Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 19, 2023 17:02   Verified By: MD on February 19, 2023 17:02   Encounter Info: Hospital, Inpatient, 02/19/23 -     * Final Report *          History of Present Illness/Subjective     This is a 77-year-old female who presents to the emergency department with complaints of shortness of breath that started on Wednesday.  She had some dry cough.  The patient is vaccinated of COVID.  No history of COPD or asthma.  While in the ED she was hypoxic to 88% on room air requiring supplemental oxygen to maintain O2 sat above 90.  On labs she has some anemia CKD stage III.  X-ray shows bilateral pulmonary opacification compatible with pneumonia, right greater than left.  She was found to be COVID-positive  -She used to be a marathon runner  Review of Systems     13 point review system is negative except for what is mentioned above  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.1 (37.1-37.1)  Temp (FAHR) 98.8 (98.8-98.8), BP 111/59 (111-111)/(59-59), HR 72 (72-72), RR 20 (20-20), O2Sat 96 (96-96) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    72.6 kg    02/19/23  Previous Daily Weight:    72.6 kg    02/19/23  BMI:    29.3    02/19/23    Overweight (BMI 25-29.9) Patient Height  Current Height:    157.5 cm    02/19/23        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: Bilateral wheezing and coarse breath sounds  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   Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. COVID-19     - remdesivir,  - dexamathsone 10 days  - inflammatory markers   CAD - Coronary artery disease    - resume core measures   Depression     - resume home meds   GERD (gastroesophageal reflux disease)    - resume home meds   HTN (hypertension)    - resume home meds   Pneumonia     - ceftriaxone doxy,  - pneumonia workup   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/19/23 16:55:00   dexamethasone, 6 mg, IV Push, Injection, Q24H, 02/19/23 17:00:00 , for 10 Days, 02/28/23 17:00:00   famotidine, 20 mg, Orally, Tablet, Q24H, 02/19/23 17:00:00   heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 02/19/23 17:00:00   labetalol, 10 mg, IV Push, Injection, Q6H, PRN, Systolic Blood Pressure, 02/19/23 16:55:00  Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 02/19/23 16:55:00 , for 1 Days, 02/20/23 16:54:00 , 100 mL/hr, Clinical Weight  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 02/19/23 16:55:00   remdesivir, 200 mg, IVPB, Injection, ONCE, 02/19/23 17:00:00, 02/19/23 17:00:00, 500 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 250  remdesivir, 100 mg, IVPB, Injection, At Bedtime, 02/19/23 21:00:00, for 4 Doses, 02/22/23 21:00:00   2000 mg Sodium, 20 gm Saturated Fat Diet  Admit to Inpatient   Basic Metabolic Panel  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Oxygen Need Greater Than  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  CBC w/Differential  CK SerPl QN  Comp Metabolic Panel  Continuous Oxygen Saturation  CRP SerPl QN  D-Dimer Pl QN  Dysphagia Screen by RN  Ferritin SerPl QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  L pneumophila Ag Ur QL  Level of Care  Nasal Cannula  OT Evaluation and Treatment  Patient Isolation  Procalcitonin  PT Evaluation and Treatment  PTINR  Resp Evaluation or Assessment  Resuscitation Status  Strep pneumoniae Ag Urine  Titrate FiO2 to Keep O2 Sat  Troponin-I High Sensitivity  Vital Signs  Weight   Code Status   Resuscitation Status - Ordered    -- 02/19/23 16:55:00, DNR/Comprehensive Care   Chronic Problem List    Arthritis  CAD - Coronary artery disease  Chronic diarrhea  Chronic epigastric pain  Chronic pain syndrome  Depression  Dysphagia  Encounter for long-term current use of medication  Excessive use of nonsteroidal anti-inflammatory drugs (NSAIDs)  GERD (gastroesophageal reflux disease)  Hernia, hiatal  History of duodenal ulcer  HTN (hypertension)  Insomnia  Irritable bowel syndrome with diarrhea  Multiple duodenal ulcers  Seasonal allergies  Status post cervical spinal fusion  Procedure/Surgical History  ?s/p C2-T2 posterior cervical fusion (12/15/2021) ?Colonoscopy (10/05/2020) ?Esophagogastroduodenoscopy (11/08/2016) ?Colonoscopy (03/11/2014) ?Cholecystectomy ?Knee replacement ?Tubal ligation   Surgical History Internal  12/15/2021    Cervical Fusion Posterior  (Postr)   10/05/2020    Colonscpy Bx      Medications   Home Medications (8) Active  amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily, for blood pressure  fluticasone 50 mCg/inh nasal spray 1 Spray, Nostrils, Both, BID  ibuprofen 600 mg oral tablet 1 Tablet, Orally, Q6H  lisinopril-hydroCHLOROthiazide 20 mg-12.5 mg oral tablet 1 Tablet, Orally, BID, for blood pressure  Misc Supplies See Instructions, moist mouth swabs to clean / moisturize mouth q2 and prn  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, BID  Prozac 20 mg oral capsule 20 mg = 1 Capsule, Orally, Daily  Vitamin D3 125 mCg (5,000 intl units) oral capsule 125 mCg = 1 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  dexamethasone, Injection, 6 mg, IV Push, Q24H, Start: 02/19/23 17:00:00  famotidine, Tablet, 20 mg, Orally, Q24H, Start: 02/19/23 17:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 02/19/23 17:00:00  remdesivir, Injection, 200 mg, IVPB, ONCE, Start: 02/19/23 17:00:00  remdesivir, Injection, 100 mg, IVPB, At Bedtime, Start: 02/19/23 21:00:00  Lactated Ringers  1,000 mL IV  100 mL/hr       One-Time Medications Given 02/18/23 00:00:00 TO 02/19/23 17:02:28  None Reported  PRN Medications (0600 - 0559) from 02/18 - 02/19  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   labetalol, 10 mg, IV Push, Q6H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   Allergies   Viibryd (swelling)  penicillins (Anaphylaxis)  sulfa drugs (Hives)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   Lives with Alone.   Nutrition/Health   Diet: Low sodium.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Family history is negative  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.4 k/cumm (02/19/23 09:36:00)  RBC: 3.95 million/cumm (02/19/23 09:36:00)  Hgb: 11.3 GM/dL Low (02/19/23 09:36:00)  Hct: 33.8 % Low (02/19/23 09:36:00)  MCV: 86 fL (02/19/23 09:36:00)  MCH: 28.7 pg (02/19/23 09:36:00)  MCHC: 33.6 GM/dL (02/19/23 09:36:00)  RDW: 15.3 % High (02/19/23 09:36:00)  Platelet: 217 k/cumm (02/19/23 09:36:00)  MPV: 9.3 fL (02/19/23 09:36:00)  Neutrophils %: 72 % (02/19/23 09:36:00)  Lymphocytes %: 17 % (02/19/23 09:36:00)  Monocytes %: 9 % (02/19/23 09:36:00)  Eosinophils %: 2 % (02/19/23 09:36:00)  Basophils %: 1 % (02/19/23 09:36:00)  Absolute Neutrophil: 7.5 k/cumm (02/19/23 09:36:00)  Absolute Lymphocyte: 1.8 k/cumm (02/19/23 09:36:00)  Absolute Monocyte: 0.9 k/cumm (02/19/23 09:36:00)  Absolute Eosinophil: 0.2 k/cumm (02/19/23 09:36:00)  Absolute Basophil: 0.1 k/cumm (02/19/23 09:36:00)  RBC Morphology: Normal, (02/19/23 09:36:00)  Platelet Estimate: Adequate. (02/19/23 09:36:00)  Platelet Morphology: Normal, (02/19/23 09:36:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (02/19/23 09:36:00)  Potassium SerPl QN: 3.3 mmol/L Low (02/19/23 09:36:00)  Chloride SerPl QN: 101 mmol/L (02/19/23 09:36:00)  Carbon Dioxide SerPl QN: 27 mmol/L (02/19/23 09:36:00)  Anion Gap: 11 mmol/L (02/19/23 09:36:00)  BUN SerPl QN: 8 mg/dL (02/19/23 09:36:00)  Creatinine SerPl QN: 1.04 mg/dL (02/19/23 09:36:00)  Estimated GFR (CKD-EPI, no race): 55 mL/min/1.73m2 Low (02/19/23 09:36:00)  Estimated CRCL (CG): 42 mL/min Low (02/19/23 09:36:00)  Glucose SerPl QN: 126 mg/dL High (02/19/23 09:36:00)  Calcium Total SerPl QN: 8.8 mg/dL (02/19/23 09:36:00)  Alkaline Phos SerPl QN: 59 Units/L (02/19/23 09:36:00)  ALT SerPl QN: 22 Units/L (02/19/23 09:36:00)  AST SerPl QN: 43 Units/L High (02/19/23 09:36:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (02/19/23 09:36:00)  Total Protein SerPl QN: 6.8 GM/dL (02/19/23 09:36:00)  Albumin SerPl QN: 4 GM/dL (02/19/23 09:36:00)  Troponin-I High Sensitivity: 10 ng/L (02/19/23 09:36:00)  BNP Pl QN: 268 pg/mL High (02/19/23 09:36:00)  Lactate Venous Pl QN: 0.9 mmol/L (02/19/23 09:36:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (02/19/23 09:11:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/19/23 09:11:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/19/23 09:11:00)  Rapid Influenza A PCR: Not Detected (02/19/23 09:11:00)  Rapid Influenza B PCR: Not Detected (02/19/23 09:11:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/19/2023 09:43 - XR Chest PA or AP  IMPRESSION: Bilateral pulmonary opacification compatible with acute pneumonia.Thank you for consulting our team of subspecialty emergencyradiologists at Physicians radiology.Healthcare providers wishing to discuss this case further can contactthe Emergency Radiology reading room at.                Signature Line Electronically Signed on 02/19/23 17:02  ________________________________________________________ MD