Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on October 31, 2023 18:50  Verified By: MD on October 31, 2023 18:50    Encounter Info: Hospital, Inpatient, 10/31/23 -     * Final Report *          History of Present Illness/Subjective     69 year old male with Hx of Atrial fibrillation status post maze procedure on warfarin, coronary artery disease status post stents, asthma, GERD, T2DM, HLD, and HTN, presents to the ED via private vehicle c/o fever.  According to the patient, he was in his usual state of health until 3 days ago when he woke up with fever and chills.  He checked his temperature and was reported to be 101.4.  chills was followed by shortness of breath, faint wheezing, cough, and diaphoresis. He states that the shortness of breath is worse on exertion. Patient endorses chest tightness. He has used nebulizers with slight improvement.  He continues to manage himself at home for the past 3 days and had to present to the ER today because he was feeling worse.  No recent travel, he endorsed positive contacts with setting family members with respiratory illnesses.  Of note, he had a colonoscopy 3 weeks ago for colonic polyps.  He states he is scheduled for upper GI endoscopy for his hernia  Pt notes known hernia.   Denies urinary changes or weight gain.  No nausea or vomiting.  PSHx of cardiac stents, 3x CABG, and prosthetic aortic valve placement. Patient is anticoagulated on warfarin.   In the ER  Vital signs was unremarkable besides remarkable hypoxia and tachycardia.  He was given albuterol and Lasix in the ER with improvement of symptoms.  On bedside evaluation in the ER, he was awake and alert, a AAOx3 on 2.5 L of oxygen and saturating well.  He appeared comfortable.   Labs  WBC 7.5, hemoglobin 9.3, platelets 196, PT/INR 50.2/4.67  Sodium 134, potassium 4.2, BUN/creatinine 23/1.36, glucose 145, BNP 692, lactate venous 1.5  Urinalysis negative for UTI  COVID-negative  Flu AB- not detected   Imaging   ECHO done today 1. Left ventricular systolic function is normal with an ejection fraction by Biplane Method of Discs of 60 %. 2. Left ventricular segmental wall motion is normal. 3. Mild concentric left ventricular hypertrophy. 4. Mild left atrial dilatation. 5. Normally functioning prosthetic aortic valve. 6. Gradient recorded across prosthetic aortic valve within expected range.7. Dilated inferior vena cava with <50% collapse upon inspiration.   CXR  Diffuse airspace opacities in both lungs greater on the right favored to represent pulmonary edema pattern or less likely bilateral pneumonia.  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 Vitals & Measurements most recent past 24 hours   Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported     General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: DIFFUSE RALES and crackles to auscultation, Respirations are non-labored. on 2L of INC Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling,     Assessment/Plan     69 year old male with Hx of Atrial fibrillation status post maze procedure on warfarin, coronary artery disease status post stents, asthma, GERD, T2DM, HLD, and HTN, presents to the ED via private vehicle c/o fever and shortness of breath   1. Sepsis   A41.9   Meets SIRS criteria on admission with fever and tachypnea  Source is likely from pneumonia Present on admission, adequate capillary refill/perfusing pressure on repeat examination, imaging positive for infiltrate, at low risk for hemodynamic and respiratory instability. Blood cultures pending,  urinalysis appears negative at this time,  procalcitonin pending, lactate  WNL.    Continue empiric coverage with ceftriaxone and doxycycline.  De-escalate therapy as appropriate.  SARS CoV 2 negative.  Flu AB not detected   2. Hypoxia   R09.02   As a result of fluid overload and pneumonia.  RT eval to follow  We will continue oxygen supplementation to maintain SPO2 above 92% patient is on room air at baseline.   3. Pneumonia   J18.9   Seen on x-ray.  Likely atypical pneumonia given appearance.  We will send pneumonia labs.  Follow-up procalcitonin.  Follow-up blood culture   4. Fluid overload   E87.70   Seen on x-ray.  Status post IV Lasix in the ER with improvement of respiratory status.  We will hold off further diuresis today and will reassess tomorrow given ongoing sepsis.  We will repeat chest x-ray if needed tomorrow.   5. Anemia   D64.9   Chronic.  No ongoing signs of blood loss.  According to the patient, he is scheduled for upper GI endoscopy in the coming weeks.  We will monitor with daily labs.   6. Anticoagulated on warfarin   Z79.01   Noted.  Supra therapeutic INR noted.  Will defer to pharmacy to manage warfarin   7. Anxiety   F41.9   Chronic problem.  Resume home meds.   8. Atrial fibrillation   I48.91   Not in RVR.  Resume beta-blocker.  Pharmacy to dose warfarin.   9. Chronic GERD   K21.9   Resume home meds.   10. Diabetes mellitus   E11.9   CDA protocol in place.  Carb consistent diet.   11. Hypertension   I10   We will hold off medications due to ongoing sepsis.   12. Elevated INR   R79.1    13. Elevated brain natriuretic peptide (BNP) level   R79.89     Code Status   None Recorded   Chronic Problem List    Anemia  Anticoagulated on warfarin  Anxiety  Aortic valve stenosis with insufficiency  Asthma  Atrial fibrillation  Balanoposthitis  Chronic bronchitis (disorder)  Chronic GERD  Coronary artery disease with angina pectoris  Depression  Diabetes mellitus  Family hx of prostate cancer  Hemorrhoids  History of colon polyps  Hypercholesteremia  Hypertension  Hypertriglyceridemia  Ingrown toenail of both feet  Lower urinary tract symptoms (LUTS)  Nasal congestion  Recurrent major depression (disorder)  Stented coronary artery  Procedure/Surgical History  ?cancer removed from thumb (10/14/2023) ?Colonoscopy (10/04/2023) ?Diabetic retinal eye exam (11/30/2021) ?Diabetic retinal eye exam (11/30/2020) ?colonoscopy (05/19/2017) ?back ?Knee ?tonsils ?vasectomy   Surgical History Internal  10/04/2023    Colonscpy Diagnostic/Screen    MD  05/23/2022    Coronary Art Bypass Graft W Aortic Valve    MD  05/19/2017    Colonscpy Bx    MD  Medications   Home Medications (26) Active  amiodarone 200 mg oral tablet See Instructions, 1 tab daily  amLODIPine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Anusol-HC 2.5% topical cream See Instructions, Topical BID, use with applicators  Anusol-HC 25 mg rectal suppository 25 mg = 1 Suppository, Rectally, Daily  aspirin 81 mg oral tablet, delayed release 81 mg = 1 Tablet, Orally, Daily  cloNIDine 0.1 mg oral tablet 0.1 mg = 1 Tablet, Orally, TID  fenofibrate 200 mg oral capsule 200 mg = 1 Capsule, Orally, Daily, with food  Flonase See Instructions, 50 mCg intraNASAL  Janumet 50 mg-1000 mg oral tablet   Janumet XR 50 mg-1000 mg oral tablet, extended release 1 Tablet, Orally, BID  Lancets Check up to 3 times daily, Other, Unscheduled, Dispense QS 90 days  levothyroxine 75 mCg (0.075 mg) oral tablet 75 mCg = 1 Tablet, Orally, Daily  losartan-hydroCHLOROthiazide 50mg-12.5mg oral tablet 1 Tablet, Orally, Daily  metoPROLOL succinate 200 mg oral tablet, extended release 200 mg = 1 Tablet, Orally, Daily  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  rosuvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Shingrix intramuscular injection 0.5 mL, IM, ONCE  Slo-Niacin 500 mg oral tablet, extended release 500 mg = 1 Tablet, Orally, BID  spironolactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Symbicort 160 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  True Metrix Blood Glucose Meter See Instructions, Check 3 times dailyDx: E11.65  True Metrix Blood Glucose Test Strips See Instructions, Check 3 times dailyDx: E11.65  Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  Vitamin D3 1000 units oral tablet 25 mCg = 1 Tablet, Orally, Daily  warfarin 2 mg oral tablet 2 mg = 1 Tablet, Orally, Daily  Zoloft 100 mg oral tablet 150 mg = 1.5 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 10/30/23 00:00:00 TO 10/31/23 18:50:11  None Reported  PRN Medications (0600 - 0559) from 10/30 - 10/31  None Reported  Allergies   Tequin  doxycycline  Tessalon Perles  Zithromax Z-Pak  codeine  penicillins  predniSONE  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse.   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Insomnia: Negative: Mother and Father.  Narcolepsy: Negative: Mother and Father.  Prostate cancer: Father and Grandfather.  Restless legs: Negative: Mother and Father.  Sleep apnea: Negative: Mother and Father.  Sleep problem: Negative: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.5 k/cumm (10/31/23 12:33:00)  RBC: 3.59 million/cumm Low (10/31/23 12:33:00)  Hgb: 9.3 GM/dL Low (10/31/23 12:33:00)  Hct: 28.5 % Low (10/31/23 12:33:00)  MCV: 79 fL Low (10/31/23 12:33:00)  MCH: 25.9 pg Low (10/31/23 12:33:00)  MCHC: 32.6 GM/dL (10/31/23 12:33:00)  RDW: 16.1 % High (10/31/23 12:33:00)  Platelet: 196 k/cumm (10/31/23 12:33:00)  MPV: 9.3 fL (10/31/23 12:33:00)  Neutrophils %: 77 % (10/31/23 12:33:00)  Lymphocytes %: 14 % (10/31/23 12:33:00)  Monocytes %: 8 % (10/31/23 12:33:00)  Eosinophils %: 1 % (10/31/23 12:33:00)  Basophils %: 1 % (10/31/23 12:33:00)  Absolute Neutrophil: 5.8 k/cumm (10/31/23 12:33:00)  Absolute Lymphocyte: 1 k/cumm (10/31/23 12:33:00)  Absolute Monocyte: 0.6 k/cumm (10/31/23 12:33:00)  Absolute Eosinophil: 0.1 k/cumm (10/31/23 12:33:00)  Absolute Basophil: 0.1 k/cumm (10/31/23 12:33:00)  Chemistry:  Sodium SerPl QN: 134 mmol/L Low (10/31/23 12:33:00)  Potassium SerPl QN: 4.2 mmol/L (10/31/23 12:33:00)  Chloride SerPl QN: 100 mmol/L (10/31/23 12:33:00)  Carbon Dioxide SerPl QN: 27 mmol/L (10/31/23 12:33:00)  Anion Gap: 7 mmol/L (10/31/23 12:33:00)  BUN SerPl QN: 23 mg/dL High (10/31/23 12:33:00)  Creatinine SerPl QN: 1.36 mg/dL (10/31/23 12:33:00)  Estimated GFR (CKD-EPI, no race): 56 mL/min/1.73m2 Low (10/31/23 12:33:00)  Estimated CRCL (CG): 63 mL/min (10/31/23 12:33:00)  Glucose SerPl QN: 145 mg/dL High (10/31/23 12:33:00)  Calcium Total SerPl QN: 9.2 mg/dL (10/31/23 12:33:00)  Alkaline Phos SerPl QN: 10 Units/L Low (10/31/23 12:33:00)  ALT SerPl QN: 21 Units/L (10/31/23 12:33:00)  AST SerPl QN: 29 Units/L (10/31/23 12:33:00)  Bilirubin Direct SerPl QN: 0.2 mg/dL (10/31/23 12:33:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (10/31/23 12:33:00)  Total Protein SerPl QN: 6.8 GM/dL (10/31/23 12:33:00)  Albumin SerPl QN: 3.8 GM/dL (10/31/23 12:33:00)  Troponin-I High Sensitivity: 9 ng/L (10/31/23 12:33:00)  BNP Pl QN: 692 pg/mL High (10/31/23 12:33:00)  Lactate Venous Pl QN: 1.5 mmol/L (10/31/23 13:37:00)  Coagulation:  PT: 50.2 seconds High (10/31/23 12:38:00)  INR: 4.67 High (10/31/23 12:38:00)  Urine Studies:  Color: Yellow (10/31/23 13:37:00)  Clarity: Clear (10/31/23 13:37:00)  Specific Gravity: 1.009 (10/31/23 13:37:00)  pH: 5.5 (10/31/23 13:37:00)  Protein: NEGATIVE (10/31/23 13:37:00)  Glucose: Normal (10/31/23 13:37:00)  Ketones: NEGATIVE (10/31/23 13:37:00)  Bilirubin: NEGATIVE (10/31/23 13:37:00)  Hgb Ur: NEGATIVE (10/31/23 13:37:00)  Nitrite: NEGATIVE (10/31/23 13:37:00)  Urobilinogen: Normal (10/31/23 13:37:00)  Leukocyte Esterase Ur: NEGATIVE (10/31/23 13:37:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (10/31/23 12:33:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (10/31/23 12:33:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (10/31/23 12:33:00)  Rapid Influenza A PCR: Not Detected (10/31/23 12:33:00)  Rapid Influenza B PCR: Not Detected (10/31/23 12:33:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 10/31/2023 13:13 - XR Chest PA and Lateral  IMPRESSION:Diffuse airspace opacities in both lungs greater on the right favoredto represent pulmonary edema pattern or less likely bilateralpneumonia.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 10/31/23 18:50  ________________________________________________________ MD