Received Mar 25, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| DTAP | DTAP (DAPTACEL) | SANOFI PASTEUR | UNK | u8264aa | — |
Document Type: Internal Medicine IP Progress Note Document Subject: Progress Note Comprehensive Encounter Info: Observation, 03/20/25 - 03/24/25 * Final Report * Subjective Patient is an 87-year-old female past medical history of A-fib, CKD, GERD, hypothyroidism, hypertension, Raynaud's disease, rheumatoid arthritis, TIA, GERD who presented to the ER with complaints of nausea. Patient was seen and evaluated by her bedside today. She feels very tired. She is attributing her tiredness to metoprolol as she endorsed that metoprolol always makes her feel that way. At home, she is on bisoprolol due to intolerance to metoprolol. Heart rate is still very difficult to control with metoprolol and diltiazem. ???????Cardiology has been consulted to assist with heart rate control Hypertensive on vitals Review of Systems All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI??????? Objective Vitals and Measurements Vitals & Measurements most recent past 24 hours T: 37.2 °C (Oral) TMIN: 36.3 °C (Route Not Specified) TMAX: 37.2 °C (Oral) BP: 145/107 HR: 109 (Monitored) RR: 16 SpO2: 93% Oxygen Therapy: Room air Oxygen Flow Rate: 2 (L/min) WT: 59.1 kg Hemodynamics Neurologic Glasgow Coma Score: 15 Patient Weight Current Daily Weight: 59.1 kg 03/24/25 Previous Daily Weight: 58.1 kg 03/23/25 Difference from Previous: 1.000 kg Weight for Nutrition: 240 kg 03/22/25 BMI: 23.4 03/21/25 Normal Weight (BMI 18.5-24.9) Patient Height Current Height: 152.4 cm 03/24/25 Nutritional Orders: Ensure Enlive., 03/21/25 17:22:00 EDT, With Meals ---------------------- 2000 mg Sodium, 20 gm Saturated Fat Diet, Start on: 03/21/25 1:16:00 EDT, "No Fluid Restrictions" mL Nursing ---------------------- Intake/Output I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 03/23 - 03/24 Total Intake 480.00 mL Total Output 0.00 mL Balance 480.00 mL Physical Exam General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: No murmur. Respiratory: Lungs are clear to auscultation, Respirations are non-labored. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, ??????? Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling, ??????? Lines, Tubes, and Drains IV cannula Forearm Right 22 gauge PIV Assessment/Plan Acute-on-chronic kidney injury N17.9 1. Acute-on-chronic kidney injury N17.9 Improved today and almost back to baseline. Nephrology following. - will need to establish with nephro as o/p Continue to hold nephrotoxics 2. Chronic kidney disease-mineral and bone disorder N18.9 3. Hypokalemia E87.6 Resolved with replacement 4. Elevated troponin R79.89 Downtrended. 5. Prolonged QT interval R94.31 replace electrolytes, avoid qtc prolonging meds Repeat EKG 6. Anemia D64.9 no overt bleeding, stable on recheck 7. Atrial fibrillation I48.20 Still In RVR. dced Metoprolol due to previous intolerance replaced with carvedilol Bisoprolol is unavailable in IUH - continue home apixaban renally dose, Cardiology consulted 8. Hypertension I10 Continue antihypertensives 9. Recurrent falls R29.6 PT/OT consulted 10. Severe Aortic Stenosis I35.0 noted Outpt f/u Dyslipidemia E78.5 GERD (gastroesophageal reflux disease) K21.9 not on medication tx Hypothyroidism E03.9 Just recently started on levothyroxine for tsh uptrending 18, symptomatic hypothyroid T4 is normal Rheumatoid arthritis M06.9 continues home leflunomide and prednisone. Rheumatoid arthritis (disorder) M06.9 Skin pruritus L29.9 resolving Eucerin cream, appears this may be precipitated by dry skin resulting in excoriated areas ppx - on Eliquis. Fluids Lines: PIV Diet: Heart Healthy Code Status/Goals of Care Discussion: Full Code VTE ppx: On therapeutic anticoagulation Dispo: Inpatient Anticipated Length of stay on admission: Less than 2 midnights Discharge Disposition: _Expect the patient to be medically ready for discharge in tomorrow, pending patient vital signs (HR/BP/RR/T) are within stable discharge parameters Location: Plan for discharge to be determined after therapy evaluations Discharge Needs: None Case Management Engaged Anemia D64.9 Atrial fibrillation I48.20 Chronic kidney disease-mineral and bone disorder N18.9 Dyslipidemia E78.5 Elevated troponin R79.89 GERD (gastroesophageal reflux disease) K21.9 Hypertension I10 Hypokalemia E87.6 Hypothyroidism E03.9 Prolonged QT interval R94.31 Recurrent falls R29.6 Rheumatoid arthritis M06.9 Rheumatoid arthritis (disorder) M06.9 Severe Aortic Stenosis I35.0 Skin pruritus L29.9 Orders: carvedilol, 25 mg, Orally, Tablet, BID, 03/24/25 21:00:00 EDT Electrocardiogram Code Status Resuscitation Status - Ordered -- 03/21/25 1:16:00 EDT, DNR/DNI/Comprehensive Care Medications Active Scheduled Inpatient Medications apixaban, Tablet, 2.5 mg, Orally, BID, Start: 03/21/25 09:00:00 carvedilol, Tablet, 25 mg, Orally, BID, Start: 03/24/25 21:00:00 cetirizine, Tablet, 10 mg, Orally, Daily, Start: 03/21/25 12:03:00 diltiaZEM (diltiaZEM (Eqv-Cardizem CD) 120 mg/24 hours oral capsule, extended release), Cap, Extended Rel, 120 mg, Orally, Daily, Start: 03/23/25 22:00:00 folic acid, Tablet, 1 mg, Orally, Daily, Start: 03/21/25 12:04:00 leflunomide, Tablet, 10 mg, Orally, Daily, Start: 03/22/25 09:00:00 levothyroxine, Tablet, 25 mCg, Orally, Daily, Start: 03/22/25 06:00:00 predniSONE, Tablet, 2.5 mg, Orally, Daily, Start: 03/21/25 12:04:00 One-Time Medications Given 03/23/25 00:00:00 TO 03/24/25 12:13:42 metoPROLOL (metoPROLOL tartrate), Tablet, 25 mg, Orally, ONCE, (1 DOSE 03/23/25 11:44:00) metoPROLOL (metoPROLOL tartrate), Injection, 5 mg, IV Push, ONCE, (1 DOSE 03/23/25 14:18:00) metoPROLOL (metoPROLOL tartrate), Injection, 5 mg, IV Push, ONCE, (1 DOSE 03/23/25 17:09:00) PRN Medications (0600 - 0559) from 03/23 - 03/24 OXYcodone, 2.5 mg, Orally, Q4H, 0 Dose(s) acetaminophen, 1,000 mg, Orally, Q8H, 0 Dose(s) fentaNYL, 12.5 mCg, IV Push, Q4H, 0 Dose(s) hydrOXYzine, 25 mg, Orally, Q8, 0 Dose(s) magnesium sulfate, 2 GM, IVPB, Q12H, 0 Dose(s) magnesium sulfate, 4 GM, IVPB, Q12H, 0 Dose(s) morphine, 1 mg, IV Push, Q10min, 0 Dose(s) potassium chloride, 20 mEq, Orally, Unscheduled, 0 Dose(s) potassium chloride, 30 mEq, Orally, Unscheduled, 0 Dose(s) potassium chloride, 40 mEq, Orally, Unscheduled, 0 Dose(s) potassium phosphate-sodium phosphate, 250 mg, Orally, Unscheduled, 0 Dose(s) trimethobenzamide, 200 mg, IM, Q8H, 0 Dose(s) Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 9.1 k/cumm (03/24/25 02:15:00) RBC: 3.6 million/cumm Low (03/24/25 02:15:00) Hgb: 10.1 GM/dL Low (03/24/25 02:15:00) Hct: 30.4 % Low (03/24/25 02:15:00) MCV: 85 fL (03/24/25 02:15:00) MCH: 28 pg (03/24/25 02:15:00) MCHC: 33.1 GM/dL (03/24/25 02:15:00) RDW: 19.4 % High (03/24/25 02:15:00) Platelet: 477 k/cumm High (03/24/25 02:15:00) MPV: 7.9 fL (03/24/25 02:15:00) Chemistry: Sodium SerPl QN: 135 mmol/L (03/24/25 02:15:00) Potassium SerPl QN: 4.3 mmol/L (03/24/25 02:15:00) Chloride SerPl QN: 100 mmol/L (03/24/25 02:15:00) Carbon Dioxide SerPl QN: 25 mmol/L (03/24/25 02:15:00) Anion Gap: 10 mmol/L (03/24/25 02:15:00) BUN SerPl QN: 34 mg/dL High (03/24/25 02:15:00) Creatinine SerPl QN: 1.28 mg/dL High (03/24/25 02:15:00) Estimated GFR (CKD-EPI, no race): 41 mL/min/1.73m2 Low (03/24/25 02:15:00) Estimated CRCL (CG): 24 mL/min Low (03/24/25 02:15:00) Glucose SerPl QN: 94 mg/dL (03/24/25 02:15:00) Calcium Total SerPl QN: 8.7 mg/dL (03/24/25 02:15:00) Phosphorus SerPl QN: 3.5 mg/dL (03/24/25 02:15:00) Magnesium SerPl QN: 2.1 mg/dL (03/24/25 02:15:00) Urine Studies: Color: Light-Yellow (03/23/25 18:24:00) Clarity: Clear (03/23/25 18:24:00) Specific Gravity: 1.017 (03/23/25 18:24:00) pH: 6.5 (03/23/25 18:24:00) Protein: 100 Abnormal (03/23/25 18:24:00) Glucose: Normal (03/23/25 18:24:00) Ketones: NEGATIVE (03/23/25 18:24:00) Bilirubin: NEGATIVE (03/23/25 18:24:00) Hgb Ur: NEGATIVE (03/23/25 18:24:00) Nitrite: NEGATIVE (03/23/25 18:24:00) Urobilinogen: 2.0 2 Abnormal (03/23/25 18:24:00) Leukocyte Esterase Ur: NEGATIVE (03/23/25 18:24:00) WBC: 0-5 (03/23/25 18:24:00) RBC: None Seen (03/23/25 18:24:00) Bacteria: NONE (03/23/25 18:24:00) Squamous Epithelial: Few (03/23/25 18:24:00) Diagnostics Radiology Results - Last 24 hours Across Visits 03/24/2025 07:11 - XR Chest PA or AP Portable IMPRESSION:1. Large hiatal hernia.2. Increasing bilateral infiltrates with increasing atelectasis andconsolidation in the left lower lobe and a small-moderate leftpleural effusion.