Document Type: History and Physical   Document Subject: History & Physical Note    Inpatient, 03/27/23 -     * Final Report *        Chief Complaint   Shortness of breath  History of Present Illness/Subjective     This is a 54-year-old female with a past medical history of a flutter, CHF, stasis dermatitis of her lower extremities who presented to ED with a chief complaint of shortness of breath.  She states that her shortness of breath has been worsening over the past few weeks as well as increasing leg swelling.  She was recently started on levothyroxine and Eliquis went when she was diagnosed last week with atrial flutter.  She is a 1.5 pack/day smoker.  She states she does not drink alcohol.  She notes her legs are chronically swollen but were worse over the last few weeks.   In the ED she was found to be in A-fib flutter with rapid ventricular response she was given Cardizem push and responded to a degree.  Patient was taking Toprol, will change to Lopressor to better control heart rate.  Her lab work was relatively benign other than leukocytosis.  Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI.  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.8 °C (Oral)  HR: 110 (Monitored)  HR: 92 (Peripheral)  RR: 19  BP: 108/73  SpO2: 92%  WT: 138 kg  BMI: 40.1  Oxygen Therapy: Room air  Oxygen Flow Rate: 0 (L/min)   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    138 kg    03/27/23  Previous Daily Weight:    138 kg    03/27/23  BMI:    40.1    03/27/23    Morbid Obesity (BMI > = 40) Patient Height  Current Height:    185.4 cm    03/27/23        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:  diffuse crackles b/l with minor wheezing Cardiovascular:  Tachycardic, a flutter, no murmur appreciated Gastrointestinal:  Soft, non-tender, non-distended, obese abdomen Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  B/l LE edema with erythema and tenderness as well exudative slough on the left leg Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  Assessment/Plan     This is a 54-year-old female with past medical history of CHF and recently diagnosed atrial flutter started on Eliquis who presents with chief complaint of shortness of breath found to have a flutter with RVR and sepsis likely due to lower extremity cellulitis admitted to ICU for further management.   1. Atrial flutter with rapid ventricular response   I48.92  Switch Toprol to Lopressor for better rate control, maintain telemetry monitoring, tropes negative, EKG not concerning for ACS, cardio as needed if rate control is not achieved with the switch of medications   2. CHF (congestive heart failure)   I50.9  Continue other home medications  Stop torsemide and start Lasix 40 mg IV daily, titrate as needed   3. Stasis dermatitis   I87.2   4. Sepsis   A41.9   5. Leukocytosis   D72.829   6. Cellulitis of lower extremity   L03.119  Given patient's allergy to vancomycin we will start linezolid, monitor CBC, and cefepime to cover for cellulitis with risk factors for MRSA  Wound care per nursing  Additional imaging as needed  Obtain CRP and procalcitonin   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 03/27/23 19:51:00 EDT  apixaban, 5 mg, Orally, Tablet, BID, 03/28/23 9:00:00 EDT  cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Other (MUST specify in Comments), 03/28/23 0:00:00 EDT, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  furosemide, 40 mg, IV Push, Injection, Daily, 03/28/23 9:00:00 EDT  hydroCODONE-acetaminophen, 1 Tablet, Orally, Tablet, Q6H, PRN, Pain, Moderate (4-6 out of 10), 03/28/23 2:56:00 EDT  levothyroxine, 50 mCg, Orally, Tablet, Daily, 03/28/23 6:00:00 EDT  linezolid, 600 mg, IVPB, Infusion, Q12H, Indication: Other (MUST specify in Comments), 03/27/23 23:00:00 EDT, 150 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 300  metoPROLOL, 25 mg, Orally, Tablet, BID, 03/27/23 22:10:00 EDT  polyethylene glycol 3350, 17 GM, Orally, Powder, Daily, PRN, Constipation - Use First, 03/27/23 19:51:00 EDT  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV, 03/27/23 23:56:00 EDT, Other - See Comments, Clinical Weight  2000 mg Sodium, 20 gm Saturated Fat Diet  Admit to Inpatient  Auto Diff  Blood CX  Blood CX  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  CBC w/Differential  cefePIME Pharmacy Dosing Consult  Comp Metabolic Panel  Creatinine SerPl QN  CRP High Sensitiv SerPl QN  Diagnosis  Hgb  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Level of Care  Magnesium SerPl QN  Medical Service  Phosphorus SerPl QN  Procalcitonin  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  T4 Free Direct SerPl QN  Telemetry Class III 24hr Recommendation  Troponin-I High Sensitivity  TSH w FreeT4 reflex  Vital Signs  Weight  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 50 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.  Code Status   Resuscitation Status - Ordered    -- 03/27/23 19:51:00 EDT, Full Code   Chronic Problem List    Atrial flutter with rapid ventricular response  CHF (congestive heart failure)  Elevated d-dimer  Pleural effusion  Severe obesity  Stasis dermatitis  Tobacco use  Procedure/Surgical History  ?Displaced Fx ?Laproscopy     Medications   Home Medications (6) Active  Eliquis 5 mg oral tablet 5 mg, Orally, BID  ibuprofen 600 mg oral tablet 600 mg = 1 Tablet, Orally, TID  levothyroxine 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Daily  metoPROLOL Succinate ER 25 mg oral tablet, extended release 25 mg, Orally, Daily  ocular lubricant solution 1 Drop, Eye, Left, Q2H  torsemide 20 mg oral tablet 20 mg, Orally, Every Other Day  Active Scheduled Inpatient Medications  apixaban, Tablet, 5 mg, Orally, BID, Start: 03/28/23 09:00:00  cefePIME, Injection, 1 GM, IVPB, Q8H, Indication: Other (MUST specify in Comments), Start: 03/28/23 00:00:00  furosemide (Lasix), Injection, 40 mg, IV Push, Daily, Start: 03/28/23 09:00:00  levothyroxine, Tablet, 50 mCg, Orally, Daily, Start: 03/28/23 06:00:00  linezolid, Infusion, 600 mg, IVPB, Q12H, Indication: Other (MUST specify in Comments), Start: 03/27/23 23:00:00  metoPROLOL (metoPROLOL tartrate), Tablet, 25 mg, Orally, BID, Start: 03/27/23 22:10:00  Sodium Chloride 0.9%  500 mL IV  Other - See Comments       One-Time Medications Given 03/27/23 00:00:00 TO 03/28/23 06:32:37  None Reported  PRN Medications (0600 - 0559) from 03/27 - 03/28  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q6H, 1  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Allergies   vancomycin (Hives)  Neosporin  cortisone  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 14.7 k/cumm High (03/28/23 02:44:00)  RBC: 4.78 million/cumm (03/28/23 02:44:00)  Hgb: 12.9 GM/dL (03/28/23 02:44:00)  Hct: 38 % (03/28/23 02:44:00)  MCV: 79 fL Low (03/28/23 02:44:00)  MCH: 27.1 pg (03/28/23 02:44:00)  MCHC: 34.1 GM/dL (03/28/23 02:44:00)  RDW: 15.7 % High (03/28/23 02:44:00)  Platelet: 364 k/cumm (03/28/23 02:44:00)  MPV: 7.6 fL (03/28/23 02:44:00)  Neutrophils %: 72 % (03/28/23 02:44:00)  Lymphocytes %: 12 % (03/28/23 02:44:00)  Monocytes %: 12 % (03/28/23 02:44:00)  Eosinophils %: 3 % (03/28/23 02:44:00)  Basophils %: 1 % (03/28/23 02:44:00)  Absolute Neutrophil: 10.5 k/cumm High (03/28/23 02:44:00)  Absolute Lymphocyte: 1.7 k/cumm (03/28/23 02:44:00)  Absolute Monocyte: 1.7 k/cumm High (03/28/23 02:44:00)  Absolute Eosinophil: 0.5 k/cumm High (03/28/23 02:44:00)  Absolute Basophil: 0.2 k/cumm (03/28/23 02:44:00)  Chemistry:  Sodium SerPl QN: 134 mmol/L Low (03/28/23 02:44:00)  Potassium SerPl QN: 3.9 mmol/L (03/28/23 02:44:00)  Chloride SerPl QN: 100 mmol/L (03/28/23 02:44:00)  Carbon Dioxide SerPl QN: 25 mmol/L (03/28/23 02:44:00)  Anion Gap: 9 mmol/L (03/28/23 02:44:00)  BUN SerPl QN: 18 mg/dL (03/28/23 02:44:00)  Creatinine SerPl QN: 0.79 mg/dL (03/28/23 02:44:00)  Estimated GFR (CKD-EPI, no race): 89 mL/min/1.73m2 (03/28/23 02:44:00)  Estimated CRCL (CG): >120 (03/28/23 02:44:00)  Glucose SerPl QN: 111 mg/dL High (03/28/23 02:44:00)  Calcium Total SerPl QN: 8.8 mg/dL (03/28/23 02:44:00)  Phosphorus SerPl QN: 3.8 mg/dL (03/28/23 02:44:00)  Alkaline Phos SerPl QN: 77 Units/L (03/28/23 02:44:00)  ALT SerPl QN: 8 Units/L (03/28/23 02:44:00)  AST SerPl QN: 10 Units/L Low (03/28/23 02:44:00)  Bilirubin Total SerPl QN: 0.7 mg/dL (03/28/23 02:44:00)  Total Protein SerPl QN: 6.4 GM/dL (03/28/23 02:44:00)  Albumin SerPl QN: 3 GM/dL Low (03/28/23 02:44:00)  Magnesium SerPl QN: 1.9 mg/dL (03/28/23 02:44:00)  Troponin-I High Sensitivity: 10 ng/L (03/28/23 02:44:00)  BNP Pl QN: 276 pg/mL High (03/27/23 09:24:00)  TSH 3rd Gen SerPl QN: 5.34 mcU/mL High (03/27/23 20:19:00)  Coagulation:  D-Dimer Pl QN: 506 ng/mL DDU High (03/27/23 09:24:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (03/27/23 12:03:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (03/27/23 12:03:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 03/27/2023 09:28 - XR Chest PA or AP Portable  Impression:1.  Interval development of cardiomegaly and vascular congestioncompared with prior study. There are also subtle interstitialopacities suspicious for early pulmonary edema.2.  There is new asymmetric elevation left hemidiaphragm and adjacentsmall left effusion, of uncertain significance.    03/27/2023 11:38 - Venous Duplex Scan LE Bilateral  Impression:1.   No evidence for deep or superficial venous thrombosis of thebilateral lower extremities.