Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on February 14, 2023 18:01  Verified By: NP on February 14, 2023 18:01  Encounter Info: Hospital, Emergency, 02/14/23 - 02/14/23    * Final Report *  Document Has Been Revised And Contains Addenda          History of Present Illness/Subjective     Patient is a 76-year-old man with a past medical history of chronic A-fib on anticoagulation, hypertension, CVA, hyponatremia, hyperlipidemia, CABG, GERD and COPD who presented to the ER today with chief complaint fever, shortness of breath and productive cough x2 days.  Patient is a current smoker and wears 2-1/2 L oxygen as needed.     Upon ER evaluation EKG showed right bundle Branch block no significant change from previous.  He did meet SIRS criteria with fever, tachypnea.  Initial temp was 102.9, heart rate was up to 95, respiratory rate was up to 32, blood pressure was 108/60, lab work was completed showed a white blood cell count of 10.8, hemoglobin was 12.4, sodium was 132, renal function was at his baseline, glucose was 140, troponin was 11 with repeat being 10, BN P was 85 and lactate was 2.4.  ABG drawn showed pH 7.42 and a PCO2 was 34.  COVID and flu testing was negative.  Chest x-ray showed mild streaky opacities in the lung bases most likely atelectasis or scarring.     While in the ER he received ceftriaxone, albuterol, and doxycycline patient will be brought in for further evaluation management of sepsis, pneumonia, COPD exacerbation.  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)  Temp (CEL) 37.1 (37.1-39.4)  Temp (FAHR) 98.8 (98.8-102.9), BP 125/61 (108-125)/(59-61), HR 87 (87-95), RR 14 (14-32), O2Sat 94 (94-94) Neurologic (most recent and range for last 24 hours) CS 15(15-15)     Patient Weight  Current Daily Weight:    93.3 kg    02/14/23    Patient Height  Current Height:    180.3 cm    02/14/23        Constitutional:  No acute distress,  well-nourished Eyes:  PEERL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs bibasilar coarseness 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 x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Sepsis   A41.9   Blood cultures pending.  Antibiotics are started in the ER ? Sepsis order set initiated, continue with Unasyn and doxycycline.   2. Pneumonia   J18.9   Evidence of pneumonia seen on chest x-ray ? Procalcitonin, Legionella and strep are pending, blood cultures pending, continue with Unasyn and doxycycline ? RT protocol   3. Hypoxia   R09.02   RT protocol   4. COPD exacerbation   J44.1  RT protocol  Started doxycycline and Solu-Medrol   5. Chronic obstructive lung disease   J44.9    7. GERD (gastroesophageal reflux disease)   K21.9   Resume PPI   8. Hx of CABG   Z95.1   Resume home meds   9. Hyperlipidemia   E78.5   Resume home meds   10. Hyponatremia   E87.1   Mild, 132, continue to monitor daily labs   11. History of CVA (cerebrovascular accident)   Z86.73   Noted, patient lives at home   12. Essential hypertension   I10    13. Chronic atrial fibrillation with RVR   I48.20   Resume apixaban and beta-blocker   ???????Patient is a full code ? Fully anticoagulated on apixaban   Code Status   None Recorded   Chronic Problem List    Abscess or cellulitis, neck rt  Carotid artery stenosis  Chronic atrial fibrillation with RVR  Chronic obstructive lung disease  COPD exacerbation  Coronary atherosclerosis  Depressive disorder  Essential hypertension  GERD (gastroesophageal reflux disease)  Heart valve disorder  History of colon cancer  History of colon polyps  History of CVA (cerebrovascular accident)  History of peptic ulcer  Hx of CABG  Hyperlipidemia  Hyponatremia  Pneumonia  Prostatic hypertrophy, benign, with obstruction  Right ankle sprain  Sepsis  Tobacco use  Urinary incontinence  Ventricular premature beats  Procedure/Surgical History  ?AAA (11/01/2021) ?Colonoscopy (09/15/2015) ?CABG - Coronary artery bypass graft (05/06/2014) ?Esophagogastroduodenoscopy (08/11/2011) ?cariac cath (2010) ?colectomy (1984) ?Tonsillectomy and adenoidectomy     Medications   Home Medications (22) Active  albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, PRN, Neb Inhal, 4 Times Daily  amiodarone 200 mg oral tablet 200 mg = 1 Tablet, Orally, Daily  Antivert 12.5 mg oral tablet 12.5 mg = 1 Tablet, PRN, Orally, TID  aspirin 81 mg oral tablet, delayed release 81 mg = 1 Tablet, Orally, Daily  Crestor 40 mg oral tablet 40 mg = 1 Tablet, Orally, QHS  Daliresp 500 mCg oral tablet 500 mCg = 1 Tablet, Orally, Daily  Eliquis 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  Lasix 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Lexapro 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  lisinopril 2.5 mg oral tablet 2.5 mg = 1 Tablet, Orally, Daily  metoPROLOL tartrate 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  Nitrostat 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, Sublingually, Q5min  Ozempic 2 mg/1.5 mL (0.25 mg or 0.5 mg dose) subcutaneous solution 0.5 mg, Subcutaneous, Every Saturday  potassium chloride 10 mEq oral capsule, extended release 10 mEq = 1 Capsule, Orally, Daily  PriLOSEC OTC 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, BID  ProAir HFA 90 mCg/inh inhalation aerosol 180 mCg = 2 Puff, PRN, Inhalation, Q4H  Spiriva 18 mCg inhalation capsule 18 mCg = 1 Capsule, Inhalation, Daily  Symbicort 160 mcg-4.5 mcg/inh inhalation aerosol 2 Puff, Inhalation, BID  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, QAM  Vitamin D3 25 mCg (1,000 intl units) oral capsule 75 mCg = 3 Capsule, Orally, Daily  Wellbutrin SR 150 mg/12 hours oral tablet, sustained release 150 mg = 1 Tablet, Orally, BID  Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, Orally, Q6H, to treat and to prevent nausea and vomiting  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/13/23 00:00:00 TO 02/14/23 18:01:37  acetaminophen, Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 02/14/23 14:56:00)  albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 5 mg, Neb Inhal, ONCE, (1 DOSE 02/14/23 14:39:00)  ceftRIAXone, Injection, 2 GM, IV Push, ONCE, (1 DOSE 02/14/23 14:56:00)  hydroCODONE-acetaminophen (hydroCODONE-acetaminophen 5 mg-325 mg oral tablet), Tablet, 1 Tablet, Orally, ONCE, (1 DOSE 02/14/23 17:18:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 02/14/23 15:19:00)  PRN Medications (0600 - 0559) from 02/13 - 02/14  None Reported  Allergies   Contrast Dye (difficulty breathing, face swelling, lip swelling)  codeine (C/O: a swelling, [X]Other and unspecified abnormalities of breathing, Hives)  iodine ([X]Other and unspecified abnormalities of breathing, C/O: a swelling, Hives)  Social History    Alcohol   Past, Beer, 3-5 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   Heart disease..: Mother.  Lung cancer..: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.8 k/cumm High (02/14/23 14:43:00)  RBC: 4.15 million/cumm Low (02/14/23 14:43:00)  Hgb: 12.4 GM/dL Low (02/14/23 14:43:00)  Hct: 37.3 % Low (02/14/23 14:43:00)  MCV: 90 fL (02/14/23 14:43:00)  MCH: 29.8 pg (02/14/23 14:43:00)  MCHC: 33.2 GM/dL (02/14/23 14:43:00)  RDW: 15.4 % High (02/14/23 14:43:00)  Platelet: 222 k/cumm (02/14/23 14:43:00)  MPV: 7.7 fL (02/14/23 14:43:00)  Neutrophils %: 91 % (02/14/23 14:43:00)  Lymphocytes %: 5 % (02/14/23 14:43:00)  Monocytes %: 4 % (02/14/23 14:43:00)  Eosinophils %: 0 % (02/14/23 14:43:00)  Basophils %: 0 % (02/14/23 14:43:00)  Absolute Neutrophil: 9.8 k/cumm High (02/14/23 14:43:00)  Absolute Lymphocyte: 0.5 k/cumm Low (02/14/23 14:43:00)  Absolute Monocyte: 0.4 k/cumm (02/14/23 14:43:00)  Absolute Eosinophil: 0 k/cumm (02/14/23 14:43:00)  Absolute Basophil: 0 k/cumm (02/14/23 14:43:00)  Chemistry:  Sodium SerPl QN: 132 mmol/L Low (02/14/23 14:43:00)  Potassium SerPl QN: 3.7 mmol/L (02/14/23 14:43:00)  Chloride SerPl QN: 98 mmol/L (02/14/23 14:43:00)  Carbon Dioxide SerPl QN: 25 mmol/L (02/14/23 14:43:00)  Anion Gap: 9 mmol/L (02/14/23 14:43:00)  BUN SerPl QN: 14 mg/dL (02/14/23 14:43:00)  Creatinine SerPl QN: 1.13 mg/dL (02/14/23 14:43:00)  Estimated GFR (CKD-EPI): 67 mL/min/1.73m2 (02/14/23 14:43:00)  Estimated CRCL (CG): 65 mL/min (02/14/23 14:43:00)  Glucose SerPl QN: 140 mg/dL High (02/14/23 14:43:00)  Calcium Total SerPl QN: 9.3 mg/dL (02/14/23 14:43:00)  Alkaline Phos SerPl QN: 63 Units/L (02/14/23 14:43:00)  ALT SerPl QN: 14 Units/L (02/14/23 14:43:00)  AST SerPl QN: 13 Units/L (02/14/23 14:43:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (02/14/23 14:43:00)  Total Protein SerPl QN: 7 GM/dL (02/14/23 14:43:00)  Albumin SerPl QN: 4.2 GM/dL (02/14/23 14:43:00)  Troponin-I High Sensitivity: 10 ng/L (02/14/23 15:38:00)  BNP Pl QN: 85 pg/mL (02/14/23 14:43:00)  Lactate Venous Pl QN: 1.3 mmol/L (02/14/23 17:09:00)  pH Bld Venous QN: 7.42 (02/14/23 14:43:00)  PCO2 Bld Venous QN: 34 mmHg Low (02/14/23 14:43:00)  PO2 Bld Venous QN: 61 mmHg High (02/14/23 14:43:00)  Base Excess Bld Venous: -2 mmol/L (02/14/23 14:43:00)  Bicarb Bld Venous Calc: 22 mmol/L (02/14/23 14:43:00)  O2 Sat Bld Venous Calc: 92 % (02/14/23 14:43:00)  Patient Temperature: 37 DegC (02/14/23 14:43:00)  Urine Studies:  Color: Yellow (02/14/23 14:38:00)  Clarity: Clear (02/14/23 14:38:00)  Specific Gravity: 1.010 (02/14/23 14:38:00)  pH: 6.0 (02/14/23 14:38:00)  Protein: NEGATIVE (02/14/23 14:38:00)  Glucose: NEGATIVE (02/14/23 14:38:00)  Ketones: NEGATIVE (02/14/23 14:38:00)  Bilirubin: NEGATIVE (02/14/23 14:38:00)  Hgb Ur: TRACE. Abnormal (02/14/23 14:38:00)  Nitrite: POSITIVE Abnormal (02/14/23 14:38:00)  Urobilinogen: NormalUro (02/14/23 14:38:00)  Leukocyte Esterase Ur: TRACE. Abnormal (02/14/23 14:38:00)  WBC: 21-50 Abnormal (02/14/23 14:38:00)  RBC: None Seen (02/14/23 14:38:00)  Bacteria: Many Abnormal (02/14/23 14:38:00)  Squamous Epithelial: Moderate (02/14/23 14:38:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/14/23 14:43:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/14/23 14:43:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/14/23 14:43:00)  Rapid Influenza A PCR: Not Detected (02/14/23 14:43:00)  Rapid Influenza B PCR: Not Detected (02/14/23 14:43:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/14/2023 15:18 - XR Chest PA or AP Portable  IMPRESSION:1.  Mild streaky opacities in the lung bases most likely atelectasisor scarring.Thank you for consulting our team. Please contact us with any questions.                Signature Line Electronically Signed on 02/14/23 18:01 ________________________________________________________ NP  Electronically Signed on 02/14/23 18:02 ________________________________________________________ NP    Addendum by MD on February 14, 2023 23:00:43 (Verified)    I saw and evaluated the patient in addition to the NP.  I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care.  General:  Alert and oriented, No acute distress. Eyes:   Extraocular movements are intact, no scleral icterus HEENT:  Normocephalic, Normal hearing, Moist oral mucosa Respiratory:  bibasilar crackles with scattered wheezes, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness. Cardiovascular:  Regular rate and irreg irreg  rhythm Gastrointestinal:  Soft, nontender, nondistended, normal bowel sounds Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: Alert, no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  MD   Signature Line Electronically Signed on 02/14/23 23:02 ________________________________________________________ MD