   Spiriva 18 mCg inhalation capsule   theophylline 300 mg/12 hours oral tablet, extended release   torsemide 20 mg oral tablet   traMADOL   Tymlos 80 mCg/0.04 mL subcutaneous solution 80 mCg, Subcutaneous, Daily, Dispense Pen Needles (8mm, 31 gauge)  Active Scheduled Inpatient Medications  azithromycin, Tablet, 500 mg, Orally, Daily, Indication: Pneumonia - CAP, Start: 01/23/23 09:00:00    One-Time Medications Given 01/21/23 00:00:00 TO 01/22/23 18:36:14  None Reported  PRN Medications (0600 - 0559) from 01/21 - 01/22  None Reported  Allergies   minocycline (Rash)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   PHLC   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12.9 k/cumm High (01/22/23 12:46:00)  RBC: 4.49 million/cumm (01/22/23 12:46:00)  Hgb: 12.6 GM/dL (01/22/23 12:46:00)  Hct: 38.5 % (01/22/23 12:46:00)  MCV: 86 fL (01/22/23 12:46:00)  MCH: 28 pg (01/22/23 12:46:00)  MCHC: 32.7 GM/dL (01/22/23 12:46:00)  RDW: 15.6 % High (01/22/23 12:46:00)  Platelet: 224 k/cumm (01/22/23 12:46:00)  MPV: 8.5 fL (01/22/23 12:46:00)  Neutrophils %: 79 % (01/22/23 12:46:00)  Lymphocytes %: 14 % (01/22/23 12:46:00)  Monocytes %: 6 % (01/22/23 12:46:00)  Eosinophils %: 0 % (01/22/23 12:46:00)  Basophils %: 1 % (01/22/23 12:46:00)  Absolute Neutrophil: 10.2 k/cumm High (01/22/23 12:46:00)  Absolute Lymphocyte: 1.7 k/cumm (01/22/23 12:46:00)  Absolute Monocyte: 0.8 k/cumm (01/22/23 12:46:00)  Absolute Eosinophil: 0.1 k/cumm (01/22/23 12:46:00)  Absolute Basophil: 0.1 k/cumm (01/22/23 12:46:00)  Chemistry:  Sodium SerPl QN: 134 mmol/L Low (01/22/23 12:46:00)  Potassium SerPl QN: 4 mmol/L (01/22/23 12:46:00)  Chloride SerPl QN: 93 mmol/L Low (01/22/23 12:46:00)  Carbon Dioxide SerPl QN: 35 mmol/L High (01/22/23 12:46:00)  Anion Gap: 6 mmol/L (01/22/23 12:46:00)  BUN SerPl QN: 14 mg/dL (01/22/23 12:46:00)  Creatinine SerPl QN: 0.76 mg/dL (01/22/23 12:46:00)  Estimated GFR (CKD-EPI, no race): 77 mL/min/1.73m2 (01/22/23 12:46:00)  Estimated CRCL (CG): 55 mL/min Low (01/22/23 12:46:00)  Glucose SerPl QN: 102 mg/dL High (01/22/23 12:46:00)  Calcium Total SerPl QN: 9.1 mg/dL (01/22/23 12:46:00)  Alkaline Phos SerPl QN: 60 Units/L (01/22/23 12:46:00)  ALT SerPl QN: 6 Units/L Low (01/22/23 12:46:00)  AST SerPl QN: 13 Units/L (01/22/23 12:46:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (01/22/23 12:46:00)  Total Protein SerPl QN: 8.8 GM/dL High (01/22/23 12:46:00)  Albumin SerPl QN: 4.1 GM/dL (01/22/23 12:46:00)  Troponin-I High Sensitivity: 8 ng/L (01/22/23 12:46:00)  BNP Pl QN: 87 pg/mL (01/22/23 12:46:00)  Lactate Venous Pl QN: 0.9 mmol/L (01/22/23 12:46:00)  pH Bld Venous QN: 7.34 Low (01/22/23 12:46:00)  PCO2 Bld Venous QN: 68 mmHg Critical (01/22/23 12:46:00)  PO2 Bld Venous QN: <35 Low (01/22/23 12:46:00)  Base Excess Bld Venous: 8 mmol/L High (01/22/23 12:46:00)  Bicarb Bld Venous Calc: 37 mmol/L High (01/22/23 12:46:00)  O2 Sat Bld Venous Calc: 53 % (01/22/23 12:46:00)  Patient Temperature: 37 DegC (01/22/23 12:46:00)  Coagulation:  D-Dimer Pl QN: 207 ng/mL DDU (01/22/23 12:46:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (01/22/23 13:03:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (01/22/23 13:03:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 01/22/2023 12:53 - XR Chest PA or AP Portable  IMPRESSION: Patchy infiltrate right upper lobe probably due topneumonia.                Signature Line Electronically Signed on 01/22/23 18:37 EST ________________________________________________________ MD  Electronically Signed on 01/22/23 18:44 EST ________________________________________________________ MD