Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on July 21, 2023 10:01 EDT   Verified By: MD on July 23, 2023 07:28 EDT   Encounter Info: Hospital, Inpatient, 07/21/23 -     * Final Report *          History of Present Illness/Subjective     Patient is an 82-year-old woman who presents to the hospital with complaints of chest pain that started suddenly.  She has a history of hypertension, hyperlipidemia, atrial fibrillation on anticoagulation.  The chest pain happened while she was having an ice cream and it was sudden sharp radiated to the back and was unbearable which prompted her to come to the hospital.  There were no associated symptoms  At the moment she does have some uncomfortable feeling on the chest but no chest pain or pressure  Her blood pressures were soft initially but have improved somewhat.  She does meet severe sepsis criteria as per SIRS so was admitted to the ICU.  Lab values are as significant for anemia of 10.5 she had normal hemoglobin in May this year.  CKD.  There is some elevation of troponin from 10-14.  Lactic acid is 2.4 urine analysis is negative for infection  Review of Systems     18 point review of system is negative except what is mentioned above  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  BP: 105/72  HR: 89 (Monitored)  RR: 27  SpO2: 96%   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight    Patient Height  Current Height:    162.6 cm            Constitutional:  No acute distress,  Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus  ENMT:  Moist oral mucosa  Neck:  Supple, non-tender, intact range of motion  Respiratory:  Lungs CTAB  Cardiovascular:  Regular rate and rhythm  Gastrointestinal:  Soft, non-tender, non-distended  Musculoskeletal: Varicose veins  Integumentary:  Intact, warm, dry no rashes  Neurologic: Alert & Oriented   Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Severe sepsis   R65.20  she was in Afib, LIKLEY confounding the Sirs CRITERIA A bit, Nevertheless sepsis can trigger afib as well.  - protocol in place, broad spectrum antibiotics. pro cal , lactate   2. Chest pain   R07.9  Last EF from May this year is 35.  I will trend the troponins patient also has aortic stenosis which was seen by cardiology in May.  The plan was to do a TEE as an outpatient.  -I will repeat an echocardiogram this visit.  - Lexi SCAN  - i dont see a stress test in the system,  - Cardiology consult   3. Pulmonary edema   J81.1  - afib to be the inciting event,  - lasix dose controlled by her blood pressures, they are soft, s/p lasix 40 IV.   4. Afib   I48.91  - noted resume home meds and anticoagulation   5. Benign essential hypertension   I10  - noted, HOLD MEDS FOR NOW, soft bp   6. Chronic kidney disease, stage 3   N18.30  - avoid nephrotoxic meds   7. Anemia   D64.9  - will send anemia workup   8. Lactic acid acidosis   E87.20  - repeat levels   Orders:   magnesium oxide, 400 mg, Orally, Tablet, Daily, 07/22/23 9:00:00    nitroGLYCerin, 0.4 mg, Sublingually, Tablet, Q5min, PRN, Chest Pain, 07/21/23 9:46:00    pantoprazole, 20 mg, Orally, Tab, Delayed Rel, Daily, 07/22/23 9:00:00    PARoxetine, 20 mg, Orally, Tablet, At Bedtime, 07/21/23 21:00:00    warfarin, See Instructions, Maintenance, Take 1 tablet (5mg) orally on Sun, Tues, THurs, Sat. Take 0.5 tablet (2.5mg) on Mon, Wed, Fri., 03/30/23 10:36:00    warfarin, 5 mg, Orally, Tablet, Every Tue Thur Sat Sun, 07/22/23 21:00:00    warfarin, 2.5 mg, Orally, Tablet, Every Mon Wed Fri, 07/21/23 21:00:00    Electrocardiogram  NM Myo Perf Rest/Stress W/Lexiscan  Pharmacy Dosing Consult  Treadmill Only  Troponin-I High Sensitivity  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  50 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    Abdominal pain  Abnormal loss of weight  Aching  Acquired hypogammaglobulinemia  Acute respiratory failure  Anticoagulated on warfarin  Aortic stenosis  Arthritis  Benign essential hypertension  CAD in native artery  Cardiomyopathy  Chronic atrial fibrillation  Chronic diarrhea  Chronic hypoxemic respiratory failure  Chronic kidney disease, stage 3  Colon, diverticulosis  Congestive heart failure  Depression  Dyspnea  Elevated antinuclear antibody (ANA) level  Elevated INR  Elevated lipase  Elevated rheumatoid factor  Esophageal stricture  Falls frequently  Frequent UTI  History of diverticulitis  Hyperlipidemia  Hypothyroidism, acquired  Inflammatory arthritis  Low magnesium level  On warfarin therapy  Periorbital swelling  Pneumonia  Preventive measure  Pulmonary edema  Recurrent falls  Shortness of breath  Skin lesions  Sleep apnea  Subcutaneous nodule of both hands  Subtherapeutic anticoagulation  Synovitis  Thrombocytopenia  Weakness  Procedure/Surgical History  ?Bowel Resection (03/01/2020) ?Colonoscopy (12/01/2018) ?Upper GI endoscopy (2018) ?TEE and cardioversoin (12/16/2016) ?Esophagogastroduodenoscopy (12/09/2016) ?Colonoscopy (06/16/2014) ?Cardiac Stents (01/01/2008) ?hysterectomy (1995) ?Tubal ligation (1972) ?tonsillectomy (1946) ?Ankle fracture ?cataract repair ?heart cath ?heart cath ?hysterectomy ?right bimal ORIF   Surgical History Internal  03/19/2020    EGD Gastric Tube Place Chg/Removal    MD  03/05/2020    Laparotomy Exploratory    MD  12/08/2018    EGD Diagnostic    MD  12/09/2016    EGD Diagnostic    MD  04/08/2016    Ankle Fracture Open Reduction  (Right)   MD  Medications   Home Medications (21) Active  cyanocobalamin 100 mCg oral tablet 100 mCg = 1 Tablet, Orally, QAM  diltiaZEM 120 mg/24 hours oral tablet, extended release 120 mg = 1 Tablet, Daily  folic acid 1 mg oral tablet , TAKE 1 TABLET BY MOUTH ONCE DAILY  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, BID  Macrobid 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  magnesium oxide 400 mg oral tablet 400 mg = 1 Tablet, Orally, Daily  methotrexate 2.5 mg oral tablet 2.5 mg = 1 Tablet, Orally, Daily  metoPROLOL tartrate 50 mg oral tablet 25 mg = 0.5 Tablet, Orally, BID  mirtazapine 15 mg oral tablet 15 mg = 1 Tablet, Orally, At Bedtime  nalOXone 4 mg / 0.1 mL nasal spray , ADMINISTER A SINGLE SPRAY IN ONE NOSTRIL UPON SIGNS OF OPIOID OVERDOSE. CALL 911. REPEAT AFTER 2-3 MINUTES IF NO RESPONSE.  Nitrostat 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, QAM  ondansetron 4 mg oral tablet, disintegrating , DISSOLVE 1 TABLET IN MOUTH THREE TIMES DAILY AS NEEDED FOR NAUSEA  OXYcodone-acetaminophen 5 mg-325 mg oral tablet 1 Tablet, TAKE 1 TABLET BY MOUTH EVERY 6 HOURS AS NEEDED FOR PAIN FOR 5 DAYS  PARoxetine 20 mg oral tablet 20 mg = 1 Tablet, Orally, At Bedtime  Potassium Chloride (Eqv-Klor-Con M20) 20 mEq oral tablet, extended release 20 mEq = 1 Tablet, Orally, Daily  predniSONE 10 mg oral tablet 10 mg = 1 Tablet, Orally, QPM  Vitamin C 500 mg oral tablet 500 mg = 1 Tablet, Orally, QAM  Vitamin D3 1,000 intl units (25 mCg) oral capsule 1,000 Units = 1 Capsule, Orally, QAM  vitamin E 400 intl units oral capsule 400 Units = 1 Capsule, Orally, QAM  warfarin 5 mg oral tablet See Instructions, Take 1 tablet (5mg) orally on Sun, Tues, THurs, Sat. Take 0.5 tablet (2.5mg) on Mon, Wed, Fri.  Active Scheduled Inpatient Medications  magnesium oxide, Tablet, 400 mg, Orally, Daily, Start: 07/22/23 09:00:00  pantoprazole, Tab, Delayed Rel, 20 mg, Orally, Daily, Start: 07/22/23 09:00:00  PARoxetine, Tablet, 20 mg, Orally, At Bedtime, Start: 07/21/23 21:00:00  warfarin, Tablet, 5 mg, Orally, Every Tue Thur Sat Sun, Start: 07/22/23 21:00:00  warfarin, Tablet, 5 mg, Orally, Every Tue Thur Sat Sun, Start: 07/22/23 21:00:00  warfarin, Tablet, 2.5 mg, Orally, Every Mon Wed Fri, Start: 07/21/23 21:00:00  warfarin, Tablet, 2.5 mg, Orally, Every Mon Wed Fri, Start: 07/21/23 21:00:00    One-Time Medications Given 07/20/23 00:00:00 TO 07/21/23 10:01:08  None Reported  PRN Medications (0600 - 0559) from 07/20 - 07/21  nitroGLYCerin, 0.4 mg, Sublingually, Q5min, 0  Dose(s)   Allergies   Contrast Dye (Rash)  glycopyrrolate  Red Dye (rash)  ZyrTEC  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   daughter lives with pt   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Cancer: Father.  Diabetes mellitus: Father and Brother.  Heart disease: Father.  Heart disease..: Mother.  High blood pressure..: Mother.  Leukemia: Father.  Myocardial infarction: Mother.  Stroke...: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.4 k/cumm (07/21/23 01:46:00)  RBC: 3.48 million/cumm Low (07/21/23 01:46:00)  Hgb: 10.5 GM/dL Low (07/21/23 01:46:00)  Hct: 32.3 % Low (07/21/23 01:46:00)  MCV: 93 fL (07/21/23 01:46:00)  MCH: 30.1 pg (07/21/23 01:46:00)  MCHC: 32.4 GM/dL (07/21/23 01:46:00)  RDW: 21.4 % High (07/21/23 01:46:00)  Platelet: 253 k/cumm (07/21/23 01:46:00)  MPV: 6.9 fL Low (07/21/23 01:46:00)  Neutrophils %: 66 % (07/21/23 01:46:00)  Lymphocytes %: 23 % (07/21/23 01:46:00)  Monocytes %: 10 % (07/21/23 01:46:00)  Eosinophils %: 0 % (07/21/23 01:46:00)  Basophils %: 1 % (07/21/23 01:46:00)  Absolute Neutrophil: 6.9 k/cumm (07/21/23 01:46:00)  Absolute Lymphocyte: 2.4 k/cumm (07/21/23 01:46:00)  Absolute Monocyte: 1 k/cumm (07/21/23 01:46:00)  Absolute Eosinophil: 0 k/cumm (07/21/23 01:46:00)  Absolute Basophil: 0.1 k/cumm (07/21/23 01:46:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (07/21/23 01:46:00)  Potassium SerPl QN: 4.4 mmol/L (07/21/23 01:46:00)  Chloride SerPl QN: 100 mmol/L (07/21/23 01:46:00)  Carbon Dioxide SerPl QN: 27 mmol/L (07/21/23 01:46:00)  Anion Gap: 11 mmol/L (07/21/23 01:46:00)  BUN SerPl QN: 17 mg/dL (07/21/23 01:46:00)  Creatinine SerPl QN: 1.04 mg/dL (07/21/23 01:46:00)  Estimated GFR (CKD-EPI, no race): 54 mL/min/1.73m2 Low (07/21/23 01:46:00)  Estimated CRCL (CG): 41 mL/min Low (07/21/23 01:46:00)  Glucose SerPl QN: 140 mg/dL High (07/21/23 01:46:00)  Calcium Total SerPl QN: 8.7 mg/dL (07/21/23 01:46:00)  Alkaline Phos SerPl QN: 68 Units/L (07/21/23 01:46:00)  ALT SerPl QN: 9 Units/L (07/21/23 01:46:00)  AST SerPl QN: 14 Units/L (07/21/23 01:46:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (07/21/23 01:46:00)  Total Protein SerPl QN: 7.2 GM/dL (07/21/23 01:46:00)  Albumin SerPl QN: 3.8 GM/dL (07/21/23 01:46:00)  Lipase SerPl QN: 43 Units/L (07/21/23 01:46:00)  CK SerPl QN: 47 Units/L (07/21/23 01:46:00)  Troponin-I High Sensitivity: 14 ng/L High (07/21/23 01:46:00)  Lactate Venous Pl QN: 2.4 mmol/L High (07/21/23 04:15:00)  Coagulation:  PT: 18.8 seconds High (07/21/23 01:46:00)  INR: 1.64 High (07/21/23 01:46:00)  Urine Studies:  Color: Yellow (07/21/23 02:35:00)  Clarity: Clear (07/21/23 02:35:00)  Specific Gravity: 1.020 (07/21/23 02:35:00)  pH: 6.5 (07/21/23 02:35:00)  Protein: NEGATIVE (07/21/23 02:35:00)  Glucose: NEGATIVE (07/21/23 02:35:00)  Ketones: NEGATIVE (07/21/23 02:35:00)  Bilirubin: NEGATIVE (07/21/23 02:35:00)  Hgb Ur: NEGATIVE (07/21/23 02:35:00)  Nitrite: NEGATIVE (07/21/23 02:35:00)  Urobilinogen: NormalUro (07/21/23 02:35:00)  Leukocyte Esterase Ur: NEGATIVE (07/21/23 02:35:00)  Micro - Last 7 days  Urine CX: NEG (07/17/23 15:23:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 07/21/2023 02:14 - XR Chest PA or AP Portable  IMPRESSION: 1.  Possible small bilateral pleural effusion.2.  Pulmonary vascular and interstitial prominence may indicateCHF/pulmonary edema in the correct clinical setting.Template Version: Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at XRAY with any questions.                Signature Line Electronically Signed on 07/23/23 07:28 EDT ________________________________________________________ MD