History of Present Illness    Patient is a 77  year old female who presents from Facility with complaint of hypoxia and dyspnea that started several days ago. Patient has PMH of anxiety, anemia type 2 diabetes, HTN, HLD, COPD (2L baseline). This am was found at Facility that O2 saturations were 80% on baseline 2L, on 4L O2 up to 83%.   Patient was taken to Hospital, initially required nasal canula, eventually requiring BIPAP. At outside hospital lab work indicates a leukocytosis of 17.7, hgb of 8.0, AKI with BUN of 22 and Cr of 2.04, D-dimer was elevated, ABG indicates acidosis with pH of 7.25 and pCo2 of 86.8 and pO2 of 67, satting 88%. COVID negative. UA was positive for moderate leuks, many bacteria, negative nitrites. Upon arrival to facility patient was on BiPAP satting 100%, decision was made to transition to HFNC which patient has so far tolerated well. Patient received Levaquin 750mg x1 and Flagyl 500mg IV x1 due to concern for COPD exacerbation and aspiration pneumonia.   Patient denies any fever, chills, chest pain, abdominal pain, lightheadedness, syncope, feeling like her heart is racing too fast or too slow, no back pain, muscle aches, no constipation.  Endorses cough, shortness of breath, wheezing nausea, vomiting (has a hard time holding her food and drink down besides water for a while), abdominal pain, and weakness.       Physical Exam  Vitals & Measurements  HR: 55  RR: 18  SpO2: 99%      General: NAD, alert and oriented x2 (person and year, not oriented to place) HEENT: normocephalic, atraumatic, PERRLA, EOMI, normal hearing; moist oral mucosa; no epistaxis, no pharyngeal erythema or exudates, no oral petechia or lesions Neck: supple, normal ROM, no lymphadenopathy, no JVD CV: RRR, no murmurs appreciated, normal peripheral perfusion, trace peripheral effusion Resp: Expiratory wheezing appreciated, nonlabored breathing, HFNC in place GI: soft, hiatal hernia appreciated, ,nondistended, normal bs MSK: no swelling or deformity noted, endorses right knee pain Skin: intact, dry, no rash appreciated Neuro: AxOx2 moving all extremities with normal strength and tone; CN 2-12 grossly intact, No focal deficits Psych: Calm, cooperative, appropriate mood and affect  Assessment/Plan      24 hour plan:  -inflammatory work up  -monitor respiratory status  Neuro/Psych Dementia  -cont home donepezil  Pulmonary Dyspnea  COPD-Baseline of 2L  Concern for Aspiration PNA  -speech therapy consult  -CRP/ESR/Procal pending  -CXR pending  -Urine Strep and Legionella pending  -Moxifloxacin 400mg daily, start day 11/4  --consider restarting Levaquin 750mg daily  -Prednisone 40mg daily  -speech eval pending  Cardiovascular Concern for CHF exacerbation  Anemia  -Echo pending  -BNP pending  -hgb of 8 at outside hospital  -pending CBC  GI Nausea  Vomiting  GERD  Hiatal Hernia  -prn zofran  -CMP pending  -will replace electrolytes as needed  Renal/GU AKI  UTI  -s/p 2 fluid boluses via Facility and EMS  -pending CMP  -pending UA, UA at Facility indicates UTI  Endocrine T2DM  Osteoporosis  -will hold alendronate  -SSI  ID COPD Exacerbation  Concern for Aspiration PNA  Microbiology  -pending UA with reflex  -pending blood cultures  Antimicrobials  -received Levaquin 750mg daily  -received 500mg Flagyl  Heme/Onc  -no acute concerns  MSK  -no acute concerns   Diet: NPO pending speech eval  VTE prophylaxis: Heparin  GI prophylaxis:  Disposition: MICU  Code status: Full   Seen and discussed with attending Dr.   Problem List/Past Medical History   Ongoing  No qualifying data  Historical  No qualifying data    Medications   Inpatient  acetaminophen 325 mg oral tablet, 650 mg= 2 Tablet(s), Oral, q8h, PRN  albuterol-ipratropium 2.5 mg-0.5 mg Neb Soln, 3 mL, Hi-Flow Neb, q1h, PRN  albuterol-ipratropium 2.5 mg-0.5 mg Neb Soln, 3 mL, Hi-Flow Neb, q4h  Aricept, 10 mg= 2 Tablet(s), Oral, At Bedtime  Breo Ellipta 100 mcg-25 mcg/inh inhalation powder, 1 Inhalation, Inhalation, Daily  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet, 325 mg= 1 Tablet(s), Oral, bid  heparin 5,000 units/mL, 5000 units= 1 mL, Subcutaneous, q8h  Lomotil, 1 Tablet(s), Oral, qid, PRN  moxifloxacin, 400 mg= 1 Tablet(s), Oral, qAM  predniSONE, 40 mg= 2 Tablet(s), Oral, Daily  Zofran 4 mg oral tablet, 4 mg= 1 Tablet(s), Oral, q6h, PRN  Home  acetaminophen 325 mg oral tablet, 650 mg= 2 Tablet(s), Oral, q8h, PRN  Acidophilus Probiotic Blend oral capsule, 1 capsule(s), Oral, Daily  Advair Diskus 250 mcg-50 mcg inhalation powder, 1 Puff, Inhalation, bid  Albuterol Eqv-ProAir HFA 90 mcg/inh inhalation aerosol, 2 Puff, Inhalation, q4h, PRN  alendronate 70 mg oral tablet, 70 mg= 1 Tablet(s), Oral, qMonday  aluminum hydroxide-magnesium hydroxide 200 mg-200 mg/5 mL oral suspension, 5 mL, Oral, qid  amLODIPine 10 mg oral tablet, 10 mg= 1 Tablet(s), Oral, Daily  ammonium lactate 12% topical lotion, 1 Application, Topical, bid, PRN  bisacodyl 5 mg oral delayed release tablet, 5 mg= 1 Tablet(s), Oral, At Bedtime  calcium carbonate 500 mg (200 mg elemental calcium) oral tablet, chewable, 500 mg= 1 Tablet(s), Oral, Daily  Calmoseptine 0.44%-20.6% topical ointment, 1 Application, Topical, Daily  carvedilol 12.5 mg oral tablet, 12.5 mg= 1 Tablet(s), Oral, bid  citalopram 40 mg oral tablet, 40 mg= 1 Tablet(s), Oral, Daily  Combivent Respimat 20 mcg-100 mcg/inh inhalation aerosol, 1 Puff, Inhalation, qid  donepezil 10 mg oral tablet, 10 mg= 1 Tablet(s), Oral, At Bedtime  famotidine 40 mg oral tablet, 40 mg= 1 Tablet(s), Oral, At Bedtime  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet, 325 mg= 1 Tablet(s), Oral, bid  Fish Oil 1000 mg oral capsule, 1000 mg= 1 capsule(s), Oral, tid  fluticasone 50 mcg/inh nasal spray, 1 Spray, Each Nostril, bid  GlucaGen 1 mg injection, 1 mg, IM, Once, PRN  glucose 40% preservative-free oral gel, 1 Packet, Oral, Once, PRN  hydrALAZINE 25 mg oral tablet, 25 mg= 1 Tablet(s), Oral, Daily  isosorbide mononitrate 30 mg oral tablet, extended release, 30 mg= 1 Tablet(s), Oral, qAM  lactulose 10 g/15 mL oral syrup, 20 g= 30 mL, Oral, At Bedtime, PRN  levothyroxine 50 mcg (0.05 mg) oral tablet, 50 mcg= 1 Tablet(s), Oral, Daily  Lomotil 2.5 mg-0.025 mg oral tablet, 1 Tablet(s), Oral, q4h, PRN  LORazepam 0.5 mg oral tablet, 0.5 mg= 1 Tablet(s), Oral, tid  MiraLax oral powder for reconstitution, 17 g, Oral, Daily  nitroglycerin 0.4 mg sublingual tablet, 0.4 mg= 1 Tablet(s), Sublingual, q5min, PRN  Norco 5 mg-325 mg oral tablet, 1 Tablet(s), Oral, q8h, PRN  omeprazole 20 mg oral delayed release tablet, 20 mg= 1 Tablet(s), Oral, bid AC  Senna Plus 50 mg-8.6 mg oral tablet, 1 Tablet(s), Oral, bid  sucralfate 1 g/10 mL oral suspension, 1 g= 10 mL, Oral, PC & Bedtime  Vitamin D2 1.25 mg (50,000 intl units) oral capsule, 50000 IntUnits= 1 capsule(s), Oral, qFriday  Zofran 4 mg oral tablet, 4 mg= 1 Tablet(s), Oral, q8h, PRN  ZyrTEC 10 mg oral tablet, 10 mg= 1 Tablet(s), Oral, Daily  Allergies   lisinopril  morphine  penicillins  Social History   Former smoker        Diagnostic Results  (11/03/2021 15:28 CDT XR Chest Portable) IMPRESSION:  Cardiomegaly with mild pulmonary edema and small left pleural  effusion. [1]     [1] XR Chest Portable; MD, 11/03/2021 15:28 CDT   Addendum by MD, on November 03, 2021 22:49:42 CDT (Verified)    On the above mentioned date as mentioned in the document header, the patient was seen and examined at the bedside. The key/critical portions of the medicine service were independently performed by me and the management was discussed in detail with the author of this document. Total critical care time spent on patient care excluding procedure  but including clinical case history, laboratory findings, microbiology data, medications, essential ICU flow sheets, ventilator data and imaging studies was > 52 minutes. I agree with the above documented assessment and plan except as follows:  Diagnosis: Acute hypoxic and hypercarbic respiratory failure on BiPAP/HFNC Suspected acute COPD exacerbation versus aspiration pneumonia versus CHF exacerbation Acute kidney injury under evaluation   PMH: Type 2 diabetes, anxiety, anemia, hypertension, hyperlipidemia, COPD on 2 L oxygen   Labs: ABG at Facility revealed acidosis with pH of 7.25, PCO2 56.8, PO2 67, saturation 88%, COVID-19 negative, UA positive for any bacteria negative for nitrites CBCD WBC 17.7, hemoglobin 8, hematocrit 27.9, platelet count 276, MCV 101.2 UA negative for UTI, D-dimer is 2.2 CMP: Calcium 8.5 sodium 136, potassium 4.4, chloride 96, bicarb 30.8, BUN 22, creatinine 2.04 11/3/2021 blood cultures pending   Imaging: 11/3 chest x-ray portable revealed cardiomegaly with mild pulmonary edema and small left pleural effusion   Management: S/p fluid bolus 2 L at Facility, patient awake alert well-oriented to time place and person at bedside Patient is currently full code, currently on high flow nasal cannula 8 L saturating more than 90% Positive for history of diarrhea and viral symptomatology before shortness of breath, For suspected CHF we will get NT proBNP and echocardiogram, patient awaiting speech evaluation to be initiated on diet For suspected aspiration pneumonia patient is already received Levaquin and Flagyl at Facility, will start moxifloxacin tomorrow in a.m. For suspected COPD exacerbation will get respiratory pathogen panel, urine Legionella and strep antigen, procalcitonin, CRP, ESR, We will also get a twelve-lead EKG to estimate the QTc interval, as needed bronchodilators started on prednisone oral for COPD exacerbation Treatment plan discussed with patient and her daughter at the bedside