Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on February 11, 2023 06:11   Verified By: DO on February 11, 2023 06:11   Encounter Info: Hospital, Inpatient, 02/11/23 -     * Final Report *        Chief Complaint   shortness of breath  History of Present Illness/Subjective     This is a 54-year-old male who presented to ED with history of shortness of breath he states that the symptoms began couple days ago and then worsened prior to his arrival he says he feels like he is drowning he has a history of CHF and he states that his legs have been swollen recently.  He also says he has had some chest pain associated with shortness of breath feeling like something is sitting on his chest.  Also endorses a dry cough denies any fever, abdominal pain, nausea, vomiting, diarrhea, change in BM or urination, denies head neck or back pain.   At ED he was started on nitro and Cardizem drips when he was discovered to be in A-fib with RVR.  He was transferred to ICU for further care.  This patient is critically ill due to metabolic, hemodynamic and/or respiratory instability. They require high complexity evaluation, decision making, and care. They require ICU level of care and monitoring due to high risk of clinical decompensation with high risk of morbidity and mortality. Critical care time includes, but is not limited to, bedside assessment, review of medical record, radiographic and laboratory results, ventilator and/or respiratory management, review of ekg and/or cardiac monitoring, critical decision making, coordination of care with consultants and/or care team, and documentation of critical intervention/plans, and consultation with patient and/or family. Time excludes any procedural time.  I spent greater than 55 minutes in the evaluation and management of this patient with more than 50% of the time spent counseling and/or coordinating care.  I counseled the patient and/or family about the findings, differential diagnoses, my assessment, recommendations, and plan.  I coordinated care with the multidisciplinary healthcare team.  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) 36.6 (36.6-36.6)  Temp (FAHR) 97.9 (97.9-97.9), BP 124/91 (103-134)/(81-98), HR 107 (97-113), RR 26 (14-27), O2Sat 90 (90-90) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    130 kg    02/11/23    Patient Height        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:  decreased lung sounds in both bases, fine crackles worse inferiorly, significant dry cough Cardiovascular:  Tachycardic irregular rhythm Gastrointestinal:  Soft, non-tender, non-distended, obese abdomen Musculoskeletal:  2+ pitting edema in b/l LE associated with some erythema and warmth vs chronic changes 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. Atrial fibrillation with RVR   I48.91  continue cardizem drip, address underlying precipitating causes, likely fluid overload  goal HR is <120   2. Combined congestive systolic and diastolic heart failure   I50.40  bnp is significantly elevated, decreased lung sounds in bases, and LE pitting edema suggest acute exacerbation of CHF  give 40mg lasix iv stat  cont home meds  obtain echo  maintain telemetry  strict i/o's  goal to achieve fluid negative state  daily weights  serial trops/ecg  cardio eval prn  obtain hga1c, lipid panel, tsh   3. Hypertension   I10  cont home meds   4. Obstructive sleep apnea   G47.33  cont cpap at night if patient is compliant outpatient   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 02/11/23 2:40:00  apixaban, 5 mg, Orally, Tablet, BID, 02/11/23 9:00:00  diltiaZEM 125 mg + Dextrose 5% in Water 125 mL, Total Volume (mL) = 125, IV, 02/11/23 2:49:00, Titrate - See comments  furosemide, 40 mg, IV Push, Injection, ONCE, NOW, 02/11/23 5:51:00, 02/11/23 5:51:00   furosemide, 40 mg, IV Push, Injection, Daily, 02/11/23 9:00:00   nitroGLYCerin 50 mg + Dextrose 5% in Water 250 mL, Total Volume (mL) = 250, IV, 02/11/23 2:57:00, Titrate - See Comments  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 02/11/23 2:40:00   umeclidinium, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 02/11/23 9:00:00   2000 mg Sodium, 20 gm Saturated Fat Diet  Admit to Inpatient CAH  Apixaban Education: Pharmacy  Bladder Scan  Blood Gas Venous QN  BNP Pl QN  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  Care Management Consult  Care Management Consult  CBC w/Differential  Comp Metabolic Panel  CPAP Intermittent  Creatinine SerPl QN  Diagnosis  Echocardiogram with Cardiac Doppler PW/CW/Color  Hgb  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Intake + Output Strict  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Medical Service  Nutrition Consult  Resp Evaluation or Assessment  Resuscitation Status  Single Oxygen Saturation  Telemetry Class III 24hr Recommendation  Titrate FiO2 to Keep O2 Sat  Troponin-I High Sensitivity  TSH w FreeT4 reflex  Vital Signs  Weight  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 02/11/23 2:40:00, Full Code   Chronic Problem List    Chronic pain  Combined congestive systolic and diastolic heart failure  Encounter for long-term (current) use of medications  Hypertension  Lumbar radicular pain  Obesity  Obstructive sleep apnea  Osteoarthritis of left hip  Procedure/Surgical History  ?Adenoidectomy ?Cervical spine ?Hiatal Hernia ?Knee injury - major ?Sinus surgery ?Tonsillectomy     Medications   Home Medications (12) Active  apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  digoxin 125 mCg (0.125 mg) oral tablet 125 mCg = 1 Tablet, Orally, Daily  DME CPAP Not Applicable, Other, Unscheduled, CPap and suppliesDX 0SA G47.33  Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, BID  lisinopril 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  metoPROLOL tartrate 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID  Misc Supplies See Instructions, Blood pressure cuffDx:  Hypertension with CHF  Norco 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q6H, G89.29  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  Proventil HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily  Spiriva 18 mCg inhalation capsule 18 mCg = 1 Capsule, Inhalation, Daily, Use two inhalations of one capsule each dose  spironolactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  apixaban, Tablet, 5 mg, Orally, BID, Start: 02/11/23 09:00:00  furosemide, Injection, 40 mg, IV Push, Daily, Start: 02/11/23 09:00:00  umeclidinium (Incruse Ellipta 62.5 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 02/11/23 09:00:00  nitroGLYCerin PREMIX + Dextrose 5% in Water PREMIX IV Titrate - See Comments 5 mCg/min    diltiaZEM PREMIX + Sodium Chloride 0.9% IV  Titrate - See comments 5 mg/hr    nitroGLYCerin PREMIX + Dextrose 5% in Water PREMIX IV Titrate - See Comments 5 mCg/min  02/11/23  diltiaZEM PREMIX + Dextrose 5% in Water PREMIX IV Titrate - See comments 5 mg/hr  02/11/23    One-Time Medications Given 02/10/23 00:00:00 TO 02/11/23 06:11:30  furosemide (Lasix), Injection, 40 mg, IV Push, ONCE, (1 DOSE 02/11/23 06:09:00)  PRN Medications (0600 - 0559) from 02/10 - 02/11  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   sulfa drugs  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse.   Substance Abuse   Past   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.9 k/cumm High (02/10/23 21:04:00)  RBC: 4.51 million/cumm (02/10/23 21:04:00)  Hgb: 13.2 GM/dL Low (02/10/23 21:04:00)  Hct: 40 % (02/10/23 21:04:00)  MCV: 89 fL (02/10/23 21:04:00)  MCH: 29.2 pg (02/10/23 21:04:00)  MCHC: 32.9 GM/dL (02/10/23 21:04:00)  RDW: 14.2 % (02/10/23 21:04:00)  Platelet: 286 k/cumm (02/10/23 21:04:00)  MPV: 7 fL (02/10/23 21:04:00)  Neutrophils %: 66 % (02/10/23 21:04:00)  Lymphocytes %: 24 % (02/10/23 21:04:00)  Monocytes %: 8 % (02/10/23 21:04:00)  Eosinophils %: 1 % (02/10/23 21:04:00)  Basophils %: 1 % (02/10/23 21:04:00)  Absolute Neutrophil: 7.2 k/cumm (02/10/23 21:04:00)  Absolute Lymphocyte: 2.6 k/cumm (02/10/23 21:04:00)  Absolute Monocyte: 0.9 k/cumm (02/10/23 21:04:00)  Absolute Eosinophil: 0.2 k/cumm (02/10/23 21:04:00)  Absolute Basophil: 0.1 k/cumm (02/10/23 21:04:00)  Chemistry:  Sodium SerPl QN: 137 mmol/L (02/10/23 21:04:00)  Potassium SerPl QN: 4.2 mmol/L (02/10/23 21:04:00)  Chloride SerPl QN: 104 mmol/L (02/10/23 21:04:00)  Carbon Dioxide SerPl QN: 21 mmol/L Low (02/10/23 21:04:00)  Anion Gap: 12 mmol/L High (02/10/23 21:04:00)  BUN SerPl QN: 19 mg/dL (02/10/23 21:04:00)  Creatinine SerPl QN: 0.98 mg/dL (02/10/23 21:04:00)  Estimated GFR (CKD-EPI, no race): >90 (02/10/23 21:04:00)  Estimated CRCL (CG): 118 mL/min (02/10/23 21:04:00)  Glucose SerPl QN: 122 mg/dL High (02/10/23 21:04:00)  Calcium Total SerPl QN: 8.6 mg/dL (02/10/23 21:04:00)  Magnesium SerPl QN: 2 mg/dL (02/11/23 04:21:00)  Troponin-I High Sensitivity: 7 ng/L (02/11/23 04:21:00)  BNP Pl QN: 390 pg/mL High (02/10/23 21:04:00)  Lactate Venous Pl QN: 1.1 mmol/L (02/10/23 21:04:00)  pH Bld Venous QN: 7.48 High (02/11/23 04:21:00)  PCO2 Bld Venous QN: 38 mmHg Low (02/11/23 04:21:00)  PO2 Bld Venous QN: 84 mmHg High (02/11/23 04:21:00)  Base Excess Bld Venous: 5 mmol/L High (02/11/23 04:21:00)  Bicarb Bld Venous Calc: 28 mmol/L (02/11/23 04:21:00)  O2 Sat Bld Venous Calc: 97 % (02/11/23 04:21:00)  Patient Temperature: 37 DegC (02/11/23 04:21:00)  TSH 3rd Gen SerPl QN: 1.52 mcU/mL (02/11/23 04:21:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/10/23 21:10:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/10/23 21:10:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/10/2023 20:59 - XR Chest PA or AP Portable  IMPRESSION:1.  Mild pulmonary vascular congestion. No focal pulmonaryconsolidation, pleural effusion or pneumothorax. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 02/11/23 06:11  ________________________________________________________ DO