Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on December 06, 2022 07:39 EST   Verified By: DO on December 06, 2022 07:39 EST   Encounter Info: Inpatient, 12/06/22 -     * Final Report *        Chief Complaint   shortness of breath  History of Present Illness/Subjective     Patient is an elderly male with history of COPD who presented to ED w/ cough and generalized weakness.  Does have shortness of breath but reports no significant deviation from baseline. Symptoms started about 1 week ago and have progressively worsened since that time.  Reports his wife had flulike symptoms about 2 days prior to his onset of symptoms.  He has had significantly decreased oral intake.  He has been so weak that he fell a couple days ago.  However, denies head trauma or injuries.  He is remained afebrile.  He is unable to get up independently due to the severity of his weakness. In the ED he was discovered to have influenza A, elevated trop, aki, elevated bnp, and is requiring 4L O2 via oxymask. He denies chest pain, productive cough, admits to some wheezing. Patient states he is thirsty.  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) 37 (37-37)  Temp (FAHR) 98.6 (98.6-98.6), BP 112/86 (112-112)/(86-86), HR 100 (100-107), RR 20 (18-20), O2Sat 92 (92-92) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    68.7 kg    12/06/22  Previous Daily Weight:    68.7 kg    12/06/22  BMI:    24.1    12/06/22    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    169 cm    12/06/22        Constitutional: No acute distress, frail appearing, weak, appears dry Eyes: no scleral icterus, no conjunctival injection, dry mucuous membranes HENT: no edema, atraumatic Neck:  normal ROM Cardiovascular: tachycardic, regular rhythm, No edema Pulmonary: no respiratory distress, rhonchi bilaterally, with mild wheeze Abdomen: nondistended, no tenderness, no rebound, noguarding MSK: atraumatic, no deformities, no cyanosis Neurologic: motor function grossly intact, sensation grossly intact Skin: dry, warm Psych: calm and cooperative  Assessment/Plan     admit to med/surg   1. Influenza A   J10.1   2. CHF (congestive heart failure)   I50.9   3. COPD exacerbation   J44.1  supportive care and supplemental o2  not a candidate for tamiflu due to onset of symptoms being approx 7 days prior  droplet isolation  resp assessment  doxycycline for possible atypical pneumonia  duonebs  likely not a chf exacerbation given patient is dry   4. Acute on chronic renal failure   N17.9  renal function is improving with iv and supplemental o2  avoid nephrotoxic medications   5. Anemia   D64.9  transfuse hg <7, drop in hg likely related to dilutional change, repeat hg in 4 hours   6. Thrombocytopenia   D69.6  trend plt count, no dvt chemical ppx while platelets are <100K  possibly due to influenza, cont to monitor   7. Elevated troponin   R77.8  likely due to demand ischemia and initial hypoxia  cont to trend trops until peaked, cardio eval prn if not improving  no chest pain at present and ecg does not demonstrate evidence of ACS  cont to monitor   8. Diabetes mellitus with hyperglycemia   E11.65  accuchecks, iss, diabetic diet, hold home meds for now   9. Elevated bilirubin   R17  resolved   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 12/06/22 4:46:00 EST  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 12/06/22 4:46:00 EST, PRN - See Comments  doxycycline, 100 mg, IVPB, Injection, BID, 12/06/22 10:00:00 EST, 100 mL/hr, Infuse Over 1 Hours, Total Volume (mL) = 100  fluticasone-vilanterol, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 12/06/22 9:00:00 EST  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 12/06/22 4:46:00 EST  glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 12/06/22 4:46:00 EST  insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 12/06/22 4:46:00 EST  methylPREDNISolone, 40 mg, IV Push, Injection, Daily, 12/06/22 9:00:00 EST  180 gm Carb per day Diet  Admit to Inpatient CAH  Bladder Scan  Call (Specify)  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  CBC  CBC w/Differential  Comp Metabolic Panel  Comp Metabolic Panel  Electrocardiogram  Fall Precautions  Fluid Intake Requirement  Gluc-Strip POC  Hgb  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Oxygen Protocol  Initiate Respiratory Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  Nasal Cannula  Notify Provider  Notify Provider  Notify Provider  OT Evaluation and Treatment  Patient Isolation  Peripheral IV Insertion  Phosphorus SerPl QN  PT Evaluation and Treatment  Reason for Not Ordering Long-acting Insulin  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Telemetry Class III 24hr Recommendation  Titrate FiO2 to Keep O2 Sat  Troponin-I High Sensitivity  TSH w FreeT4 reflex  Turn Cough + Deep Breathe  Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 12/06/22 4:46:00 EST, Full Code   Chronic Problem List    Anemia  CAD (coronary artery disease)  Chronic cough  Chronic HFrEF (heart failure with reduced ejection fraction)  Chronic ITP (idiopathic thrombocytopenia)  Colonic polyp  COPD (chronic obstructive pulmonary disease)  Dermatitis, atopic  Diet-controlled diabetes mellitus  Encounter for long-term current use of medication  GERD (gastroesophageal reflux disease)  Hematuria  Hip pain  History of hip replacement  Hx of staphylococcal infection  Hyperlipidemia  Hypertension  Intermittent claudication  Macrocytosis  Macrocytosis without anemia  Mallet finger  Nasal septal deviation  Obstructive sleep apnea  Psoriasis  S/P implantation of automatic cardioverter/defibrillator (AICD)  Skin lesion  Snoring  Stage 3 chronic kidney disease  Tobacco use  Vascular dementia  Procedure/Surgical History  ?Diabetic retinal eye exam (12/21/2021) ?Eye examination (12/20/2018) ?colonoscopy (08/01/2016) ?Hip replacement (07/01/2013) ?egd (05/09/2012) ?CABG - Coronary artery bypass graft (2002) ?Heart Sx 2004 ?Polypectomy ?Rt THR JWS 7/1/13   Surgical History Internal  08/01/2016    Colonscpy Diagnostic/Screen      Medications   Home Medications (17) Active  acitretin 10 mg oral capsule 10 mg = 1 Capsule, Orally, Every Mon Wed Fri  allopurinol 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID  amLODIPine 2.5 mg oral tablet , TAKE 1 TABLET BY MOUTH EVERY DAY  apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, QHS  Breo Ellipta 200 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily  Flomax 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily  furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Mapap Arthritis Pain 650 mg oral tablet, extended release 1,300 mg = 2 Tablet, Orally, Q8H  memantine 5 mg oral tablet See Instructions, 1 Tablet Orally bid X 1 week then 2 in am 1 in pm x 1 week then 2 twice a day  metoPROLOL tartrate 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID  multivitamin 1 Tablet, Orally, Daily  Nitrostat 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  valsartan 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily  Vitamin C 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  Active Scheduled Inpatient Medications  doxycycline, Injection, 100 mg, IVPB, BID, Start: 12/06/22 10:00:00  fluticasone-vilanterol (Breo Ellipta 200 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 12/06/22 09:00:00  methylPREDNISolone (soluMEDROL), Injection, 40 mg, IV Push, Daily, Start: 12/06/22 09:00:00  Lactated Ringers  1,000 mL IV  150 mL/hr     Dextrose 10% in Water 500 mL IV PRN - See Comments       One-Time Medications Given 12/05/22 00:00:00 TO 12/06/22 07:39:23  None Reported  PRN Medications (0600 - 0559) from 12/05 - 12/06  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   Allergies   penicillins (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   CAD - Coronary artery disease: Mother and Brother.  DM (diabetes mellitus)...: Grandmother.  Kidney disease: Brother and Brother.Negative: Mother and Father.  Stroke: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 4.1 k/cumm (12/06/22 05:31:00)  RBC: 2.55 million/cumm Low (12/06/22 05:31:00)  Hgb: 9.7 GM/dL Low (12/06/22 05:31:00)  Hct: 28.2 % Low (12/06/22 05:31:00)  MCV: 111 fL High (12/06/22 05:31:00)  MCH: 38 pg High (12/06/22 05:31:00)  MCHC: 34.3 GM/dL (12/06/22 05:31:00)  RDW: 13.3 % (12/06/22 05:31:00)  Platelet: 62 k/cumm Low (12/06/22 05:31:00)  MPV: 8.4 fL (12/06/22 05:31:00)  Neutrophils %: 83 % (12/05/22 20:18:00)  Lymphocytes %: 8 % (12/05/22 20:18:00)  Monocytes %: 10 % (12/05/22 20:18:00)  Eosinophils %: 0 % (12/05/22 20:18:00)  Basophils %: 0 % (12/05/22 20:18:00)  Absolute Neutrophil: 4.2 k/cumm (12/05/22 20:18:00)  Absolute Lymphocyte: 0.4 k/cumm Low (12/05/22 20:18:00)  Absolute Monocyte: 0.5 k/cumm (12/05/22 20:18:00)  Absolute Eosinophil: 0 k/cumm (12/05/22 20:18:00)  Absolute Basophil: 0 k/cumm (12/05/22 20:18:00)  RBC Morphology: See description UC (12/05/22 20:18:00)  Dacryocyte: Few (1+). (12/05/22 20:18:00)  Macrocyte: Few (1+). (12/05/22 20:18:00)  Microcyte: Few (1+). (12/05/22 20:18:00)  Platelet Estimate: Decreased. (12/05/22 20:18:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (12/06/22 05:31:00)  Potassium SerPl QN: 4.2 mmol/L (12/06/22 05:31:00)  Chloride SerPl QN: 100 mmol/L (12/06/22 05:31:00)  Carbon Dioxide SerPl QN: 24 mmol/L (12/06/22 05:31:00)  Anion Gap: 15 mmol/L High (12/06/22 05:31:00)  BUN SerPl QN: 50 mg/dL High (12/06/22 05:31:00)  Creatinine SerPl QN: 2.12 mg/dL High (12/06/22 05:31:00)  Estimated GFR (CKD-EPI, no race): 30 mL/min/1.73m2 Low (12/06/22 05:31:00)  Estimated CRCL (CG): 24 mL/min Low (12/06/22 05:31:00)  Glucose SerPl QN: 186 mg/dL High (12/06/22 05:31:00)  Calcium Total SerPl QN: 8.4 mg/dL Low (12/06/22 05:31:00)  Phosphorus SerPl QN: 3 mg/dL (12/06/22 05:31:00)  Alkaline Phos SerPl QN: 60 Units/L (12/06/22 05:31:00)  ALT SerPl QN: 41 Units/L (12/06/22 05:31:00)  AST SerPl QN: 89 Units/L High (12/06/22 05:31:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (12/06/22 05:31:00)  Total Protein SerPl QN: 5.6 GM/dL Low (12/06/22 05:31:00)  Albumin SerPl QN: 3.1 GM/dL Low (12/06/22 05:31:00)  Magnesium SerPl QN: 1.7 mg/dL (12/06/22 05:31:00)  Troponin-I High Sensitivity: 78 ng/L High (12/06/22 05:31:00)  BNP Pl QN: 636 pg/mL High (12/05/22 20:18:00)  Lactate Venous Pl QN: 1.3 mmol/L (12/05/22 20:18:00)  pH Bld Venous QN: 7.44 (12/05/22 20:18:00)  PCO2 Bld Venous QN: 36 mmHg Low (12/05/22 20:18:00)  PO2 Bld Venous QN: <35 Low (12/05/22 20:18:00)  Base Excess Bld Venous: 1 mmol/L (12/05/22 20:18:00)  Bicarb Bld Venous Calc: 24 mmol/L (12/05/22 20:18:00)  O2 Sat Bld Venous Calc: 68 % (12/05/22 20:18:00)  Patient Temperature: 37 DegC (12/05/22 20:18:00)  TSH 3rd Gen SerPl QN: 0.75 mcU/mL (12/06/22 06:00:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (12/05/22 19:50:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (12/05/22 19:50:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/05/22 19:50:00)  Rapid Influenza A PCR: Detected Abnormal (12/05/22 19:50:00)  Rapid Influenza B PCR: Not Detected (12/05/22 19:50:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/05/2022 20:20 - XR Chest PA or AP Portable  IMPRESSION:  Airspace opacities, left greater than right, which are new comparedto prior chest radiograph on 3/23/2022, however were present on theprior CT on 8/15/2022.                Signature Line Electronically Signed on 12/06/22 07:39 EST ________________________________________________________ DO