Received Mar 21, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) | SANOFI PASTEUR | N/A | U8532CA | SYR |
Document Type: History and Physical Document Subject: History & Physical Note Performed By: MD on March 20, 2025 16:26 EDT Verified By: MD on March 20, 2025 17:54 EDT Encounter Info: Hospital, Inpatient, 03/20/25 - * Final Report * History of Present Illness/Subjective 81 year old female with past medical history of asthma, HTN, HLD, CKD, presents to the ED for malaise, dyspnea/hypoxia that started few days prior to presentation. According to the patient, she was in her usual state of health until about few days when she noticed shortness of breath and tiredness. Shortness of breath is associated with cough productive of white sputum, congestion and sore throat. She also endorsed nausea but denies vomiting. No diarrhea or constipation. no fever or chills. She denied any sick contacts or recent travel. In the ER Vital signs Blood pressure 98/58, heart rate 90, respiratory rate 20, SpO2 94% on 4 L Labs WBC 9.4, hemoglobin 15.3, platelets 196, sodium 138, potassium 4.2, bicarb 102, BUN/creatinine 27/1.48, glucose 165, lactic venous 3.0 Urinalysis unremarkable COVID-negative Flu AB-positive Imaging Chest x-ray 1. Coarse lower lung markings may indicate bronchitis, reactive airways disease or early congestive changes. 2. No consolidating infiltrates or other acute findings. 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 Vitals & Measurements most recent past 24 hours Hemodynamics Neurologic Patient Weight Patient Height None Reported General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: diffuse rales to auscultation, Respirations are non-labored. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: bilat leg swelling, ???????L UE swelling Assessment/Plan 1. Shortness of breath R06.02 2. Hypoxia R09.02 3. Acute bronchitis J20.9 4. Influenza A J10.1 81-year-old man with a history of hyperlipidemia, prediabetes, stage III CKD presents to the ER due to generalized weakness with labs showing positive flu A and patient is requiring 4 L of oxygen through nasal cannula. Baseline is room air. Diffuse Rales noticed on auscultation Will start renal dose Tamiflu Continue oxygen supplementation and wean as able RT eval to follow Prednisone DuoNebs as needed Airborne isolation 5. AKI (acute kidney injury) N17.9 Likely prerenal from hypovolemia Will minimize use of potentially nephrotoxic agents to the extent possible, and will monitor urine output and labs. Low threshold to involve nephrology if renal function worsens. Gentle hydration Hold Lasix and lisinopril 6. Anxiety and depression F41.9 Chronic. 7. History of Roux-en-Y gastric bypass Z98.84 Noted 8. Hypertension I10 Blood pressure currently soft. Hold blood pressure medications 9. History of breast cancer Z85.3 Noted. Significant left arm swelling noted. Patient endorsed it is chronic as a result of left mastectomy Outpatient follow-up with oncologist 10. Prediabetes R73.03 Obtain A1c 11. Stage 3 chronic kidney disease N18.30 12.Severe sepsis Inpatient Sepsis Bundle Care: Sepsis Bundle was Started in the Emergency Department Sepsis with End Organ dysfunction _ Source _ Associated End Organ Dysfunction _ Associated Underlying Device _ Drug Resistance Unknown at this time Patient has chronic organ dysfunction as evidenced by _ Initial Lactate Done IF Initial Lactate >2, Repeat Lactate Auto ordered if applicable IF 2nd lactate greater than initial, continue to trend Lactate Levels, Auto Ordered if applicable Antibiotics Started in the Emergency Department, YES Blood Cultures Collected prior to Antibiotic start, YES Target Volume=30mg/kg Crystalloid Fluids 30mg/kg Crystalloid Fluids were given in the Emergency Department YES. IF NO, reason _ , Instead _ Septic Shock is present on admission NO Vasopressor(S) were initiated in the Emergency Department, N/A Sepsis Reassessment/Review of Systems completed at _ Greater than 5???????5 minutes total with greater than 50% of time face-to-face with patient reviewing course, plan of care, and in care coordination Code Status None Recorded Chronic Problem List Acid reflux Anxiety and depression Arthritis of right knee Asthma Edema Encounter for follow-up High cholesterol History of breast cancer History of Roux-en-Y gastric bypass History of total left knee replacement Hypertension Left shoulder pain Meningioma Morbid obesity Osteoarthritis of left shoulder Prediabetes Right shoulder pain Stage 3 chronic kidney disease Umbilical hernia Ventral incisional hernia Procedure/Surgical History ?Total knee replacement (10/23/2023) ?back surgery x2 ?Bilateral cataracts ?bilateral foot surgery ?Bunionectomy ?Cataract ?Cholecystectomy ?Gallbladder ?Gastric bypass ?H/O: hysterectomy ?Heel ?History of left mastectomy ?Knee ?Left reverse total shoulder arthroplasty 02/15/24 ?Mastectomy ?nose surgery ?Thyroid surgery Surgical History Internal 10/23/2023 Knee Arthroplasty (Left) , MD Medications Home Medications (13) Active allopurinol 300 mg oral tablet 300 mg = 1 Tablet, Orally, QAM amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, QAM DME (Vendor) Walker See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed. furosemide 40 mg oral tablet 40 mg = 1 Tablet, Orally, QAM lisinopril 10 mg oral tablet lovastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, QAM magnesium oxide See Instructions, Orally montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, QAM omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, QAM OXYcodone 5 mg oral tablet 5 mg = 1 Tablet, PRN, Orally, Q4H PARoxetine 20 mg oral tablet 20 mg = 1 Tablet, Daily Tylenol 1,000 mg, PRN, Orally, Q6H Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H Active Scheduled Inpatient Medications None Reported One-Time Medications Given 03/19/25 00:00:00 TO 03/20/25 16:25:47 None Reported PRN Medications (0600 - 0559) from 03/19 - 03/20 None Reported Allergies Cats (Difficulty Breathing) mixed grass pollens allergen extract (Unknown) Social History Alcohol Current, 1-2 times per year Electronic Cigarette/Vaping E-Cigarette Use Never. Home/Environment Lives with Siblings. Sexual Orientation and Gender Identity Which of the following do you identify most closely with? (check all that apply) Heterosexual (or straight). What is your current gender identity? (check all that apply) Female. Substance Abuse Denies Tobacco Tobacco Use: Former smoker, quit more than 30 days ago. Family History Cancer: Mother, Sister and Brother. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 9.4 k/cumm (03/20/25 13:39:00) RBC: 5.02 million/cumm (03/20/25 13:39:00) Hgb: 15.3 GM/dL High (03/20/25 13:39:00) Hct: 46.4 % (03/20/25 13:39:00) MCV: 93 fL (03/20/25 13:39:00) MCH: 30.6 pg (03/20/25 13:39:00) MCHC: 33.1 GM/dL (03/20/25 13:39:00) RDW: 16.6 % High (03/20/25 13:39:00) Platelet: 196 k/cumm (03/20/25 13:39:00) MPV: 8.8 fL (03/20/25 13:39:00) Neutrophils %: 80 % (03/20/25 13:39:00) Lymphocytes %: 13 % (03/20/25 13:39:00) Monocytes %: 6 % (03/20/25 13:39:00) Eosinophils %: 0 % (03/20/25 13:39:00) Basophils %: 0 % (03/20/25 13:39:00) Absolute Neutrophil: 7.5 k/cumm (03/20/25 13:39:00) Absolute Lymphocyte: 1.2 k/cumm (03/20/25 13:39:00) Absolute Monocyte: 0.6 k/cumm (03/20/25 13:39:00) Absolute Eosinophil: 0 k/cumm (03/20/25 13:39:00) Absolute Basophil: 0 k/cumm (03/20/25 13:39:00) Chemistry: Sodium SerPl QN: 138 mmol/L (03/20/25 13:39:00) Potassium SerPl QN: 4.2 mmol/L (03/20/25 13:39:00) Chloride SerPl QN: 102 mmol/L (03/20/25 13:39:00) Carbon Dioxide SerPl QN: 26 mmol/L (03/20/25 13:39:00) Anion Gap: 10 mmol/L (03/20/25 13:39:00) BUN SerPl QN: 27 mg/dL High (03/20/25 13:39:00) Creatinine SerPl QN: 1.48 mg/dL High (03/20/25 13:39:00) Estimated GFR (CKD-EPI, no race): 35 mL/min/1.73m2 Low (03/20/25 13:39:00) Estimated CRCL (CG): 34 mL/min Low (03/20/25 13:39:00) Glucose SerPl QN: 165 mg/dL High (03/20/25 13:39:00) Calcium Total SerPl QN: 9.1 mg/dL (03/20/25 13:39:00) Alkaline Phos SerPl QN: 85 Units/L (03/20/25 13:39:00) ALT SerPl QN: 10 Units/L (03/20/25 13:39:00) AST SerPl QN: 15 Units/L (03/20/25 13:39:00) Bilirubin Total SerPl QN: 0.7 mg/dL (03/20/25 13:39:00) Total Protein SerPl QN: 7.6 GM/dL (03/20/25 13:39:00) Albumin SerPl QN: 4.2 GM/dL (03/20/25 13:39:00) Troponin-I High Sensitivity: 6 ng/L (03/20/25 15:08:00) BNP Pl QN: 46 pg/mL (03/20/25 13:39:00) Lactate Venous Pl QN: 3 mmol/L High (03/20/25 13:39:00) Urine Studies: Color: Yellow (03/20/25 14:50:00) Clarity: Clear (03/20/25 14:50:00) Specific Gravity: 1.015 (03/20/25 14:50:00) pH: 5.5 (03/20/25 14:50:00) Protein: 30 Abnormal (03/20/25 14:50:00) Glucose: Normal (03/20/25 14:50:00) Ketones: NEGATIVE (03/20/25 14:50:00) Bilirubin: NEGATIVE (03/20/25 14:50:00) Hgb Ur: NEGATIVE (03/20/25 14:50:00) Nitrite: NEGATIVE (03/20/25 14:50:00) Urobilinogen: Normal (03/20/25 14:50:00) Leukocyte Esterase Ur: NEGATIVE (03/20/25 14:50:00) WBC: 0-5 (03/20/25 14:50:00) RBC: 0-2 (03/20/25 14:50:00) Bacteria: NONE (03/20/25 14:50:00) Squamous Epithelial: Few (03/20/25 14:50:00) Hyaline Casts: 0-2 (03/20/25 14:50:00) Misc UA Micro: Misc UA Micro (03/20/25 14:50:00) All Other Labs: COVID 19 Specimen Source: Nasopharyngeal (03/20/25 13:41:00) Coronavirus SARS-CoV2 Rapid: Not Detected (03/20/25 13:41:00) Micro - Last 7 days Rapid Influenza Method: PCR - Liat (03/20/25 13:41:00) Rapid Influenza A PCR: Detected Abnormal (03/20/25 13:41:00) Rapid Influenza B PCR: Not Detected (03/20/25 13:41:00) Diagnostics Radiology Results - Last 24 hours Across Visits 03/20/2025 14:02 - XR Chest PA or AP Portable IMPRESSION:1. Coarse lower lung markings may indicate bronchitis, reactiveairways disease or early congestive changes.2. No consolidating infiltrates or other acute findings. Signature Line Electronically Signed on 03/20/25 17:54 EDT ________________________________________________________ MD