Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on November 17, 2022 04:29  Verified By: on November 17, 2022 04:29  Encounter Info: Emergency, 11/17/22 - 11/17/22    * Final Report *        Basic Information  Time Seen: 11/17/2022 02:47  Chief Complaint  SOA  History of Present Illness     65-year-old who appears older than her stated age presents to the emergency department with EMS in extremis.  History obtained primarily via EMS.  Patient had shortness of breath with significant hypoxia on room air.  Patient's initial room air sats were in the upper 70s to low 80s.  Patient was speaking in short sentences.  She denied chest pain or fevers.  Onset of symptoms is unclear.  Per chart she has a past medical history of CHF peripheral vascular disease venous insufficiency and NSTEMI.   Patient did not receive any breathing treatments prehospital.  Was satting in the mid 80s on 2 L nasal cannula upon arrival  Review of Systems     Unable to obtain review of systems secondary to severity of disease.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Heart Rate:       86 bpm  Resp Rate:       20 br/min  BP:       124 / 73 mmHg  SpO2 (%):       95 %  O2 Flow (l/min):          4 L/min  O2 Device:       BIPAP  FiO2 (%):       0.50        Height CM: 157.5 cm  Weight KG: 63.1 kg  Ideal Body Weight: 50.12 kg      Heart Rate: 117 bpm High (11/17/22 02:43:00) Height CM: 157.5 cm (11/17/22 02:43:00)  Respiratory Rate: 38 br/min High (11/17/22 02:43:00) Weight KG: 63.1 kg (11/17/22 02:43:00)  Systolic Blood Pressure: 124 mmHg (11/17/22 02:43:00) Ideal Body Weight: 50.12 kg (11/17/22 02:43:00)  Diastolic Blood Pressure: 82 mmHg (11/17/22 02:43:00)   Oxygen Delivery: Nasal Cannula (11/17/22 02:43:00)       Constitutional: Severe distress, Skin: Dry, warm, pale  HENT: Normocephalic, Atraumatic Neck: Supplenormal ROM Cardiovascular: tachycardic, regular rhythm, symmetric distal pulsesNo edema Pulmonary: Severe respiratory distress, tachypnea, speaking in short sentences, satting in the low 80s on 2 L nasal cannula good air movement bilaterally but somewhat diminished in both bases. Abdomen: Nondistended, no tenderness, guarding none, rebound none, signs none Musculoskeletal: No deformities, no tenderness to palpation Neurologic: Alert,, No focal neuro deficit, Motor strength normal, Coordination intact Psych: Anxious, Medical Decision Making     ED nursing documentation reviewed   Per prior chart review: Discharge summary from November 1, 2022 patient presented to ED with increasing shortness of breath was found to have CHF exacerbation with elevated troponin and renal disease.  Per chart most recent echo showed an EF of over 50%.   Personal interpretation of EKG: 2:50 AM normal sinus rhythm rate of 98 prolonged QTC at 551, ST segment depression in the lateral precordial leads, the 4 through 6-lead I and lead II.  These ST segments depressions are more significant in the lateral precordial leads then they have been on most recent EKG.  ST depression in I and II are new.   Labs for this visit: reviewed  Imaging studies for this visit: reviewed, personal interpretation right lower lobe infiltrate with bilateral pulmonary edema and enlarged cardiac silhouette.   Started patient on BiPAP to aid work of breathing and hypoxia.  Patient's oxygenation status is significantly improved with a 50% FiO2 and her respiratory work of breathing has also significantly improved after just a short period of being on BiPAP.  11/17/22 03:10:37  Sent inquiry to see if ICU beds are available as pt will need admission and is on rescue Bipap.   Patient is tachycardic, hypoxic, hypothermic and has leukocytosis all chest x-ray.  Have started broad-spectrum antibiotics to cover respiratory bacteria.  Selected doxycycline over azithromycin secondary to prolongation of QTC.  She is at her baseline anemia.  Also given single dose of diuretics as patient's chest x-ray shows bilateral pulmonary edema and cardiomegaly.   K significantly low.  Am replacing.  11/17/22 04:26:00  Pt accepted to ICU.     Procedures     Critical Care Procedure Note: 75 minutes  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 the 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 patients response to treatment, frequent reassessment, and discussions with other providers. The critical care time was performed to asses 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 section and the rest of this note for further information on patient assessment and treatment.  Condition     guarded   Transfer to ICU  Assessment/Plan       1. Sepsis   A41.9    2. PNA (pneumonia)   J18.9    3. Pulmonary edema   J81.1    4. Hypokalemia   E87.6    5. Sepsis with acute hypoxic respiratory failure   A41.9    6. Acute exacerbation of CHF (congestive heart failure)   I50.9    Orders:   ampicillin-sulbactam, 3 GM, IVPB, Injection, ONCE, 11/17/22 9:00:00, 11/17/22 9:00:00, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  potassium chloride, 20 mEq, IVPB, Infusion, Q2H, 11/17/22 4:00:00, for 2 Doses, 11/17/22 6:00:00, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100  **Coronavirus SARS-CoV2 Rapid  Auto Diff  Basic Metabolic Panel  BIPAP Continuous  Blood CX  Blood CX  Blood Gas Venous QN  BNP Pl QN  Cardiac Monitor  CBC w/Differential  Continuous Oxygen Saturation  COVID 19 PCR  CTA Chest Pulm Embolism W/IV Contrast  Electrocardiogram  Electrocardiogram  Lactate Pl Venous QN  Lactate Pl Venous QN  Peripheral IV Insertion  Resp Evaluation or Assessment  Sepsis Tracking  Troponin-I High Sensitivity  XR Chest PA or AP Portable    Chronic Problem List    Atherosclerosis of left lower extremity with intermittent claudication  Atherosclerosis of right lower extremity with intermittent claudication  Bilateral iliac artery stenosis  CHF exacerbation  Dissection of left iliac artery  Dissection of right iliac artery  Elevated troponin  Varicose veins of right lower extremity with pain  Venous insufficiency of right leg  Procedure/Surgical History  ?CEA - Carotid endarterectomy (2006) ?abscess on right neck removed ?Cesarean section  Surgical History Internal  08/04/2016    Carotid Endarterectomy  (Left)  07/25/2016    Arteriogram Arch  Medications  Home Medications (10) Active amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily aspirin 81 mg oral tablet, delayed release 81 mg = 1 Tablet, Orally, Daily atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, QHS clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily metoPROLOL tartrate 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID pantoprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, Daily rivaroxaban 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily sertraline 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily Vitamin D3 (cholecalciferol) 25 mCg, Orally, Daily  Medication Administration   Given  ampicillin-sulbactam, IVPB  doxycycline, IVPB  furosemide, 40 mg, IV Push  potassium chloride IVPB, IVPB  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Quit June 2022.  Family History   Diabetes mellitus: Mother, Father and Grandmother.  Hypertension: Mother and Grandmother.  Lung cancer: Father.  Lab Results       Hemogram-Platelets-WBC Differential LATEST RESULTS  HISTORICAL RESULTS          WBC  11/17/22 02:50  14.6  High  11/01/22  9.8          RBC  11/17/22 02:50  3.46  Low  11/01/22  3.55  Low          Hgb  11/17/22 02:50  9.7  Low  11/01/22  10.2  Low          Hct  11/17/22 02:50  30.1  Low  11/01/22  30.2  Low          MCV  11/17/22 02:50  87  11/01/22  85          MCH  11/17/22 02:50  28.0  11/01/22  28.8          MCHC  11/17/22 02:50  32.2  11/01/22  33.8          RDW  11/17/22 02:50  16.3  High  11/01/22  16.9  High          Platelet  11/17/22 02:50  453  High  11/01/22  302          MPV  11/17/22 02:50  7.3  11/01/22  7.7          Neutrophils %  11/17/22 02:50  56  11/01/22  72          Lymphocytes %  11/17/22 02:50  33  11/01/22  15          Monocytes %  11/17/22 02:50  7  11/01/22  9          Eosinophils %  11/17/22 02:50  3  11/01/22  3          Basophils %  11/17/22 02:50  1  11/01/22  1          Absolute Neutrophil  11/17/22 02:50  8.2  High  11/01/22  7.0          Absolute Lymphocyte  11/17/22 02:50  4.8  High  11/01/22  1.4          Absolute Monocyte  11/17/22 02:50  1.0  11/01/22  0.9          Absolute Eosinophil  11/17/22 02:50  0.5  High  11/01/22  0.3          Absolute Basophil  11/17/22 02:50  0.1  11/01/22  0.1           Routine Chemistry Tests  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  11/17/22 02:50  142  11/01/22  138          Potassium SerPl QN  11/17/22 02:50  2.7  Critical  11/01/22  4.3          Chloride SerPl QN  11/17/22 02:50  96  Low  11/01/22  97  Low          Carbon Dioxide SerPl QN  11/17/22 02:50  20  Low  11/01/22  29          Anion Gap  11/17/22 02:50  26  High  11/01/22  12  High          BUN SerPl QN  11/17/22 02:50  41  High  11/01/22  27  High          Creatinine SerPl QN  11/17/22 02:50  1.76  High  11/01/22  1.53  High          Estimated GFR (CKD-EPI, no race)  11/17/22 02:50  32  Low  11/01/22  38  Low          Estimated CRCL 11/17/22 02:50  28  Low  11/01/22  31  Low          Glucose SerPl QN  11/17/22 02:50  384  High  11/01/22  95          Calcium Total SerPl QN  11/17/22 02:50  9.9  11/01/22  9.3          Troponin-I High Sensitivity  11/17/22 02:50  34  High  10/31/22  15  High          BNP Pl QN  11/17/22 02:50  1045  High  11/01/22  1057  High          Lactate Venous Pl QN  11/17/22 02:50  11.7  High  08/30/22  0.8           Blood Gases LATEST RESULTS  HISTORICAL RESULTS          pH Bld Venous QN  11/17/22 02:50  7.24  Low  10/31/22  7.48  High          PCO2 Bld Venous QN  11/17/22 02:50  47  10/31/22  40          PO2 Bld Venous QN  11/17/22 02:50  60  High  10/31/22  46  High          Base Excess Bld Venous  11/17/22 02:50  -7  Low  10/31/22  6  High          Bicarb Bld Venous Calc  11/17/22 02:50  20  Low  10/31/22  30  High          O2 Sat Bld Venous Calc  11/17/22 02:50  85  10/31/22  85          Patient Temperature  11/17/22 02:50  37.0  10/31/22  37.0           Molecular Diagnostic Tests  LATEST RESULTS  HISTORICAL RESULTS          COVID 19 Specimen Source  11/17/22 02:54  Nasal  08/29/22  Nasopharyngeal          Coronavirus SARS-CoV2 Rapid  11/17/22 02:54  Not Detected  08/29/22  Not Detected      Diagnostic Results  XR Chest PA or AP Portable    11/17/22 03:29:12  IMPRESSION:  1. Bilateral patchy airspace and interstitial infiltrates in the mid  to lower lung and pulmonary vascular prominence. Consider either CHF  or multifocal pneumonia in the correct clinical setting.   Template Version:   Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss  this case further can contact.   Electronically Signed by:         ************************************************** CTA Chest Pulm Embolism W/IV Contrast    11/17/22 04:15:37  IMPRESSION:  1. No obvious pulmonary embolism.  2. Bilateral layering small pleural effusion, multifocal patchy  diffuse infiltrates and mild to moderate cardiomegaly likely  represent CHF in the correct clinical setting. The differential  diagnosis includes multifocal pneumonia.  3. Severe central canal stenosis at T6-7 secondary to a posterior  marginal osteophyte.   Template Version:    Thank you for consulting. Healthcare providers  wishing to discuss this case further can contact the ER.  Thank you for consulting our team of subspecialty radiologist. Healthcare providers wishing to discuss  this case further can contact.   Electronically Signed by:           Signature Line Electronically Signed on 11/17/22 04:29 ________________________________________________________