Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on May 29, 2023 17:25   Verified By: NP on May 29, 2023 17:25   Encounter Info: Inpatient, 05/29/23 -     * Final Report *  Document Has Been Revised And Contains Addenda          History of Present Illness/Subjective     59 year old female w/ a hx of COPD on 2L O2 at baseline presents to the ED via private vehicle for evaluation of worsening SOA, fever, and productive cough over the last 24 hours. Pt was admitted on 5/6/2023 hospital for sepsis, COPD, and pneumonia. She explains that her current systems feel worse than then, and she has had to raise her O2 to 4L last night. Pt had a CT performed on 5/25/2023 which shows evidence of pneumonia, and she was informed of this. Denies vomiting or diarrhea. Denies hx of tobacco use.   Upon ER evaluation her room air sat dropped below 88% and he was requiring up to 5 L per nasal cannula.  Temperature was 37.4, heart rate was elevated at 118 respiratory rate was 20 and blood pressure was initially 105/73.  Lab work obtained white blood cell count was elevated at 12.2, hemoglobin was 10.7, sodium was 135, potassium was 3.3, renal function was at her baseline with GFR greater than 90, glucose was 97, troponin was 27 BN P was 56, lactate was 1.2, VBG obtained with a pH of 7.48 and PCO2 was 40, COVID testing was negative. CXR showed Worsening multifocal airspace disease, likely infectious.  Due to failure to improve with outpatient treatment for pneumonia patient will be brought in for further evaluation and management of pneumonia, sepsis.   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   Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress,  well-nourished Eyes:  PEERL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs crackles and exp 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 x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Sepsis   A41.9   Sepsis order set in place ? Due to pneumonia failed outpatient treatment ? We will start vancomycin pharmacy dosing, cefepime and doxycycline ? Pending labs respiratory culture, procalcitonin, strep and MRSA PCR ? De-escalate antibiotic therapy as warranted as labs return   2. Pneumonia   J18.9   Requiring oxygen at this time at increased flow within baseline. ? Chronic O2 use of 2 to 4 L at home, now on 5l nc ? RT protocol ? See plan above  -CXR 5/29 Worsening multifocal airspace disease, likely infectious.      3. Hypoxia   R09.02   Continue O2 as needed   4. Failure of outpatient treatment   Z78.9   Meets inpatient criteria   5. GERD (gastroesophageal reflux disease)   K21.9   Resume PPI   6. SOB (shortness of breath)   R06.02   As above   pneumonia plus?minus COPD exacerbation   7. Hypokalemia   E87.6  replacement protocol   Chronic back pain   M54.9   Resume home meds   COPD exacerbation   J44.1   RT protocol continue Breo, Mucinex, doxycycline and IV steroids  -Pt does not smoke , no hx of smoking, no work place exposures  -Pt is a RT   Hypertension   I10   resume home meds   Sleep apnea   G47.30   RT routine evaluation and protocol  -pt wears cpap at 8    ???????Patient is a full code ? DVT's prophylaxis with Lovenox   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 05/29/23 17:25:00  albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, PRN, Shortness of Breath/Wheezing, 05/29/23 17:24:00 RT Care Assessment and Protocol per Policy  albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, 05/29/23 19:00:00 RT Care Assessment and Protocol per Policy  calcium carbonate, 750 mg, Orally, Tab, Chewable, 4 Times Daily, PRN, Indigestion, 05/29/23 17:25:00   cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 05/29/23 18:00:00  for 5 Days, 06/03/23 10:00:00 EDT, Total Volume (mL) = 50  docusate-senna, 2 Tablet, Orally, Tablet, BID, 05/29/23 21:00:00  doxycycline, 100 mg, Orally, Capsule, BID, Indication: COPD Exacerbation, 05/29/23 22:00:00 for 5 Days, 06/03/23 10:00:00   enoxaparin, 40 mg, Subcutaneous, Injection, Q24H, 05/30/23 6:00:00   guaifenesin, 600 mg, Orally, Tab, Extended Rel, BID, 05/29/23 21:00:00   hydrocodone-acetaminophen, 1 Tablet, Orally, Tablet, Q6H, PRN, Pain, Moderate (4-6 out of 10), 05/29/23 17:25:00   labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 05/29/23 17:25:00   magnesium sulfate, 4 GM, IVPB, Injection, Q12H, PRN, Lab (Details Required), 05/29/23 17:26:00   methylPREDNISolone, 40 mg, IV Push, Injection, Q12H, 05/29/23 18:00:00   ocular lubricant, 1 App, Eyes, Both, Ophthalmic OINT, Q4H, PRN, Dry Eyes, 05/29/23 17:25:00   ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 05/29/23 17:25:00   polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 05/29/23 17:25:00   potassium chloride, 30 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 05/29/23 17:26:00   potassium chloride, 40 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 05/29/23 17:26:00   potassium phosphate-sodium phosphate, 1 Packet, Orally, Powder, Unscheduled, PRN, Lab (Details Required), 05/29/23 17:26:00  potassium phosphate-sodium phosphate, 1 Packet, Orally, Powder, Unscheduled, PRN, Lab (Details Required), 05/29/23 17:26:00   umeclidinium-vilanterol, 1 Puff, Inhalation, MDI/DPI Inhaler Treatment, Daily, 05/30/23 9:00:00   vancomycin, 1,750 mg, IVPB, Injection, ONCE, Indication: Pneumonia - HAP/VAP, NOW, 05/29/23 17:25:00 EDT, 05/29/23 17:25:00, 250 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 500  Admit to Inpatient CAH  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  CBC w/Differential  Collect Specimen  Collect Specimen  Collect Specimen  Comp Metabolic Panel  COPD Education per Respiratory Care  CPAP Nocturnal  CPAP Nocturnal with NAPs  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Heating Pad  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Level of Care  Message to Nursing  MRSA PCR  Nasal Cannula  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Peripheral IV Insertion  Procalcitonin  PT Evaluation and Treatment  Regular Diet  Resp CX + Stn  Resp Evaluation or Assessment  Resp Evaluation or Assessment  Resuscitation Status  Strep pneumoniae Ag Urine  Titrate FiO2 to Keep O2 Sat  Troponin-I High Sensitivity  Vancomycin Pharmacy Dosing Consult  Vital Signs  Vital Signs  Weight  Code Status   None Recorded   Chronic Problem List    Anemia  B12 deficiency  Bariatric surgery status  Bilateral shoulder pain  Chronic back pain  Chronic fatigue  COPD exacerbation  Depression  Encounter for long-term (current) use of medications  Failure of outpatient treatment  Fibromyalgia  GERD (gastroesophageal reflux disease)  History of total knee arthroplasty  Hypertension  Hypoxia  IBS (irritable bowel syndrome)  Laryngopharyngeal reflux  Left knee pain  Migraine headache  Neuropathy  Osteoarthritis of right shoulder  Osteoarthritis of shoulders, bilateral  Pneumonia  Polypharmacy  Pre-diabetes  Restrictive lung disease  Sepsis  Sleep apnea  SOB (shortness of breath)  Total knee replacement status  Urinary frequency  Vocal cord leukoplakia  Vocal cord nodules  Wellness examination  Procedure/Surgical History  nerve block in lower back (03/29/2023) Total knee replacement (11/27/2017) Colonoscopy (2015) EGD (2015) Mammogram (07/07/2014) Cataract Extraction (2012) Hernia repair (2009) Total hysterectomy (1997) Cholecystectomy Laparoscopic (1993) Appendectomy BONE SPUR REMOVAL Carpal tunnel release Laminectomy lap band removal LAP-BAND surgery status left eye Release of trigger finger Scleral buckle procedure Thoracotomy Total replacement of right knee joint TUMOR REMOVED   Surgical History Internal  08/31/2018    Retinal Detachment Repair  (Left)   MD  11/27/2017    Knee Arthroplasty  (Left)    MD  10/21/2016    Gastric Band Revision Lapscpy     MD  01/12/2016    Bronchoscopy Diagnostic w Fluoro     MD  Medications   Home Medications (24) Active  Advair Diskus 250 mCg-50 mCg inhalation powder 1 Puff, Inhalation, BID, Refills must be obtained from PCPrinse mouth and throat after use  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Inhalation, Q6H  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, 4 Times Daily  amitriptyline 25 mg oral tablet 25 mg = 1 Tablet, Orally, At Bedtime, for migraine prevention  busPIRone 10 mg oral tablet 10 mg = 1 Tablet, Orally, BID  cycloBENZaprine 10 mg oral tablet 10 mg = 1 Tablet, Orally, TID  Cymbalta 60 mg oral delayed release capsule 60 mg = 1 Capsule, Orally, Daily, (do not crush or chew)  Ester-C 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, Daily  famotidine 20 mg oral tablet 20 mg = 1 Tablet, PRN, Orally, Daily  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, BID  gabapentin 300 mg oral capsule 600 mg = 2 Capsule, Orally, TID  hydroCHLOROthiazide 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  hyoscyamine 0.375 mg oral tablet, extended release 0.375 mg = 1 Tablet, PRN, Orally, Q12H  ibuprofen 200 mg oral tablet 600 mg = 3 Tablet, Orally, TID  Imitrex 100 mg oral tablet 100 mg = 1 Tablet, PRN, Orally, ONCE  lansoprazole 15 mg oral delayed release capsule 15 mg = 1 Capsule, Orally, At Bedtime  loperamide 2 mg oral tablet 2 mg = 1 Tablet, PRN, Orally, Q4H  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  lysine 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, TID  Norco 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q4H  Os-Cal 500 , Orally  Singulair 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Super B Complex 1 Tablet, Orally, Daily  Vitamin D3 10 mCg (400 intl units) oral capsule 10 mCg = 1 Capsule, Orally  Active Scheduled Inpatient Medications  albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 2.5 mg, Neb Inhal, Q6H, Start: 05/29/23 19:00:00    One-Time Medications Given 05/28/23 00:00:00 TO 05/29/23 17:25:09  None Reported  PRN Medications (0600 - 0559) from 05/28 - 05/29  None Reported  Allergies   Diflucan (severe itching)  Stadol NS (Itching)  Ventolin HFA (shortness of breath)  Topamax (Tingling in extremities)  Social History    Alcohol   Current, Wine, 1-2 times per week, Previous treatment: None.   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   disability   Exercise   Exercise duration: 0.   Home/Environment   MARRIED - two children - disability, Lives with Spouse.   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Alcohol abuse: Aunt.  Autoimmune disease..: Mother.  Coronary artery disease..: Mother.  DM (diabetes mellitus)..: Father.  Heart disease..: Father.  Hypertension..: Mother.  Multiple sclerosis..: Mother and Aunt.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12.2 k/cumm High (05/29/23 14:27:00)  RBC: 3.6 million/cumm Low (05/29/23 14:27:00)  Hgb: 10.7 GM/dL Low (05/29/23 14:27:00)  Hct: 32.1 % Low (05/29/23 14:27:00)  MCV: 89 fL (05/29/23 14:27:00)  MCH: 29.7 pg (05/29/23 14:27:00)  MCHC: 33.3 GM/dL (05/29/23 14:27:00)  RDW: 13.6 % (05/29/23 14:27:00)  Platelet: 253 k/cumm (05/29/23 14:27:00)  MPV: 8 fL (05/29/23 14:27:00)  Neutrophils %: 87 % (05/29/23 14:27:00)  Lymphocytes %: 8 % (05/29/23 14:27:00)  Monocytes %: 4 % (05/29/23 14:27:00)  Eosinophils %: 1 % (05/29/23 14:27:00)  Basophils %: 0 % (05/29/23 14:27:00)  Absolute Neutrophil: 10.6 k/cumm High (05/29/23 14:27:00)  Absolute Lymphocyte: 1 k/cumm (05/29/23 14:27:00)  Absolute Monocyte: 0.5 k/cumm (05/29/23 14:27:00)  Absolute Eosinophil: 0.1 k/cumm (05/29/23 14:27:00)  Absolute Basophil: 0 k/cumm (05/29/23 14:27:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (05/29/23 14:27:00)  Potassium SerPl QN: 3.3 mmol/L Low (05/29/23 14:27:00)  Chloride SerPl QN: 97 mmol/L Low (05/29/23 14:27:00)  Carbon Dioxide SerPl QN: 27 mmol/L (05/29/23 14:27:00)  Anion Gap: 11 mmol/L (05/29/23 14:27:00)  BUN SerPl QN: 12 mg/dL (05/29/23 14:27:00)  Creatinine SerPl QN: 0.66 mg/dL (05/29/23 14:27:00)  Estimated GFR (CKD-EPI, no race): >90 (05/29/23 14:27:00)  Estimated CRCL (CG): 107 mL/min (05/29/23 14:27:00)  Glucose SerPl QN: 97 mg/dL (05/29/23 14:27:00)  Calcium Total SerPl QN: 8.6 mg/dL (05/29/23 14:27:00)  Troponin-I High Sensitivity: 27 ng/L High (05/29/23 14:27:00)  BNP Pl QN: 56 pg/mL (05/29/23 14:27:00)  Lactate Venous Pl QN: 1.2 mmol/L (05/29/23 14:27:00)  pH Bld Venous QN: 7.48 High (05/29/23 14:27:00)  PCO2 Bld Venous QN: 40 mmHg (05/29/23 14:27:00)  PO2 Bld Venous QN: 42 mmHg (05/29/23 14:27:00)  Base Excess Bld Venous: 6 mmol/L High (05/29/23 14:27:00)  Bicarb Bld Venous Calc: 30 mmol/L High (05/29/23 14:27:00)  O2 Sat Bld Venous Calc: 82 % (05/29/23 14:27:00)  Patient Temperature: 37 DegC (05/29/23 14:27:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (05/29/23 14:27:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (05/29/23 14:27:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 05/29/2023 15:16 - XR Chest PA or AP Portable  IMPRESSION:Worsening multifocal airspace disease, likely infectious.Thank you for consulting our team of subspecialty radiologists Radiology. Please contact with any questions.                Signature Line Electronically Signed on 05/29/23 17:25  ________________________________________________________ NP  Electronically Signed on 05/29/23 17:27  ________________________________________________________  NP    Addendum by MD on May 29, 2023 17:35:31 (Verified)    I saw and evaluated the patient in addition to NP. I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care.  Constitutional:  No acute distress, well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Increased WOB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  MD, FACP      Signature Line Electronically Signed on 05/29/23 17:35  ________________________________________________________ MD