Shortness of Breath     PER EMS " PT C/O SHORTNESS OF BREATH "     HPI Patient is a 74-year-old female with a past medical history of CHF, COPD, hepatitis B and C and hypertension who presents via EMS for shortness of breath.  Patient reports for the past day she is having worsening shortness of breath.  EMS noted she was about 77% on room air but improved with a breathing treatment.  Patient is denying chest pain, coughing, rhinorrhea, sore throat, dizziness, lightheadedness, leg swelling, fevers, chills, nausea, vomiting, abdominal pain, diarrhea, constipation, dysuria, hematuria.   Review of Systems CONSTITUTIONAL:  no fever, no chills, no fatigue HEAD:  no headache or loss of consciousness. EYES:  no eye pain, redness or discharge. ENMT:  no ear pain, no throat pain; no rhinorrhea or congestion. CARDIAC:  No chest pain, no exercise intolerance, no tachycardia. RESPIRATORY:  no cough, wheezing, + trouble breathing/SOB. GI:  no nausea, vomiting, diarrhea or abdominal pain. GU:  no dysuria, no increased frequency, no hesitancy MS:  no muscle aches, joint pain or injury. NEURO:  no dizziness, no change in vision, no seizure SKIN:  no rashes; no lacerations or abrasions, no bruising.    Patient's Medications New Prescriptions   No medications on file Previous Medications   ACETAMINOPHEN (TYLENOL) 500 MG PO TAB    take 500 mg by mouth as needed.   ALBUTEROL (2.5 MG/3ML) 0.083% INHAL NEBU SOLN    inhale 2.5 mg using breathing machine every 6 hours as needed for FOR SHORTNESS OF BREATH.   AMLODIPINE (NORVASC) 5 MG PO TAB    take 5 mg by mouth twice daily.   AMMONIUM LACTATE (LAC-HYDRIN) 12 % EXTERNAL LOTION    apply  to affected area twice daily.   APIXABAN (ELIQUIS) 5 MG PO TAB    take 1 Tablet by mouth every 12 hours.   BUDESONIDE (PULMICORT) 180 MCG/ACT INHAL INHALER    inhale 2 Puffs into the lungs twice daily.   FLUTICASONE (FLONASE) 50 MCG/ACT NASAL SUSPENSION    place 2 Sprays into both nostrils twice daily.   FUROSEMIDE (LASIX) 20 MG PO TAB    take 1 Tablet by mouth once daily.   HYDROXYZINE HCL (ATARAX) 25 MG PO TAB    take 1 Tablet by mouth every 4 hours as needed for FOR ITCHING.   MICONAZOLE (LOTRIMIN AF) 2 % EXTERNAL POWDER    apply  to affected area twice daily.   MULTIPLE VITAMINS-MINERALS (CENTRUM SILVER ULTRA WOMENS) PO TAB    take 1 Tab by mouth once every other day.   RA MELATONIN 5 MG PO TAB    take 1 tablet by mouth at bedtime   ROPINIROLE (REQUIP) 1 MG PO TAB    take 1 mg by mouth 4 times daily.   SACCHAROMYCES BOULARDII (FLORASTOR) 250 MG PO CAP    take 1 Capsule by mouth 3 times daily.   SALINE (OCEAN) 0.65 % NASAL SOLUTION    place  into both nostrils every 2 hours as needed (Epistaxis).   TIOTROPIUM BROMIDE-OLODATEROL (STIOLTO RESPIMAT) 2.5-2.5 MCG/ACT INHAL AERO SOLN    inhale 1 Puff into the lungs once daily.   VALSARTAN (DIOVAN) 160 MG PO TAB    take 1 Tablet by mouth once daily. Modified Medications   No medications on file Discontinued Medications   No medications on file     Allergies Allergen Reactions ? Trimethoprim Rash/Itching     Past Medical History: Diagnosis Date ? Asthma 12/27/2011 ? Bilateral edema of lower extremity 6/14/2016 ? Chronic diastolic CHF (congestive heart failure) 9/14/2016 ? Chronic obstructive pulmonary disease    ? Essential hypertension 12/27/2011 ? Hepatitis B     hx of, pt states "its gone now" ? Hepatitis C     unknown cause ? HTN (hypertension) 12/27/2011 ? Sinus tachycardia 6/14/2016   No past medical history pertinent negatives. Past Surgical History: Procedure Laterality Date ? HYSTERECTOMY       No past surgical history pertinent negatives on file.   Social History   Socioeconomic History ? Marital status: Married Tobacco Use ? Smoking status: Former Smoker     Quit date: 8/1/2013     Years since quitting: 8.4 ? Smokeless tobacco: Never Used Substance and Sexual Activity ? Alcohol use: Yes     Alcohol/week: 6.0 standard drinks     Types: 6 Shots of liquor per week ? Drug use: No     Family History Family History Problem Relation Name Age of Onset ? Cancer Father           throat ? COPD Mother          BP 138/59  | Pulse 113  | Temp 100 °F (37.8 °C) (Axillary)  | Resp 24  | Ht 149.9 cm (4' 11.02")  | Wt 113 kg (249 lb 1.9 oz)  | SpO2 94%  | BMI 50.29 kg/m²    Physical Exam  CONSTITUTIONAL: Ill-appearing, obese HEAD: Normocephalic; atraumatic EYES: Conjunctivae clear, EOM intact, PERRL ENT: No rhinorrhea; mucous membranes pink/moist, no erythema or exudate or posterior oral pharynx. NECK: Supple; non-tender; no cervical lymphadenopathy CARD: No murmurs, rubs, or gallops. Rhythm: Regular, +S1/+S2.  RESP: No respiratory distress.  Breath sounds decreased with bilateral intermittent wheezing.  No rhonchi or rales ABD: Soft; non-distended; no masses. BS x4 Quadrants. Non-Tender. EXT: Non-tender to palpation; distal pulses are normal. SKIN: Normal for age and race; warm; dry. NEURO:  Alert and answering questions appropriately. Moving all extremities.     Procedures   Other ED Provider Notes   Results for orders placed or performed during the hospital encounter of 01/23/22 Complete Blood Count (CBC) W Diff   Narrative   The following orders were created for panel order Complete Blood Count (CBC) W Diff. Procedure                               Abnormality         Status                    ---------                               -----------         ------                    Complete Blood Count (C...  Abnormal            Final result                Please view results for these tests on the individual orders. aPTT Result Value Ref Range   APTT 35.5 25.0 - 38.0 Seconds Protime International Normalized Ratio (INR) Result Value Ref Range   Protime 15.8 (H) 9.2 - 13.5 Seconds   INR 1.4   Basic Metabolic Panel (BMP) Result Value Ref Range   Sodium 142 135 - 145 mmol/L   Potassium 4.5 3.5 - 5.2 mmol/L   Chloride 99 98 - 111 mmol/L   Carbon Dioxide (CO2) 31 (H) 20 - 29 mmol/L   Anion Gap 12 5 - 17   Glucose 107 (H) 60 - 99 mg/dL   Blood Urea Nitrogen (BUN) 19 7 - 25 mg/dL   Creatinine 1.22 (H) 0.50 - 1.10 mg/dL   GFR Non African American 44 (L) >=60 mL/min/1.73m2   Calcium 8.9 8.5 - 10.5 mg/dL D-Dimer Result Value Ref Range   D-Dimer 492 0 - 499 ng/mL FEU Procalcitonin, Plasma Result Value Ref Range   Procalcitonin, Plasma 0.07 0.00 - 0.25 ng/mL   Narrative   Interpretive criteria for results:   If using as an aid in deciding on whether or not to start antibiotics for lower respiratory tract infections, providers should use the following guidance: - PCT <0.10 ng/mL - antibiotics strongly discouraged - PCT 0.10-0.25 ng/mL - antibiotics discouraged - PCT 0.26-0.50 ng/mL - antibiotics encouraged - PCT > 0.50 ng/mL - antibiotics strongly encouraged   If using as an aid in deciding on whether or not to discontinue antibiotics for suspected/confirmed sepsis, providers should use the following guidance: - PCT <= 0.50 ng/mL or > 80% decrease from peak/baseline value         - antibiotics discouraged - PCT > 0.50 ng/mL and < 80% decrease from peak/baseline value         - antibiotics encouraged   Magnesium Level Result Value Ref Range   Magnesium 2.0 1.7 - 2.5 mg/dL Phosphorus Level Result Value Ref Range   Phosphorus 2.3 2.3 - 4.4 mg/dL Troponin I Result Value Ref Range   Troponin I 0.02 <=0.03 ng/mL Complete Blood Count (CBC) W/Auto Diff Result Value Ref Range   WBC 6.3 3.3 - 10.7 bil/L   RBC 3.82 (L) 3.87 - 5.08 tril/L   Hemoglobin 10.8 (L) 12.1 - 15.0 g/dL   Hematocrit 36.0 35.4 - 44.2 %   MCV 94 80 - 100 fL   MCH 28 28 - 33 pg   MCHC 30 (L) 32 - 35 g/dL   RDW-CV 15 12 - 15 %   Platelets 307 150 - 400 bil/L   Neutrophils 4.0 1.6 - 7.2 bil/L   Lymphocytes 1.5 1.1 - 4.0 bil/L   Monocytes 0.8 0.0 - 0.8 bil/L   Eosinophils 0.0 0.0 - 0.5 bil/L   Basophils 0.0 0.0 - 0.1 bil/L   Immature Granulocytes 0.02 0.00 - 0.03 bil/L   Immature Granulocyte % 0.3 % Covid-19, Flu, RSV by NAA   Specimen: Nasopharyngeal; Swab Result Value Ref Range   Influenza A Not Detected Not Detected   Influenza B Not Detected Not Detected   RSV Not Detected Not Detected   SARS-CoV-2 (COVID-19) by NAA, Micro  Detected (A) Not Detected   Narrative   Methodology: Nucleic Acid Amplification(NAA)/Polymerase Chain Reaction(PCR)   The SARS-CoV-2 (COVID-19) test is for in vitro diagnostic use under the FDA Emergency Use Authorization (EUA) for laboratories certified under Agency to perform high complexity testing. This test has not been FDA cleared or approved. ECG   Narrative