Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on December 12, 2022 05:10   Verified By: DO on December 12, 2022 05:10   Encounter Info: Hospital, Observation, 12/11/22 -     * Final Report *        Chief Complaint   cough  History of Present Illness/Subjective     Patient presents via private vehicle due to fatigue, generalized weakness, productive cough, DOE and low grade fever   x 4 days. Patient was seen at Clinic on Thursday and diagnosed with bronchitis. She was started on amoxicillin and prednisone at that time. She was negative for Covid and flu at that time. Patient denies chest pain, n/v/d . Associated medical hx includes:  Add'l medical hx includes: HTN, HLD, OA, MDD, neuropathy,  Social hx:  lives at home alone, non smoker   CXR shows right sided infiltrate concerning for pneumonia. Patient is also Covid +. She is Covid vaccinated. Flu is negative. No leukocytosis, not septic. Not hypoxic at rest.  Discussed discharge to home with antibiotic change to Augmentin and doxy with patient and her daughter to better cover for pneumonia. Also,  advised to stop prednisone. Patient and her daughter are not comfortable with discharge at this time due to patient's general weakness since being ill. She lives at home alone, no one can stay with her.  Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.5 (36.5-36.5)  Temp (FAHR) 97.7 (97.7-97.7), BP 167/70 (144-212)/(65-89), HR 53 (53-83), RR 16 (16-18), O2Sat 94 (94-94) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    95 kg    12/11/22    Patient Height  Current Height:    152.79 cm    12/11/22        Constitutional:  No acute distress,  well-nourished Eyes:  PERRL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs are coarse, scattered rhonchi, Respirations are labored, RLL Crackles, no wheezes 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, denies SI or HI  Assessment/Plan      1. Weakness   R53.1  Will place in observation and have PT OT eval's to make sure it is safe for patient to go home since she lives alone  Likely due to #2 and #3, no focal deficits suggesting CVA or neurologic process   2. Pneumonia   J18.9  Will cover for CAP with Rocephin Doxy, collect sputum cultures, Legionella, strep antigen, and continue to monitor   3. COVID-19   U07.1  At present time disease appears to be mild, will start fluticasone inhalation, respiratory assessment, collect inflammatory markers, start famotidine, and continue to monitor, supplemental O2 as needed   4. Anemia   D64.9  Noted.  Stable, no evidence of acute bleeding, maintain hemoglobin greater than 7   5. HTN (hypertension)   I10   6. Hyperlipidemia   E78.5   7. OA (osteoarthritis)   M19.90   8. Major depression   F32.9   9. Neuropathy   G62.9  Noted.  Continue home medications as appropriate   10. DVT prophylaxis   Z29.9  Lovenox subcu and SCDs while in bed    Code Status   None Recorded   Chronic Problem List    Anxiety  Arthritis  Chronic right sacroiliac pain  Cystitis cystica  DDD (degenerative disc disease), lumbar  Depression  Essential hypertension  Headache  History of kidney stones  Hyperlipidemia  Hypothyroid  Idiopathic neuropathy  Kidney cysts  Leg cramps  Lichenoid drug reaction  Limb pain  LVH (left ventricular hypertrophy)  Major depression  Morbid obesity  OA (osteoarthritis)  OG (onychogryphosis)  OM (onychomycosis)  Onychomycosis of toenail  Osteoporosis  Peripheral neuropathy, hereditary/idiopathic  Recurrent UTI  Right hip pain  Tremor  Vertigo  Procedure/Surgical History  ?Diabetic retinal eye exam (08/09/2021) ?Eye examination (02/25/2019) ?Repair of bladder (2009) ?Total hysterectomy (2009) ?Cataract surgery ?Tonsillectomy     Medications   Home Medications (23) Active  amoxicillin 500 mg oral capsule 500 mg = 1 Capsule, Orally, TID  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily  Ativan 0.5 mg oral tablet 0.5 mg = 1 Tablet, PRN, Orally, TID  carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID  cholestyramine 4 g/5 g oral powder for reconstitution 4 GM, Orally, BID  cranberry oral tablet   doxazosin 2 mg oral tablet 2 mg = 1 Tablet, Orally, BID  Estrace Vaginal Cream 0.1 mg/gm 1 GM, Vaginally, 2x/WK, Apply pea sized amount to outside vaginal area nightly before bed x 2 weeks then 2x/week thereafter.  levothyroxine 50 mCg (0.05 mg) oral tablet 75 mCg = 1.5 Tablet, Orally, Daily  Lexapro 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Misc Med , D-Mannose1 pill BIDOTC  Nexium 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  predniSONE 10 mg oral tablet See Instructions, 5 tab orally today, then 4 tab x 3 days, then 3 tab x 3 days, then 2 tab x 3 days, then 1 tab x 3 days  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H  Sarna 0.5%-0.5% topical lotion See Instructions, PRN, Topical TID  spironolactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  Systane Ultra preserved ophthalmic solution 1 Drop  Tessalon Perles 100 mg oral capsule 100 mg = 1 Capsule, Orally, TID  Vitamin C 1,000 mg, Orally, Daily  Vitamin D3 (cholecalciferol) , Orally  Voltaren Topical 1% topical gel 2 GM, Topical, 4 Times Daily, Use dosing card to measure dose  Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q6H  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 12/11/22 00:00:00 TO 12/12/22 05:10:16  benzonatate (Tessalon Perles), Capsule, 200 mg, Orally, ONCE, (1 DOSE 12/12/22 01:25:00)  ceftRIAXone, Injection, 2 GM, IVPB, ONCE, (1 DOSE 12/11/22 21:07:00)  doxycycline, Injection, 100 mg, IVPB, ONCE, (1 DOSE 12/11/22 21:55:00)  guaiFENesin (Mucinex 600 mg oral tablet, extended release), Tab, Extended Rel, 600 mg, Orally, ONCE, (1 DOSE 12/12/22 01:40:00)  hydroCODONE-acetaminophen (hydroCODONE-acetaminophen 5 mg-325 mg oral tablet), Tablet, 1 Tablet, Orally, ONCE, (1 DOSE 12/11/22 22:19:00)  PRN Medications (0600 - 0559) from 12/11 - 12/12  None Reported  Allergies   Dyazide (Unknown)  Sular (Flushing)  Yellow Dye (Sores in mouth, Unknown)  Zocor (Unknown)  sulfa drugs (Rash)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Widow- 3 children, Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Congestive heart failure..: Father.  Diabetes mellitus type 2: Grandmother.  Diabetes...: Brother.  Emphysema: Father.  Heart disease..: Father.  Hypertension..: Mother.  Osteoarthritis: Mother.  Uterine cancer: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.3 k/cumm (12/11/22 20:18:00)  RBC: 3.42 million/cumm Low (12/11/22 20:18:00)  Hgb: 11 GM/dL Low (12/11/22 20:18:00)  Hct: 32.7 % Low (12/11/22 20:18:00)  MCV: 96 fL (12/11/22 20:18:00)  MCH: 32.1 pg (12/11/22 20:18:00)  MCHC: 33.5 GM/dL (12/11/22 20:18:00)  RDW: 12.8 % (12/11/22 20:18:00)  Platelet: 250 k/cumm (12/11/22 20:18:00)  MPV: 7.8 fL (12/11/22 20:18:00)  Neutrophils %: 83 % (12/11/22 20:18:00)  Lymphocytes %: 7 % (12/11/22 20:18:00)  Monocytes %: 10 % (12/11/22 20:18:00)  Eosinophils %: 0 % (12/11/22 20:18:00)  Basophils %: 0 % (12/11/22 20:18:00)  Absolute Neutrophil: 5.2 k/cumm (12/11/22 20:18:00)  Absolute Lymphocyte: 0.4 k/cumm Low (12/11/22 20:18:00)  Absolute Monocyte: 0.6 k/cumm (12/11/22 20:18:00)  Absolute Eosinophil: 0 k/cumm (12/11/22 20:18:00)  Absolute Basophil: 0 k/cumm (12/11/22 20:18:00)  Chemistry:  Sodium SerPl QN: 140 mmol/L (12/11/22 20:18:00)  Potassium SerPl QN: 3.9 mmol/L (12/11/22 20:18:00)  Chloride SerPl QN: 103 mmol/L (12/11/22 20:18:00)  Carbon Dioxide SerPl QN: 26 mmol/L (12/11/22 20:18:00)  Anion Gap: 11 mmol/L (12/11/22 20:18:00)  BUN SerPl QN: 17 mg/dL (12/11/22 20:18:00)  Creatinine SerPl QN: 1.14 mg/dL (12/11/22 20:18:00)  Estimated GFR (CKD-EPI, no race): 46 mL/min/1.73m2 Low (12/11/22 20:18:00)  Estimated CRCL (CG): 35 mL/min Low (12/11/22 20:18:00)  Glucose SerPl QN: 129 mg/dL High (12/11/22 20:18:00)  Calcium Total SerPl QN: 8.8 mg/dL (12/11/22 20:18:00)  Alkaline Phos SerPl QN: 48 Units/L (12/11/22 20:18:00)  ALT SerPl QN: 14 Units/L (12/11/22 20:18:00)  AST SerPl QN: 17 Units/L (12/11/22 20:18:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (12/11/22 20:18:00)  Total Protein SerPl QN: 6.2 GM/dL Low (12/11/22 20:18:00)  Albumin SerPl QN: 3.7 GM/dL (12/11/22 20:18:00)  Troponin-I High Sensitivity: 18 ng/L High (12/11/22 22:31:00)  BNP Pl QN: 125 pg/mL High (12/11/22 20:18:00)  Lactate Venous Pl QN: 1.3 mmol/L (12/11/22 20:18:00)  Blood Gas Comment: venous (12/11/22 22:31:00)  pH Bld Venous QN: 7.35 (12/11/22 22:31:00)  PCO2 Bld Venous QN: 47 mmHg (12/11/22 22:31:00)  PO2 Bld Venous QN: 46 mmHg High (12/11/22 22:31:00)  Base Excess Bld Venous: 0 mmol/L (12/11/22 22:31:00)  Bicarb Bld Venous Calc: 26 mmol/L (12/11/22 22:31:00)  O2 Sat Bld Venous Calc: 79 % (12/11/22 22:31:00)  Patient Temperature: 37 DegC (12/11/22 22:31:00)  Urine Studies:  Color: Yellow (12/11/22 22:17:00)  Clarity: Clear (12/11/22 22:17:00)  Specific Gravity: <=1.005 (12/11/22 22:17:00)  pH: 6.5 (12/11/22 22:17:00)  Protein: NEGATIVE (12/11/22 22:17:00)  Glucose: NEGATIVE (12/11/22 22:17:00)  Ketones: NEGATIVE (12/11/22 22:17:00)  Bilirubin: NEGATIVE (12/11/22 22:17:00)  Hgb Ur: NEGATIVE (12/11/22 22:17:00)  Nitrite: NEGATIVE (12/11/22 22:17:00)  Urobilinogen: NormalUro (12/11/22 22:17:00)  Leukocyte Esterase Ur: NEGATIVE (12/11/22 22:17:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (12/11/22 20:18:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (12/11/22 20:18:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/11/22 20:18:00)  Rapid Influenza A PCR: Not Detected (12/11/22 20:18:00)  Rapid Influenza B PCR: Not Detected (12/11/22 20:18:00)  Coronavirus SARS Ag FIA, POC: Negat (12/06/22 11:50:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/11/2022 20:04 - XR Chest PA or AP  IMPRESSION:Focal right basilar airspace disease concerning for pneumoniaThank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Cardiothoracic Reading Room. For after-hours or emergency department cases, pleasecall.                Signature Line Electronically Signed on 12/12/22 05:10  ________________________________________________________ DO