patient

Background Information and History of Present Illness HPI

Chief Complaint: Dyspnea and cough for three days.

A 75-year-old female presents to emergency department on 07/10/2020 at 0252 with a shortness of breath for 3 days and non-productive cough. EMS reports SPO2 80% on home CPAP. She wears CPAP at night on 2L O2 during the day for COPD. She denies HA, CP, fever/chills, problems speech/swallowing, abdomen pain, changes/difficulties bowel bladder, extremities edema, or other symptoms. COVID-19 is negative. CXR reveals RUL PNA. Also, ABG was normal. She doesn’t have a history of smoking or alcohol use. The breath sound is diminished bilaterally.

The patient weighs at 77 kg, and at the height of 172.72 cm.

Comorbidities:

COPD	Depression	Diabetes	Dyslipidemia
Obesity	GERD	Diverticulitis	Anxiety
Peripheral Neuropathy	Hypokalemia	Hypertension	History of Skin Cancer
Coronary artery disease

Past medical history: Coronary arterial disease with stent placement in 2012, COPD, hypertension, type 2 diabetes, depression and anxiety, CHF.

Allergies:

· NKFA

· IV dye, Iodine containing

· Toradol

· Tylenol

Ideal body weight: 105 + 5 (H-60) / 2.2

Age	Gender	Actual Weight	Height	IBW
75	Female	77 kg	68-inch -172.72 cm	65.9 kg

Subjective and Objective Information

Background Hx: The patient is a 75-year-old female with previous medical history significant for chronic obstructive pulmonary disease with continuous positive airway pressure use QHS admitted 7/10/20 with RUL PNA after she presented to the emergency department for SOB x 3 days accompanied by a non-productive cough. She was transferred to the intensive care unit ICU after her respiratory status continued to decline requiring increasing BIPAP support and a 12-beat run of V-tach. Interval Hx: 7/12/20 – the patient intubated overnight. Levophed started. The patient remains sedated, paralyzed, intubated. Wean levophed and propofol. 7/14/20 - the patient remains on full vent support and Levophed off. Weaning nimbex and sedation. 7/15/20 - sinus bradycardia, remains on full / high vent support, FIO2 30%, +8; now off norepinephrine and Nimbex, though remains on liberal sedation with Precedex and fentanyt, vent day #4, will d/c therapeutic Lovenox and retun to prophylactic dosing. 7/16/20 - oxygen requirements have increased, now on FIO2 100%, +10 with SpO2 94%, remains off vasopressor support, continue to diurese as tolerated, now on propofol & fentanyt. 7/17/2020 - patient remains intubated and sedated on mechanical ventilation. She does not follow commands but remains propofol and fentanyl infusion for sedation while intubated on mechanical ventilation.

· Initial Ventilator Settings:

Mode	VT	Rate	Peep	FiO2	Flow Trigger	Insp Time
A/C, VC	450 ml	18 bpm	8 cmH2O	90%	2.0	1.0 sec

7/17/2020

Equipments:

Wall oxygen, wall room air, ET tube, ET tube tie, HME, end tidal CO2 monitor, corrugated tubing, Ballard suction catheter, suction canister, Yankauer suction catheter, wall suction, oral care kit, pulse oximetry, arterial blood gas kits, ambu bag, sedation medications.

Initial Vital Signs: BP 157/70, HR 106, RR26, Temperature 97.8 F, Sp02 90% on BiPAP/CPAP

Vital	Actual Value	Normal Range	Interpretation
Blood Pressure	157/70	120/80	High
Pulse Rate	106	80-100 beats per minute	High
Temperature	97.8 degrees Fahrenheit	98.6 degrees Fahrenheit	Normal
Respiratory Rate	26	12-20	High

Date: 7/10/2020. Interpretation of the initial vital signs: patient’s blood pressure is high due to history of hypertension which causes tachycardia and tachypnea. I’d recommend lisinopril to treat the hypertension.

Patient’s initial ABG: pH 7.38, PaC02 41 mmHg, PA02 88 mmHg, HCO3 24.3, BE -0.8 on BiPAP/CPAP

Lab Value	Actual Value	Normal Range	Interpretation
pH	7.38	7.35-7.45	Normal
PCO2	41	35-45 torr	Normal
PO2	88	80-100 torr	Normal
HCO3	24.3	22-26 mEq/L	Normal
BE	-0.8	-2 to 2	Normal

Date: 07/10/2020; Results of ABG: NORMAL.

Patient’s initial labs: 07/10/2020

Lab Value	Actual Value	Normal Range	Interpretation
WBC	9.3	3.5 – 10.5 k/uL	Normal
RBC	4.01 M/uL	150 – 450 k/uL	Normal
HGB	12.7 g/dL	12.4 – 15.2 g/dL	Normal
Platelet count	232 k/uL	150 – 450 k/uL	Normal

Interpretation of the patient’s initial labs: Normal

Screening: Influenza A antigen screen: negative for Influenzae A rapid antigen screen reference value: Negative. Influenza B antigen screen: negative for influenzae B rapid antigen screen reference value: Negative. The sensitivity of rapid antigen assays for influenza viruses is low. A negative result does not exclude influenza virus infection. If influenza is prevalent, the diagnosis and initiation of therapy should be based on clinical considerations. In addition, COVID-19 is negative.

Home Medicines: write the indications of each medication from a reliable source

Medication	Usage
Atorvastatin (Lipitor)
Lisinopril
metFORMIN
Mirtazapine
Morphine
Oxycodone
Pantoprazole (ProTONIX)
Potassium chloride
Pramipexole
Tiotropium bromide
Pregabalin (Lyrica

Radiology: 07/10/2020

Reason for exam: dyspnea. Technique: chest portable lines and tubes. None LUNGS: Normal. Normal lung volume. Nonspecific interstitial opacification and some faint groundglass opacifications in the right upper lung. Pleura: No pleural fluid or pneumothorax. Cardiac structures hilar regions, and mediastinum: Normal. Trachea and bronchial structures: Midline position of the trachea. No bronchiectasis. OSSEOUS structures: No acute abnormalities. Overlying soft tissues: Normal. Upper abdomen: Visualized portions of the upper abdomen appear normal. Impression: Nonspecific airspace opacification in the right upper lung and diffuse interstitial opacification which may represent edema. Superimposed infection could be considered in the appropriate setting.

Assessment and physician plan:

Assessment:

11

Sepsis.

Pneumonia (CAP) - RUL on CXR.

Leukocytosis- Mild WBC114.

Acute on chronic hypoxic respiratory failure.

COPD.

NSTEMI likely type 2 d/t above.

Hypomagnesemia.

CKD - Creat 1.31.

Coronary artery disease DM II w/neuropathy.

Hypertension.

Dyslipidemia.

Gastroesophageal reflux disease.

Anxiety/depression.

Plan:

Admit inpatient to PCU.

BCx obtained, continue IV ABX (Azithromycin & Rocephin), Await culture growth tailor regimen as needed.

Sputum and UA Cx.

Patient received full Sepsis IVF bolus in ED.

Continue Pulse ox, Supplemental 02, Bipap, Duonebs scheduled and as needed, IS.

Replace mag and recheck level.

Trend Trop & EKG.

Routine AM lab work w/mag level.

Monitor electrolytes and replace/treat as needed.

Trend kidney Fx.

Review home medications and continue as indicated, consider dose reduction/discontinuation nephrotoxic substances

Accu-checks w/SSI, hypoglycemia protocol

Offer supportive measures

Await above ordered lab/diagnostic testing and patients’ response to outlined treatment plan

My plan and recommendations:

Write some recommendations and make a plan for this patient.