Referral Source  None None  Subjective     This 75 year old with history of anemia, aortic stenosis s/p TAVR, depression, chronic back pain, CHF, end-stage COPD on home oxygen presents as a transfer from Hospital with complaint of increased weakness/fatigue and new onset of ablation.  Patient states that began last Friday she began having symptoms of nausea and intermittent diarrhea.  She was more short breath than usual and noted increased fatigability.  Over the course of week and she was too weak to cook with still mild symptoms of nausea and intermittent loose stools.  Today shortness of breath worsened.  She denies symptoms of chest pain but has had several symptoms of chest discomfort.  No fever or chills.  No symptoms of abdominal pain.  Also noted a heart rate being faster than usual.  She denies any symptoms of orthopnea, paroxysmal nocturnal dyspnea or change in baseline peripheral edema.  No symptoms of orthostasis as well.   Emergency room her blood pressure 97/64 heart rate 155 respiratory rate 36 temperature 38.2 oxygen saturation 96% on 3 L of oxygen.   Serology: White count 14,700 with slight left shift hemoglobin 10.3 Mehta crit 32.4 and a platelet count of 184,000.  Sodium 136 potassium 3.4 chloride 99 bicarb 26 BUN 33 creatinine 1.06 blood sugar 131.  Calcium 8.3 alkaline phosphatase 43 ALT 6 AST 10 total bilirubin 0.8 protein 6 albumin 3.4 troponin 110 BNP 303 lactate 1.8.  TSH 1.21.  Chest x-ray findings of early CHF or other fluid overload state with apparent mild interstitial pulmonary edema developing right lower lung and small right pleural effusion noted.  Stable cardiomegaly and prior implant from TAVR again noted.  COVID PCR negative.   Past medical history: COPD, aortic stenosis status post TAVR, history of CHF/diastolic heart failure, depression, GERD, hypertension, iron deficiency anemia, low back pain, history of nutrition, osteoarthritis, peripheral vascular disease, restless leg syndrome.  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 last 24 hours  VITAL SIGNS  Temp C:       36.8 DegC  Heart Rate:       142 bpm  Resp Rate:       26 br/min  BP:       102 / 54 mmHg  SpO2 (%):       96 %  O2 Flow (l/min):          2 L/min  O2 Device:       Nasal Cannula     Height CM: 150 cm  Weight KG: 47.6 kg  BMI Weight in kg: 21.2 kg/m2  Ideal Body Weight: 43.33 kg           General:  Alert and oriented, No acute distress.         Eye:  Extraocular movements are intact, Vision unchanged       HEENT:  Normocephalic, Normal hearing       Neck:  Supple, Non-tender, elevated jugular is pressure       Respiratory: Bilateral wheezes with upper airway congestion and bibasilar crackles, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness.         Cardiovascular: Tachycardic rate, irregular irregular rhythm, No murmur, No gallop, Normal peripheral perfusion, Good pulses equal in all extremities, 1+ bilateral lower extremity edema.          Gastrointestinal:  Soft, nontender, nondistended, normal bowel sounds, no evidence of hepatosplenomegaly.       Lymphatics:  No lymphadenopathy neck       Musculoskeletal:  Normal range of motion, Normal strength       Integumentary:  Warm, Dry, No rash.         Feet:  Normal by visual exam, Normal pulses, Sensation intact.         Neurologic:  Alert, Oriented, Normal motor function       Psychiatric:  Cooperative, Appropriate mood & affect, Normal judgment.           Assessment/Plan       1. Atrial fibrillation with RVR   I48.91  New onset A. fib with RVR.  Patient placed in intensive care setting.  She is started on an amiodarone drip as her hypotension precludes Cardizem.  We will also start IV digoxin as well as an IV heparin drip.  We will transition to oral medication tomorrow including Eliquis therapy.  We will obtain cardiac echo to evaluate her LV systolic function.  I have cardiology see her in consultation.  Likely triggered by her COPD.   2. CHF exacerbation   I50.9  Pulmonary edema and fluid overload likely due to A. fib with RVR.  We will give judicious IV Lasix therapy in conjunction with treating A. fib RVR.  We will check cardiac echo to reevaluate her LV systolic function.  Low-sodium diet.  We will likely place her on a beta-blocker and or a similar as tolerated.   3. COPD exacerbation   J44.1  bronchospasm likely due to pulmonary edema.  RT protocol and frequent neb treatments as indicated.  We will start IV Solu-Medrol.  No indication for antibiotics at this time.   4. Elevated troponin   R77.8  Noted.  Likely associated with demand ischemia.  We will continue to trend troponin levels and obtain a cardiac echo to evaluate LV systolic function.   5. Iron deficiency anemia   D50.8  Noted.  Hemoglobin/hematocrit appear to be at baseline.  We will check iron studies and follow for any rectal bleeding once anticoagulated.   6. Diarrhea   R19.7  Noted.  Her symptoms have improved thus far.  Consider work-up if symptoms recur or persist   7. GERD (gastroesophageal reflux disease)   K21.9  Noted.  Reflux precautions and PPI therapy   8. S/P TAVR (transcatheter aortic valve replacement)   Z95.2  Noted.  Cardiac echo pending.   Orders:   acetaminophen, 1,000 mg, Orally, Tablet, Q8H, PRN, Pain Mild PO (1-3 out of 10), 11/21/22 16:25:00   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 11/21/22 16:25:00   albuterol, 2.5 mg, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q2H, PRN, Shortness of Breath/Wheezing, 11/21/22 16:25:00, RT Care Assessment and Protocol per Policy  ALprazoLAM, 0.25 mg, Orally, Tablet, Q6H, PRN, Anxiety, 11/21/22 16:43:00  amiodarone 360 mg + Dextrose 5% in Water 200 mL, Total Volume (mL) = 200, IV, 11/21/22 16:27:00, See Comments  amiodarone infusion bolus dose, 150 mg, Via Infusion Pump, Infusion, ONCE, 11/21/22 17:00:00, 11/21/22 17:00:00  digoxin, 250 mCg, Orally, Tablet, Daily, 11/22/22 9:00:00  furosemide, 40 mg, IV Push, Injection, BID, 11/21/22 17:00:00   heparin 25,000 Units + Sodium Chloride 0.45% 250 mL, Total Volume (mL) = 250, IV, 11/21/22 16:25:00, Per Nomogram  heparin infusion bolus dose, Per STANDARD Dose Heparin Nomogram, Via Infusion Pump, Infusion, Unscheduled, PRN, Other-See Comments, 11/21/22 16:25:00  influenza virus vaccine, inactivated, 0.7 mL, IM, Injection, Day of Discharge, 11/21/22 16:24:00   labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 11/21/22 16:25:00   magnesium sulfate, 4 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 11/21/22 16:28:00, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  magnesium sulfate, 2 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 11/21/22 16:28:00, 25 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 50  methylPREDNISolone, 40 mg, IV Push, Injection, Q8, 11/21/22 22:00:00   pantoprazole, 40 mg, Orally, Tab, Delayed Rel, Daily, 11/21/22 17:00:00   potassium chloride, 40 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 11/21/22 16:28:00   potassium chloride, 20 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 11/21/22 16:28:00   potassium chloride, 30 mEq, Orally, Tab, Extended Rel, Unscheduled, PRN, Lab (Details Required), 11/21/22 16:28:00   2000 mg Sodium, 20 gm Saturated Fat Diet  aPTT Pl QN  Bed Request (Decision to Admit)  BNP Pl QN  Call Bleeding  Call Blood Glucose  Call Change in Heart Rhythm  Call Diastolic Blood Pressure  Call Diastolic Blood Pressure  Call Heart Rate  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call PTT Results  Call Respiratory Distress  Call Respiratory Rate  Call Respiratory Rate  Call Systolic Blood Pressure  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  CBC  CBC w/Differential  Collect Specimen  Collect Specimen  Collect Specimen  Collect Specimen  Collect Specimen  Comp Metabolic Panel  Diagnosis  Echocardiogram with Cardiac Doppler PW/CW/Color  Height and Weight  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  IV Site Assessment  Level of Care  Magnesium SerPl QN  Magnesium SerPl QN  Medical Service  Message to Nursing  Nasal Cannula  Notify Provider  Notify Provider  Notify Provider  OT Evaluation and Treatment  PP Required: Initiate only  PT Evaluation and Treatment  Reason for Not Ordering Medication Prophylaxis  Resp Evaluation or Assessment  Resuscitation Status  T4 Free Direct SerPl QN  Troponin-I High Sensitivity  TSH w FreeT4 reflex  Vital Signs  Vital Signs  Vital Signs  Vital Signs  Weight  GI and DVT prophylaxis have been addressed.   Home medications were reviewed and appropriate medications ordered at this time.   Total critical care time: Approximately 45 minutes?atrial fibrillation with rapid ventricular spots/CHF exacerbation/COPD exacerbation  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 this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers.  This 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.   Chronic Problem List    Abdominal bruit  Acquired hallux valgus of both feet  Acute GI bleeding  Allergic rhinitis  Anemia  Antiplatelet or antithrombotic long-term use  Aortic stenosis  Blood coagulation disorder (disorder)  CHF exacerbation  Chronic back pain  Chronic diastolic heart failure  COPD (chronic obstructive pulmonary disease)  COPD exacerbation  COPD with hypoxia  Depression  Dyspnea  Female dyspareunia  GERD (gastroesophageal reflux disease)  Hammer toes, bilateral  Heart murmur  Hx of colonic polyps  Hypokalemia  Hypotension  IDA (iron deficiency anemia)  Iron deficiency anemia  Lumbar compression fracture  Lumbar spine pain  Mitral stenosis  Moderate protein-calorie malnutrition (weight for age 60-74 percent of standard) (disorder)  Osteoarthritis of knee  Osteoporosis  Plantar fasciitis, bilateral  PVD (peripheral vascular disease)  Radiculopathy  Recurrent major depression (disorder)  Respiratory failure  RLS (restless legs syndrome)  S/P TAVR (transcatheter aortic valve replacement)  Sepsis due to COVID-19  Sick sinus syndrome (disorder)  Tobacco use  Procedure/Surgical History  ?Colonoscopy (09/12/2022) ?Back (01/06/2022) ?TAVR (03/03/2020) ?Right and left heart cath (01/17/2020) ?colonoscopy (08/13/2018) ?egd (08/13/2018) ?Shoulder X-ray (01/2017) ?Esophagogastroduodenoscopy (09/12/2016) ?Mammogram - screening (05/12/2016) ?Choledochectomy (07/31/2015) ?Ablation (07/22/2015) ?Aortic Iliac Bypass Graft (02/2014) ?Colonoscopy (09/23/2013) ?Immunization refused... (06/17/2013) ?Examination of eye (11/2010) ?Chest X-ray (07/16/2010) ?Surgery (2008) ?Spinal Surgery (03/1988) ?Hysterectomy (1976) ?TL - Tubal ligation (1975) ?bladder surgery ?Left shoulder ?Rotator Cuff Repair ?Surgery   Surgical History Internal  09/12/2022    Colonscpy Diagnostic/Screen    MD  02/12/2019    Kyphoplasty    MD  08/13/2018    EGD Bx    MD  09/12/2016    EGD Diagnostic    MD  07/31/2015    Cholecystectomy Laparoscopic  (Sup)   MD  Medications  Home Medications (21) Active  albuterol HFA MDI 90mCg/puff inhalation aerosol See Instructions, INHALE 2 PUFFS BY MOUTH EVERY 6 HOURS AS NEEDED FOR WHEEZING  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, Neb Inhal, Q6H, USE 1 AMPULE IN NEBULIZER EVERY 6 HOURS AS NEEDED FOR WHEEZING  alendronate 70 mg oral tablet 70 mg = 1 Tablet, Orally, Weekly  ascorbic acid 500 mg oral tablet 500 mg = 1 Tablet, Orally, Daily  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  buDESOnide 0.5 mg/2 mL inhalation suspension 0.5 mg = 2 mL, Neb Inhal, BID, USE 1 VIAL IN NEBULIZER TWICE DAILY  cilostazol 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID  clopidogrel 75 mg, Orally, Daily  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  losartan 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  metoPROLOL Tartrate 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID, TAKE 1 TABLET BY MOUTH TWICE DAILY  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  potassium chloride 10 mEq oral capsule, extended release 1 Capsule, Orally, BID  predniSONE 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  rOPINIRole 4 mg oral tablet 1.5 Tablet, Orally, At Bedtime  rOPINIRole 4 mg oral tablet 1.5 Tablet, Orally, At Bedtime  sertraline 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  theophylline 400 mg/24 hours oral tablet, extended release 400 mg = 1 Tablet, Orally, BID, TAKE 1 TABLET BY MOUTH TWICE DAILY  traZODONE 50 mg oral tablet 75 mg = 1.5 Tablet, Orally, At Bedtime, TAKE 1 & 1/2 (ONE & ONE-HALF) TABLETS BY MOUTH AT BEDTIME  Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  Vitamin D3 25 mCg (1,000 intl units) oral tablet 25 mCg = 1 Tablet, Orally, Daily  Allergies   Nickel (Rash)  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Children.   Substance Abuse   Denies   Tobacco   Tobacco Use: Smoker, current status unknown. 1 packs per day.  Family History   Alzheimers disease: Mother.  Arthritis: Father.  Cancer: Sister and Sister.  Cancer of uterus...: Sister.  Heart disease: Father.  Stroke: Father.                Signature Line Electronically Signed on 11/21/22 16:47  ________________________________________________________ MD