Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 02, 2023 14:18 EST   Verified By: MD on February 02, 2023 14:50 EST   Encounter Info: Hospital, Observation, 02/02/23 - 02/03/23    * Final Report *          History of Present Illness/Subjective     Chief complaint: Cough and fever  HPI: Patient is a 79-year-old female patient with hypertension hyperlipidemia allergic rhinitis hypokalemia osteopenia presented to emergency department with a fever of 99.6 diarrhea chills and decreased appetite for about a week time.  Patient describes flank pain is from constant coughing and it hurts to press on it.  No sick contacts.  Upon evaluation in the emergency room patient has a white count of 20.5 increased platelets left shift BNP 43 lactate 1.4 negative troponins slight dehydration BUN 23 creatinine 1.58 urinalysis looked normal no COVID no flu a chest x-ray was obtained that showed patchy opacities in the left lung overall appearance favors acute infection.  Patient's vitals are quite stable.  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) 37.0 (37.0-37.0)  Temp (FAHR) 98.6 (98.6-98.6), BP 140/47 (119-158)/(47-111), HR 87 (58-87), RR 20 (20-20), O2Sat 94 (94-94) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    69.1 kg    02/02/23  Previous Daily Weight:    69.1 kg    02/02/23    Patient Height  Current Height:    176.4 cm    02/02/23        General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. No added sounds Cardiovascular: Normal rate, Regular rhythm. s1 s2 positive Gastrointestinal: Soft, Non-tender. BS present all 4 quadrants Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact    Assessment/Plan       1. Pneumonia   J18.9   Present on admission on chest x-ray.  -Start patient on broad-spectrum antibiotics to cover community-acquired pneumonia for atypical and typical infection.  -Check Legionella and strep pneumo and procalcitonin levels.  -De-escalate antibiotic therapy as able.   2. Elevated WBC count   D72.829   Likely due to pneumonia at this time.  -We will continue to trend CBC to monitor white count and platelets.   3. AKI (acute kidney injury)   N17.9   This is dehydration.  -Normal saline as ordered for about 2 L time and then reevaluate in the morning.   4. Hyponatremia   E87.1   Slight hyponatremia likely due to dehydration.  -Rehydration therapy as above.   5. Hypertension   I10   Blood pressure appears to be elevated.  She is taking lisinopril hydrochlorothiazide at home we will continue with the lisinopril and will hold hydrochlorothiazide during the hospitalization.   6. Hyperlipidemia   E78.5   She has history of hypercholesterolemia latest cholesterol in September was 161.  -She can barely take any Crestor and has difficulty tolerating statins.  We will recheck this tomorrow.    Code Status   None Recorded   Chronic Problem List    Allergic rhinitis  Hyperlipidemia  Hypertension  Hypokalemia  Irregular heartbeat  Mitral valve prolapse  Osteopenia  Vertigo  Procedure/Surgical History  ?colonoscopy (06/08/2018) ?Cholecystectomy ?colonoscopy over 10 yrs ago per pt ?Hip replacement   Surgical History Internal  06/08/2018    Colonscpy Bx    MD  Medications   Home Medications (6) Active  albuterol HFA MDI 90mCg/puff inhalation aerosol 1 Puff, PRN, Inhalation, Q4H  cyanocobalamin 1000 mCg/mL injectable solution 1,000 mCg, IM, Every Week, 1 injection weekly x7 weeks  hydroCHLOROthiazide 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  lisinopril 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Potassium Chloride (Eqv-K-Tab) 20 mEq oral tablet, extended release 20 mEq = 1 Tablet, Orally, BID  Syringes - 5 mL 1 Each, PRN, Misc, Unscheduled  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/01/23 00:00:00 TO 02/02/23 14:17:58  albuterol-ipratropium (albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL), Inhalation SOLN, 3 mL, Neb Inhal, ONCE, (1 DOSE 02/02/23 12:43:00)  azithromycin, Injection, 500 mg, IVPB, ONCE, (1 DOSE 02/02/23 14:04:00)  ceftRIAXone, Injection, 1 GM, IV Push, ONCE, (1 DOSE 02/02/23 14:05:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 02/02/23 12:21:00)  PRN Medications (0600 - 0559) from 02/01 - 02/02  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   Widowed, 2 children   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Heart disease..: Mother.  Stroke: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 20.5 k/cumm High (02/02/23 12:06:00)  RBC: 4.31 million/cumm (02/02/23 12:06:00)  Hgb: 12.7 GM/dL (02/02/23 12:06:00)  Hct: 39.3 % (02/02/23 12:06:00)  MCV: 91 fL (02/02/23 12:06:00)  MCH: 29.4 pg (02/02/23 12:06:00)  MCHC: 32.3 GM/dL (02/02/23 12:06:00)  RDW: 13.7 % (02/02/23 12:06:00)  Platelet: 510 k/cumm High (02/02/23 12:06:00)  MPV: 8.5 fL (02/02/23 12:06:00)  Neutrophils %: 86 % (02/02/23 12:06:00)  Lymphocytes %: 5 % (02/02/23 12:06:00)  Monocytes %: 7 % (02/02/23 12:06:00)  Eosinophils %: 1 % (02/02/23 12:06:00)  Basophils %: 0 % (02/02/23 12:06:00)  Absolute Neutrophil: 17.7 k/cumm High (02/02/23 12:06:00)  Absolute Lymphocyte: 1.1 k/cumm (02/02/23 12:06:00)  Absolute Monocyte: 1.5 k/cumm High (02/02/23 12:06:00)  Absolute Eosinophil: 0.1 k/cumm (02/02/23 12:06:00)  Absolute Basophil: 0.1 k/cumm (02/02/23 12:06:00)  Chemistry:  Sodium SerPl QN: 133 mmol/L Low (02/02/23 12:30:00)  Potassium SerPl QN: 4 mmol/L (02/02/23 12:30:00)  Chloride SerPl QN: 95 mmol/L Low (02/02/23 12:30:00)  Carbon Dioxide SerPl QN: 28 mmol/L (02/02/23 12:30:00)  Anion Gap: 10 mmol/L (02/02/23 12:30:00)  BUN SerPl QN: 23 mg/dL High (02/02/23 12:30:00)  Creatinine SerPl QN: 1.58 mg/dL High (02/02/23 12:30:00)  Estimated GFR (CKD-EPI, no race): 33 mL/min/1.73m2 Low (02/02/23 12:30:00)  Estimated CRCL (CG): 32 mL/min Low (02/02/23 12:30:00)  Glucose SerPl QN: 132 mg/dL High (02/02/23 12:30:00)  Calcium Total SerPl QN: 10.5 mg/dL (02/02/23 12:30:00)  Alkaline Phos SerPl QN: 108 Units/L (02/02/23 12:30:00)  ALT SerPl QN: 11 Units/L (02/02/23 12:30:00)  AST SerPl QN: 18 Units/L (02/02/23 12:30:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (02/02/23 12:30:00)  Total Protein SerPl QN: 8.4 GM/dL High (02/02/23 12:30:00)  Albumin SerPl QN: 4.1 GM/dL (02/02/23 12:30:00)  Lipase SerPl QN: 16 Units/L (02/02/23 12:30:00)  Troponin-I High Sensitivity: 6 ng/L (02/02/23 12:30:00)  BNP Pl QN: 43 pg/mL (02/02/23 12:06:00)  Lactate Venous Pl QN: 1.4 mmol/L (02/02/23 12:06:00)  Urine Studies:  Color: Yellow (02/02/23 12:16:00)  Clarity: Clear (02/02/23 12:16:00)  Specific Gravity: >=1.030 (02/02/23 12:16:00)  pH: 5.0 (02/02/23 12:16:00)  Protein: 30 Abnormal (02/02/23 12:16:00)  Glucose: NEGATIVE (02/02/23 12:16:00)  Ketones: TRACE. Abnormal (02/02/23 12:16:00)  Bilirubin: SC MOD Abnormal (02/02/23 12:16:00)  Hgb Ur: NEGATIVE (02/02/23 12:16:00)  Nitrite: NEGATIVE (02/02/23 12:16:00)  Urobilinogen: 1.0. (02/02/23 12:16:00)  Leukocyte Esterase Ur: NEGATIVE (02/02/23 12:16:00)  WBC: None Seen (02/02/23 12:16:00)  RBC: None Seen (02/02/23 12:16:00)  Bacteria: Moderate Abnormal (02/02/23 12:16:00)  Squamous Epithelial: Moderate (02/02/23 12:16:00)  Hyaline Casts: 6-10 (02/02/23 12:16:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/02/23 12:09:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/02/23 12:09:00)  Micro - Last 7 days  Rapid Influenza Method: FIA (02/02/23 12:09:00)  Rapid Influenza A: Negative (02/02/23 12:09:00)  Rapid Influenza B: Negative (02/02/23 12:09:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/02/2023 12:51 - XR Chest PA or AP Portable  IMPRESSION:1.  Patchy opacities in the left lung. Overall appearance favorsacute infection. Recommend follow-up radiographs in 8-10 weeks timeto confirm radiographic resolution.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 02/02/23 14:50 EST ________________________________________________________ MD