Document Type: History and Physical   Document Subject: History & Physical Note   Encounter Info: Hospital, Inpatient, 11/11/22 -     * Final Report *          History of Present Illness/Subjective     Chief complaint shortness of breath  HPI: Patient is a 73-year-old female patient with history of heart failure with preserved ejection fraction, bronchiectasis, COPD, carcinoma of tongue, CVA, chronic hypotension, pulmonary hypertension and rheumatoid arthritis who presented to emergency department via EMS complaining of low blood pressure.  Patient reported her blood pressure runs in systolic of 90s but notes it was running in the low 80s this morning.  Patient reported lightheadedness and positional changes and dyspnea.  Patient also reported several days of low oxygen and increased shortness of breath.  She states that her oxygen has been dropping into the 70s.  She is from a nursing home and staff reported the oxygen saturation in the 60s this morning patient is usually on 3 L nasal cannula.  Patient also has been having yellow sputum and subjective fever and chills.  Patient is followed by pulmonology for bronchiectasis.  History of Pseudomonas complicated by meropenem causing seizures and tobramycin causing bronchospasm.  Patient was last hospitalized in early October and was noted to use nebulizers and without any problems with those.  Patient is currently at nursing home and also notes recent RSV breakout at the residence.  Patient is DNR/DNI and comprehensive care.  She presented with oxygen saturation of 67% on 3 L nasal cannula and hypotensive at 81/53.  Patient was recently discharged from Hospital on October 7 where chief diagnoses included sepsis secondary to pneumonia COPD with exacerbation and chronic hypotension.  She was treated with broad-spectrum antibiotics at that time.  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  Vital Signs (most recent and range for last 24 hours)  None reported this timeframe     Patient Weight    Patient Height  None Reported     General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: decreased air entry bilaterally, crackles bilaterally Cardiovascular: Normal rate, Regular rhythm. s1 s2 positive Gastrointestinal: Soft, Non-tender. BS present all 4 quadrants Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact    Assessment/Plan       1. Acute on chronic respiratory failure   J96.20   Patient usually wears 3 L nasal cannula at baseline currently requiring 65 L at 100% oxygen in the emergency room saturating in low 90s.  -Acute respiratory failure is likely due to hospital-acquired pneumonia.  -Cultures have been obtained and antibiotics have been started.  -Continue with high flow nasal cannula patient is DO NOT INTUBATE DO NOT RESUSCITATE.  -Our best hope is to continue with high flow nasal cannula and/or BiPAP.  -Admit patient to ICU.   2. Severe sepsis with septic shock   R65.21   Patient is having severe sepsis meets criteria due to having respiratory rate about 20 tachycardia and hypotension presenting blood pressure 81/53 which has gotten somewhat better to 106/66.  -Sepsis bundle in place.  -We were unable to give her much fluid because of her BNP being elevated at 945.  -Start patient on normal saline 100 mL an hour.  -Emergency room doctor has placed a central line.   3. Hospital-acquired pneumonia   J18.9   Noted.  Patient was recently discharged within last 30 days from our hospital to the nursing home where there is an RSV breakout.  -We will start patient on broad-spectrum antibiotics as dictated by sepsis bundle  -Follow-up on cultures, procalcitonin levels, Legionella and strep pneumo.  -Follow-up on respiratory pathogen panel.   4. Bronchiectasis   J47.9   Noted.  Patient is seeing physician.  -Provider recently have ordered for speech therapy evaluation for aspiration as well as sputum cultures and sputum AFB cultures.  I do not see results of these unfortunately.  -We will obtain these labs.   5. NSTEMI (non-ST elevated myocardial infarction)   I21.4   Patient is likely having type II and STEMI.  Patient's cardiac enzymes are elevated at 337 initially then to 520 likely due to severe sepsis.  -Emergency room doctor was supposed to run this by cardiology.  -We will obtain cardiology consult if needed at this time due to patient's acute respiratory failure with patient is not a candidate for any intervention other than medications.  -Start patient on aspirin and Lipitor.   6. Acute on chronic heart failure with preserved ejection fraction (HFpEF)   I50.33   Noted.  Patient's BNP is quite elevated at 945 as compared to 200 something a month ago when patient was released from us.  We will cautiously give her fluids to prevent overload but she requires fluids due to hypotension and severe sepsis with septic shock.  -No need for another echo at this time.   7. Chronic hypotension   I95.89   Noted   8. Hyperlipidemia   E78.5   Resume home medications   9. Hypothyroid   E03.9   Recent TSH was 0.948 about 1 month ago.  -Resume home medications.    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 72 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    (HFpEF) heart failure with preserved ejection fraction  Allergic reaction due to correct medicinal substance properly administered  Anxiety  Atrophic vaginitis  Bronchiectasis  Carcinoma in situ of tongue  Chronic diarrhea  Chronic eczematoid otitis externa of both ears  Chronic hypotension  Chronic nausea  Compression fracture of L1 vertebra  COPD with exacerbation  CVA (cerebrovascular accident)  Depression  Depression  DNI (do not intubate)  DNR (do not resuscitate)  Dry eye syndrome  Dysfunction of both eustachian tubes  Dysphagia  Emphysema/COPD  Encounter for long-term (current) use of medications  Excessive weight loss  Fall  Fibromyalgia  GERD (gastroesophageal reflux disease)  Hip fracture, right  Hyperlipidemia  Hypotension  Hypothyroid  Hypoxemia  Insomnia  Lung nodules  Moderate mitral valve regurgitation  Nontraumatic flexor tendon rupture  Oral cancer  Osteoporosis  Pulmonary hypertension due to lung disease  Rectocele  Rheumatoid arthritis  Right heart failure due to pulmonary hypertension  Seizures  Severe obesity  Severe tricuspid valve regurgitation  Status post myringotomy with tube placement of both ears  Weight loss  Procedure/Surgical History  ?BMT (01/16/2020) ?cardiac catheterization (2020) ?colonoscopy (07/12/2017) ?Bone density scan (03/22/2017) ?Rt Thumb IPJ Fusion TAS 3/29/16 (03/29/2016) ?Lt Thumb IPJ Fusion, Partial Exc of Scaphoid TAS 12/1/2015 (12/01/2015) ?Re exc SCC Left ant tongue (02/01/2013) ?Colonoscopy (12/21/2011) ?Bx tongue by Dr. (06/09/2008) ?EGD with biopsy (03/03/2005) ?Bunion of left great toe ?Bunionectomy ?Bunionectomy ?Carpal tunnel release ?Cholecystectomy ?Foot ?Joint replacement ?knuckles replaced ?leg surgery / several surgeries ?mammogram and pap - pt REFUSES ?nodules removed ?R femur ?Rectocele ?Synovectomy ?Tubal ?Tubes   Surgical History Internal  06/07/2021    Rectocele Repair      12/14/2020    Bronchoscopy Diagnostic      07/12/2017    Colonscpy Diagnostic/Screen      05/18/2017    Toe Amputation  (Right)     10/14/2016    Bronchoscopy W Bronchial Alveoli Lavage      Medications   Home Medications (16) Active  acetaminophen 500 mg oral tablet 1,000 mg = 2 Tablet, PRN, Orally, Q6H  Ambien 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime  balsam Peru-castor oil topical ointment See Instructions, to buttocks topicaqlly every shift for wound care  DME Lumbar Back Brace Not Applicable, Other, Unscheduled, LSO for L 1 compression fracture  famotidine 20 mg oral tablet 20 mg = 1 Tablet, Orally, BID  Imitrex 100 mg oral tablet 100 mg = 1 Tablet, PRN, Orally, ONCE  Imodium A-D 2 mg oral tablet 4 mg = 2 Tablet, Orally, Q6H, after each loose stool  isosorbide dinitrate 10 mg oral tablet 10 mg = 1 Tablet, Orally, TID  Lexapro 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  midodrine 5 mg oral tablet 5 mg = 1 Tablet, Orally, TID, q 8 hrs for bp <90  mirtazapine 7.5 mg oral tablet 7.5 mg = 1 Tablet, Orally, At Bedtime, for appetite stimulant  Misc Supplement See Instructions, prosource liquid nutritional supplement 30ml daily  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN  Ocuvite 1 Tablet, Orally, QAM  Oyster Shell 1,250 mg, Orally, At Bedtime  Synthroid 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  NORepinephrine PREMIX + Sodium Chloride 0.9% PREMIX IV Titrate - See Comments 2.5013 mCg/min  11/11/22    One-Time Medications Given 11/10/22 00:00:00 TO 11/11/22 14:56:53  None Reported  PRN Medications (0600 - 0559) from 11/10 - 11/11  None Reported  Allergies   Ativan (Swelling Facial, Swelling Pharyngeal)  Amitiza ("Bone-chilling cold")  Boniva (Kidney dysfunction)  Decongestant (Rapid heart rate)  Demerol. (Headache, Vomiting)  Didronel (Heartburn)  Dilaudid (Hives)  Flagyl (Hand Swelling, Bone Pain)  Fosamax (Bone pain, Heartburn)  Protonix (Hives)  Remicade ("Numerous")  Stadol (Vomiting, Rash)  Tolectin 600 (Hives)  Viibryd (Fainting, Heart palpitations)  Voltaren (Headache)  acetaminophen (Sweating, Nausea, Flushing)  clobetasol topical (Heart burn, Headache)  dicloxacillin (Joint pain, Swollen hands, "Severe" Headache)  hydroCHLOROthiazide (bone, joint pain)  hydrocodone (Vomiting, Flushing)  methotrexate (Nausea, "Severe" weight loss, Confusion)  morphine (Headache)  Actonel (not noted)  Cats (not noted)  Unlisted Material/Environmental Allergy (see comment)  Social History    Alcohol   Current, Beer, 1-2 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   divorced x 3 children, quit smoking in 2007 G4P4, Lives with Children.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Arthritis: Mother.  COPD: Father.  Cancer: Father.  Cancer of ovary: Sister.  Depression: Father.  Hypothyroid: Mother.  Mood disorder: Father.  Osteoporosis: Mother.  Pulmonary fibrosis: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.5 k/cumm (11/11/22 10:04:00)  RBC: 4.44 million/cumm (11/11/22 10:04:00)  Hgb: 13.9 GM/dL (11/11/22 10:04:00)  Hct: 42.2 % (11/11/22 10:04:00)  MCV: 95 fL (11/11/22 10:04:00)  MCH: 31.4 pg (11/11/22 10:04:00)  MCHC: 33 GM/dL (11/11/22 10:04:00)  RDW: 14.6 % High (11/11/22 10:04:00)  Platelet: 214 k/cumm (11/11/22 10:04:00)  MPV: 8.1 fL (11/11/22 10:04:00)  Neutrophils %: 68 % (11/11/22 10:04:00)  Lymphocytes %: 22 % (11/11/22 10:04:00)  Monocytes %: 9 % (11/11/22 10:04:00)  Eosinophils %: 0 % (11/11/22 10:04:00)  Basophils %: 1 % (11/11/22 10:04:00)  Absolute Neutrophil: 5.1 k/cumm (11/11/22 10:04:00)  Absolute Lymphocyte: 1.6 k/cumm (11/11/22 10:04:00)  Absolute Monocyte: 0.7 k/cumm (11/11/22 10:04:00)  Absolute Eosinophil: 0 k/cumm (11/11/22 10:04:00)  Absolute Basophil: 0.1 k/cumm (11/11/22 10:04:00)  Chemistry:  Troponin-I High Sensitivity: 520 ng/L High (11/11/22 12:45:00)  BNP Pl QN: 945 pg/mL High (11/11/22 10:04:00)  Lactate Venous Pl QN: 1.8 mmol/L (11/11/22 10:04:00)  Anion Gap, POC: 15 mmol/L (11/11/22 10:04:00)  CO2, POC: 25 mmol/L (11/11/22 10:04:00)  BUN, POC: 22 mg/dL High (11/11/22 10:04:00)  Chloride, POC: 102 mmol/L (11/11/22 10:04:00)  Creatinine, POC: 1 mg/dL (11/11/22 10:04:00)  Estimated GFR (CKD-EPI, no race), POC: 59 mL/min/1.73m2 Low (11/11/22 10:04:00)  Estimated CRCL (CG), POC: 48 mL/min Low (11/11/22 10:04:00)  Glucose, POC: 100 mg/dL High (11/11/22 10:04:00)  Potassium, POC: 4.7 mmol/L (11/11/22 10:04:00)  Sodium, POC: 136 mmol/L (11/11/22 10:04:00)  Coagulation:  PT: 12.9 seconds (11/11/22 10:04:00)  INR: 1.13 (11/11/22 10:04:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/11/22 10:14:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/11/22 10:14:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/11/2022 10:16 - XR Chest PA or AP Portable  IMPRESSION:1.  Faint airspace disease of the left costophrenic angle. This mayrepresent basilar atelectasis superimposed upon chronic lung diseaseor infiltrate.2.  Similar diffuse coarse lung markings likely related to fibroticlung disease or emphysema.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact the Cardio. For after-hours or emergency department cases, pleasecall.    11/11/2022 12:43 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for pulmonary embolism.2.  Main pulmonary artery is dilated which can be seen in pulmonaryarterial hypertension.3.  Emphysema with diffuse bronchial wall thickening. There are areasof endobronchial debris/secretions within the lower lobes. Increasingsmall tree-in-bud nodularity and areas of consolidation within theinferior aspect of the right middle lobe and lingula as well asthroughout the lung bases. Appearance is favored to represent acomponent of aspiration pneumonitis.4.  Similar ectasia of the ascending thoracic aorta.5.  Three-vessel coronary artery atherosclerosis.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact.For after-hours or emergency department cases, please call.                Signature Line Electronically Signed on 11/11/22 16:21  ________________________________________________________