Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 02, 2023 15:09 EST   Verified By: MD on February 02, 2023 15:09 EST   Encounter Info: Hospital, Inpatient, 02/02/23 -     * Final Report *          History of Present Illness/Subjective     This is a 51-year-old female with past medical history of anemia, diabetes, hyperlipidemia, hypertension, Raynaud's disease presents to the ED with complaints of dyspnea for the 2 weeks and fatigue.  The patient has also been producing green-colored sputum and feeling feverish.  She went to a walk-in clinic yesterday and she was prescribed antibiotics and steroids.  She used to be a diabetic before but underwent gastric bypass surgery after which she did not require any medications for diabetes.  In the ED her vitals are stable except for saturation which is 87% on room air.  She is a smoker but she was never formally diagnosed of COPD.  labs are sig for Anemia and DKA.XRAY suggestive of pna.  pt will be admitted to the ICU for insulin drip  Review of Systems     13 point review of system negative except for whats mentioned in my HPI   Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.9 (36.9-36.9)  Temp (FAHR) 98.4 (98.4-98.4), BP 143/75 (117-148)/(75-94), HR 91 (78-99), RR 16 (12-22), O2Sat 90 (73-90)     Patient Weight  Current Daily Weight:    57.5 kg    02/02/23    Patient Height  Current Height:    165.1 cm    02/02/23        Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  ronchi Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM 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. Acute respiratory failure   J96.00  -The patient is saturating in the 80s in room air  -Acute hypoxic respiratory failure secondary to pneumonia  -Broad-spectrum antibiotics  -Follow pneumonia work-up  -Monitor O2 sat   2. Pneumonia   J18.9  -Problem #1   3. DKA (diabetic ketoacidosis)   E11.10  -Follow diabetic ketoacidosis protocol  -Adequate potassium replacement and fluid choice as per the protocol  -Bridged with basal bolus  -Likely exacerbated by infection   4. HTN (hypertension)   I10  -Resume home meds   5. Raynaud disease   I73.00  -Resume home meds   6. Hyperlipidemia   E78.5  -Continue statin   7. Hx of gastric bypass   Z98.84  - Adequate vitamin supplementation   Hypoxia   R09.02  -Problem 1   Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent  70 minutes of critical care time directly and personally managing the patient. This critical care time included obtaining a history, examining the patient, pulse oximetry, ordering and reviewing the studies, arranging urgent treatment with development of a management plan, evaluation of the patient?s response to treatment, frequent reassessment, and discussions with other clinicians. The critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see the MDM section and the rest of this note for further information on patient assessment and treatment.  Code Status   None Recorded   Chronic Problem List    ADD (attention deficit disorder)  Anemia  Anxiety  Arthralgia  Arthritis  Asthma  Bilateral carpal tunnel syndrome  Blood in stool  Chronic headache  Chronic pain syndrome  Chronic pain syndrome  Depression  Diarrhea  Diplopia  DM (diabetes mellitus)  Encounter for long-term (current) use of medications  Fibromyalgia  GERD (gastroesophageal reflux disease)  Heartburn  History of concussion  History of intussusception  History of opioid abuse  Hyperlipidemia  Hypertension  IBS (irritable bowel syndrome)  Long term use of drug  Lumbar radiculopathy  Malnutrition  Migraine  MRSA cellulitis  MVA (motor vehicle accident)  Obesity  Otitis media  Peripheral edema  Peripheral neuropathy  Raynaud disease  Restrictive lung disease  Rheumatoid arthritis  Right elbow pain  S/P bariatric surgery  Swelling of right elbow  Tobacco use  Procedure/Surgical History  ?Manual reduction of bowel intussusception (06/01/2013) ?Colposcopy (12/13/2011) ?egd (01/25/2011) ?History of bariatric surgery. (12/01/2006) ?TL - Tubal ligation (1998) ?BSO - Bilateral salpingo-oophorectomy ?Cholecystectomy ?L CTR DOS 12/6/17 AJM ?Myringotomy ?Rt CTR DOS 11/15/17 AJM     Medications   Home Medications (27) Active  Accu-Chek Aviva Blood Glucose Meter , as directed  Accu-Chek Aviva Blood Glucose Meter (ONCE) Not Applicable, Other, Unscheduled, Check Blood Glucose levels TID  Accu-Chek Aviva Plus Test Strips Not Applicable, Other, Unscheduled, check blood sugar TID  Accu-Chek Fastclix Lancets Not Applicable, Other, Unscheduled, to check blood sugar TID  Adderall XR 30 mg capsule 30 mg = 1 Capsule, Orally, Daily, F90.0name brand only per insurance preference  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H  Aldactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  amLODIPine 2.5 mg oral tablet 2.5 mg = 1 Tablet, Orally, Daily  cycloBENZaprine 10 mg oral tablet 10 mg = 1 Tablet, PRN, Orally, TID  diclofenac 1% topical gel 4 GM, Topical, 4 Times Daily, Use dosing card to measure dose of gel  dicyclomine 10 mg oral capsule 10 mg = 1 Capsule, Orally, 4 Times Daily  doxycycline monohydrate 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  DULOXetine 60 mg oral delayed release capsule See Instructions, TAKE ONE CAPSULE TWICE A DAY  hydroCHLOROthiazide 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Imitrex 50 mg oral tablet 50 mg = 1 Tablet, PRN, Orally, Daily, may repeat dose after 2 hours up to a maximum of 200 mg in 24 hours  Inderal LA 60 mg oral capsule, extended release 60 mg = 1 Capsule, Orally, Daily  meloxicam 15 mg oral tablet 15 mg = 1 Tablet, Orally, Daily  methotrexate 2.5 mg oral tablet 12.5 mg = 5 Tablet, Orally, Weekly  Neurontin 300 mg oral capsule 300 mg = 1 Capsule, Orally, TID  Phenergan 25 mg oral tablet 25 mg = 1 Tablet, Orally, Q6H  predniSONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H  Remeron 15 mg oral tablet 15 mg = 1 Tablet, Orally, At Bedtime  Suboxone 8 mg-2 mg sublingual film 1 Each, Sublingually, BID  sucralfate 1 g oral tablet 1 GM = 1 Tablet, Orally, 4 Times Daily  torsemide 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  Wellbutrin SR 150 mg/12 hours oral tablet, sustained release 150 mg = 1 Tablet, Orally, BID  Active Scheduled Inpatient Medications  Sodium Chloride 0.9% PREMIX + Potassium Chloride PREMIX IV 150 mL/hr     Insulin regular PREMIX + Sodium Chloride 0.9% PREMIX IV 5.75 mL/hr [0.1 Units/kg/hr] 0.1 Units/kg/hr      One-Time Medications Given 02/01/23 00:00:00 TO 02/02/23 15:09:15  MOXifloxacin, Infusion, 400 mg, IVPB, ONCE, (1 DOSE 02/02/23 13:45:00)  PRN Medications (0600 - 0559) from 02/01 - 02/02  glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   Allergies   LamISIL (sore in mouth)  Lasix (Rash)  Keflex (Unknown)  Omnicef (Unknown)  Rocephin (Unknown)  iodinated radiocontrast dyes (Unknown)  iodine (Unknown)  sulfa drugs (Unknown)  Social History    Alcohol   Current, Wine, 1-2 times per month   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Exercise   Exercise frequency: 3-4 times/week.   Home/Environment   Married, 1 Child   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   Alcohol abuse: Father.  Arthritis..: Mother.  Depression: Father.  Diabetes...: Grandmother (P).  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.5 k/cumm (02/02/23 11:23:00)  RBC: 3.39 million/cumm Low (02/02/23 11:23:00)  Hgb: 10.8 GM/dL Low (02/02/23 11:23:00)  Hct: 32.5 % Low (02/02/23 11:23:00)  MCV: 96 fL (02/02/23 11:23:00)  MCH: 31.9 pg (02/02/23 11:23:00)  MCHC: 33.3 GM/dL (02/02/23 11:23:00)  RDW: 15.4 % High (02/02/23 11:23:00)  Platelet: 397 k/cumm (02/02/23 11:23:00)  MPV: 7.9 fL (02/02/23 11:23:00)  # WBC Counted in Diff: 100 (02/02/23 11:23:00)  Neutrophil: 84 % (02/02/23 11:23:00)  Lymphocyte: 16 % (02/02/23 11:23:00)  Absolute Neutrophil: 6.3 k/cumm (02/02/23 11:23:00)  Abs Lymphocyte: 1.2 k/cumm (02/02/23 11:23:00)  RBC Morphology: Normal, (02/02/23 11:23:00)  Platelet Estimate: Clump Adequate, (02/02/23 11:23:00)  Platelet Morphology: Normal, (02/02/23 11:23:00)  Chemistry:  Sodium SerPl QN: 123 mmol/L Low (02/02/23 11:23:00)  Potassium SerPl QN: 4.6 mmol/L (02/02/23 11:23:00)  Chloride SerPl QN: 85 mmol/L Low (02/02/23 11:23:00)  Carbon Dioxide SerPl QN: 22 mmol/L (02/02/23 11:23:00)  Anion Gap: 16 mmol/L High (02/02/23 11:23:00)  BUN SerPl QN: 44 mg/dL High (02/02/23 11:23:00)  Creatinine SerPl QN: 1.12 mg/dL (02/02/23 11:23:00)  Estimated GFR (CKD-EPI, no race): 60 mL/min/1.73m2 (02/02/23 11:23:00)  Estimated CRCL (CG): 54 mL/min Low (02/02/23 11:23:00)  Glucose SerPl QN: 713 mg/dL Critical (02/02/23 11:23:00)  Calcium Total SerPl QN: 10.4 mg/dL (02/02/23 11:23:00)  Phosphorus SerPl QN: 2.3 mg/dL Low (02/02/23 12:19:00)  Alkaline Phos SerPl QN: 110 Units/L (02/02/23 11:23:00)  ALT SerPl QN: 8 Units/L (02/02/23 11:23:00)  AST SerPl QN: 7 Units/L Low (02/02/23 11:23:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (02/02/23 11:23:00)  Total Protein SerPl QN: 7.6 GM/dL (02/02/23 11:23:00)  Albumin SerPl QN: 3.9 GM/dL (02/02/23 11:23:00)  Magnesium SerPl QN: 2.6 mg/dL (02/02/23 12:19:00)  Troponin-I High Sensitivity: <3 (02/02/23 11:23:00)  BNP Pl QN: 101 pg/mL High (02/02/23 11:23:00)  Lactate Venous Pl QN: 1.6 mmol/L (02/02/23 11:23:00)  Gluc-Strip, POC: 450 mg/dL High (02/02/23 15:05:00)  pH Bld Venous QN: 7.38 (02/02/23 11:23:00)  PCO2 Bld Venous QN: 36 mmHg Low (02/02/23 11:23:00)  PO2 Bld Venous QN: 35 mmHg (02/02/23 11:23:00)  Base Excess Bld Venous: -3 mmol/L Low (02/02/23 11:23:00)  Bicarb Bld Venous Calc: 21 mmol/L Low (02/02/23 11:23:00)  O2 Sat Bld Venous Calc: 66 % (02/02/23 11:23:00)  Patient Temperature: 37 DegC (02/02/23 11:23:00)  Coagulation:  D-Dimer Pl QN: 271 ng/mL DDU (02/02/23 11:23:00)  Urine Studies:  Color: Yellow (02/02/23 12:42:00)  Clarity: Clear (02/02/23 12:42:00)  Specific Gravity: <=1.005 (02/02/23 12:42:00)  pH: 5.5 (02/02/23 12:42:00)  Protein: NEGATIVE (02/02/23 12:42:00)  Glucose: >=1000 Abnormal (02/02/23 12:42:00)  Ketones: 40 Abnormal (02/02/23 12:42:00)  Bilirubin: NEGATIVE (02/02/23 12:42:00)  Hgb Ur: NEGATIVE (02/02/23 12:42:00)  Nitrite: NEGATIVE (02/02/23 12:42:00)  Urobilinogen: NormalUro (02/02/23 12:42:00)  Leukocyte Esterase Ur: NEGATIVE (02/02/23 12:42:00)  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: PCR - Liat (02/02/23 12:09:00)  Rapid Influenza A PCR: Not Detected (02/02/23 12:09:00)  Rapid Influenza B PCR: Not Detected (02/02/23 12:09:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/02/2023 12:50 - XR Chest PA or AP Portable  IMPRESSION:1.  Bilateral lower lobe infiltrates may be multifocal pneumoniaand/or aspiration. Recommend follow-up radiograph in 6-8 weeks toensure resolution posttreatment.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at with any questions.                Signature Line Electronically Signed on 02/02/23 15:09 EST ________________________________________________________ MD