Document Type: History and Physical   Document Subject: History & Physical Note   Performed: November 10, 2022 14:26   Verified By: November 10, 2022 14:26    Encounter Info: Observation, 11/10/22 - 11/13/22    * Final Report *          History of Present Illness/Subjective     This is a 64-year-old male with past medical history of COPD, generalized anxiety disorder, GERD, PE on Xarelto, hypertension, iron deficiency anemia presented to the ED due to complaints of sudden onset shortness of breath cough and lightheadedness.  The shortness of breath and dyspnea has been present for the last couple of days but got acutely worse after the iron infusion.  So he was sent here hypoxic.  Requiring supplemental oxygen.  He was hypoxic to 80 on room air.  Denies any COVID exposure fever or chills or chest pain.  Compliant with his Xarelto.   The patient has a gas furnace, but has a carbon monoxide monitor as well which did not show high levels.  Has not had similar episode before is the first time   Labs are suggestive of leukocytosis, normal eosinophil percentage mildly hyponatremic troponin of 21 lactate of 1.2 carbon monoxide levels of 1.7% and meth hemoglobin levels of 0.3 COVID is negative CTA ruled out PE  Review of Systems     13 point review of system is negative except for what is mentioned above  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  None reported this timeframe     Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  clear breath sounds now 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. Acute hypoxemic respiratory failure    -The patient has been having shortness of breath since last couple of days but got acutely worse after the iron infusion  -CTA negative for PE  -History of PE on rivaroxaban compliant  -No clear infiltrate on the CT scan, mediastinal and hilar lymphadenopathy seen  We will treat as COPD exacerbation because wheezing was heard on examination  Unlikely anaphylaxis because the patient has been taking iron infusions before as well,  -Currently on 4 L of oxygen, repeat chest x-ray tomorrow   2. COPD mixed type   History of COPD  -Continue IV steroids twice daily  -Albuterol, ipratropium  -Respiratory therapist evaluation  -O2 as needed   3. COPD exacerbation  History of COPD  -Continue IV steroids twice daily  -Albuterol, ipratropium  -Respiratory therapist evaluation  -O2 as needed   4. History of pulmonary embolism   -History of pulmonary embolism follows   Will continue rivaroxaban lifelong   5. Hypertension   -History of hypertension  -Continue home medications   6. Iron deficiency anemia  -Severe iron deficiency anemia  -We will hold iron infusions for now, continue oral supplements  -GI eval outpatient   7. GAD (generalized anxiety disorder)    -Continue home meds   8. GERD (gastroesophageal reflux disease)   -Continue Protonix   9. Mesenteric lymphadenopathy   -History of mesenteric lymphadenopathy stable,  -Needs repeat CT scan in Jan 2023   10. Tobacco use  -Nicotine patches    Code Status   None Recorded   Chronic Problem List    Chronic abdominal pain  Chronic low back pain  Closed fracture of distal fibula  COPD mixed type  DDD (degenerative disc disease), lumbar  Encounter for screening for lung cancer  GAD (generalized anxiety disorder)  GERD (gastroesophageal reflux disease)  History of pulmonary embolism  Hypertension  Iron deficiency anemia  Mesenteric lymphadenopathy  Thrombophilia  Tobacco use  Procedure/Surgical History  ?Esophagogastroduodenoscopy (01/22/2020) ?small bowel capsule (08/08/2019) ?Colonoscopy (07/31/2019) ?Esophagogastroduodenoscopy (07/31/2019) ?small bowel capsule (07/19/2016) ?colonoscopy (06/01/2016) ?egd (06/01/2016) ?L 2-5 fusion (2008) ?Shoulder surgery (1979) ?Anemia ?History of arthroscopic shoulder surgery ?Low back disc surgery   Surgical History Internal  04/23/2021    Appendectomy Laparoscopic      01/22/2020    EGD Diagnostic      07/31/2019    EGD Diagnostic      06/01/2016    EGD Bx    Medications   Home Medications (10) Active  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H  cloNIDine 0.1 mg oral tablet 0.05 mg = 0.5 Tablet, Orally, Daily  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, Daily  GaviLyte-G oral powder for reconstitution See Instructions, as directed.  lansoprazole 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, Daily  OXYcodone 15 mg oral tablet 15 mg = 1 Tablet, PRN, Orally, Q6H  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q6H  Symbicort 160 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID, in the morning and the eveninguse with spacer chamber  tiZANidine 4 mg oral tablet 4 mg = 1 Tablet, PRN, Orally, 4 Times Daily  Xarelto 20 mg oral tablet 20 mg = 1 Tablet, Orally, With Dinner  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 11/09/22 00:00:00 TO 11/10/22 14:26:44  None Reported  PRN Medications (0600 - 0559) from 11/09 - 11/10  None Reported  Allergies   NKA  Social History    Alcohol   Current, 1-2 times per year   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Work/School description: Disabled.   Home/Environment   Divorced, no children   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   DM (diabetes mellitus)..: Father.  Hypertension..: Mother.  Osteoporosis...: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 13.4 k/cumm High (11/10/22 11:12:47)  RBC: 4.17 million/cumm Low (11/10/22 11:12:47)  Hgb: 9.2 GM/dL Low (11/10/22 11:12:47)  Hct: 31.1 % Low (11/10/22 11:12:47)  MCV: 75 fL Low (11/10/22 11:12:47)  MCH: 22.2 pg Low (11/10/22 11:12:47)  MCHC: 29.7 GM/dL Low (11/10/22 11:12:47)  RDW: 21 % High (11/10/22 11:12:47)  Platelet: 308 k/cumm (11/10/22 11:12:47)  MPV: 7 fL (11/10/22 11:12:47)  Neutrophils %: 59 % (11/10/22 11:12:47)  Lymphocytes %: 23 % (11/10/22 11:12:47)  Monocytes %: 16 % (11/10/22 11:12:47)  Eosinophils %: 1 % (11/10/22 11:12:47)  Basophils %: 1 % (11/10/22 11:12:47)  Absolute Neutrophil: 7.9 k/cumm High (11/10/22 11:12:47)  Absolute Lymphocyte: 3.1 k/cumm (11/10/22 11:12:47)  Absolute Monocyte: 2.1 k/cumm High (11/10/22 11:12:47)  Absolute Eosinophil: 0.1 k/cumm (11/10/22 11:12:47)  Absolute Basophil: 0.1 k/cumm (11/10/22 11:12:47)  Chemistry:  Troponin-I High Sensitivity: 21 ng/L High (11/10/22 10:08:00)  BNP Pl QN: 92 pg/mL (11/10/22 10:08:00)  Lactate Venous Pl QN: 1.2 mmol/L (11/10/22 10:42:00)  Anion Gap, POC: 13 mmol/L (11/10/22 09:47:00)  CO2, POC: 27 mmol/L (11/10/22 09:47:00)  BUN, POC: 12 mg/dL (11/10/22 09:47:00)  Chloride, POC: 92 mmol/L Low (11/10/22 09:47:00)  Creatinine, POC: 1.1 mg/dL (11/10/22 09:47:00)  Estimated GFR (CKD-EPI, no race), POC: 75 mL/min/1.73m2 (11/10/22 10:08:00)  Estimated CRCL (CG), POC: 74 mL/min (11/10/22 10:08:00)  Glucose, POC: 99 mg/dL (11/10/22 09:47:00)  Potassium, POC: 4.2 mmol/L (11/10/22 09:47:00)  Sodium, POC: 132 mmol/L Low (11/10/22 09:47:00)  Carboxyhemoglobin Bld QN: 1.7 % (11/10/22 10:08:00)  Methemoglobin Bld QN: 0.3 % (11/10/22 10:08:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/10/22 12:38:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/10/22 12:38:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/10/2022 10:42 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:  Areas of mild atelectasis and scarring in the lungs are similar to1/20/2022.No acute pulmonary findings are identified.There is nonspecific but increasing mediastinal and hilarlymphadenopathy. Possible etiologies would include viral response,granulomatous disease such as far scoliosis for malignant involvement(lymphoma or metastatic disease).Stable 0.6 cm left upper lobe nodule, considered benign and requiringno further evaluation.