Hospitalist Progress Notes SCHMIDT, ADDIE - 1622826

Result Type: Hospitalist Progress Notes

Result Date: January 02, 2020 12:33 PM EST
Result Status: Final
Result Title: NCH Progress Note
Performed By: Soto, MD, Adolfo on January 02, 2020 12:56 PM EST
Verified By: Soto, MD, Adolfo on January 02, 2020 12:56 PM EST
Encounter info: 10001917278, NCOL, Inpatient, 1/1/2020 - 1/7/2020

NCH Progress Note

NCH HEALTHCARE SYSTEM, NAPLES FL

Patient: SCHMIDT, ADDIE MRN: 1622826 FIN: 10001917278

Age: 85 years Sex: Female DOB: 3/14/1934
Associated Diagnoses: None
Author: Soto, MD, Adolfo

Subjective
CC: Feels better

Patient seen and examined

14 point review of systems is negative except for above documentation

Health Status
Allergies:
Allergies (1) Active Reaction
morphine None Documented

Objective
Intake and Output
Intake and Output (ST)

01/02/20 01/01/20

INTAKE 0.00 505.00

OUTPUT 0.00 653.00

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Hospitalist Progress Notes SCHMIDT, ADDIE - 1622826

BALANCE 0.00 -148.00

VS/Measurements
Vital Signs
1/2/2020 7:44 AM EST Heart Rate Monitored 68 bpm
Oxygen Saturation 99 %
1/2/2020 7:44 AM EST Nursing Respiratory Rate 18 br/min
Oxygen Flow Rate 2 L/min
Oxygen Flow Rate 2 L/min
Oxygen Therapy Nasal cannula
Oxygen Therapy Nasal cannula
1/2/2020 7:43 AM EST Temperature Oral 36.4 DegC
1/2/2020 7:43 AM EST Systolic BP 143 mmHg HI
Diastolic BP 77 mmHg
Mean BP 99 mmHg
1/2/2020 6:53 AM EST Heart Rate Monitored 73 bpm

General: Alert and oriented.

Eye: Pupils are equal, round and reactive to light, Extraocular movements are intact.
HENT: muliple facial echymosis.
Neck: Supple, No jugular venous distention.
Respiratory: Respirations are non-labored, Symmetrical chest wall expansion.
Cardiovascular: irreg-irreg.
Gastrointestinal: Soft, Non-tender, Non-distended.
Musculoskeletal: Normal range of motion, No swelling.
Integumentary: Warm, Dry.
Neurologic: Alert, Oriented.
Psychiatric: Cooperative, Appropriate mood & affect.

Results Review
Inpatient Vitals/Meds/Labs
Vitals
Vital Signs (last 24 hrs)_____ Last Charted___________
Resp Rate 18 br/min (JAN 02 07:44)
SBP H 143mmHg (JAN 02 07:43)
DBP 77 mmHg (JAN 02 07:43)
SpO2 99 % (JAN 02 07:44)
BMI 35.57 (JAN 02 00:18)

Meds
Medications (22) Active
Scheduled: (13)
aspirin 81 mg Tab Enteric 81 mg 1 tab, PO, Daily
atorvastatin 40 mg Tab 40 mg 1 tab, PO, Daily
carvedilol 6.25 mg Tab 6.25 mg 1 tab, PO, BID
levothyroxine 0.112 mg Tab 112 mcg 1 tab, PO, Daily
lisinopril 20 mg Tab 20 mg 1 tab, PO, Daily

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Hospitalist Progress Notes SCHMIDT, ADDIE - 1622826

MEDICATION INSTRUCTION: PHARMACIST: ORDER TELE MONITORING ORDERS 1 EA, Rx Dosing, Once Med
MEDICATION INSTRUCTION: PHARMACIST: ORDER TELE MONITORING ORDERS 1 EA, Rx Dosing, Once Med
nystatin TOPical Powder 1 app, Topical, TID
pantoprazole 40 mg Tab Enteric 40 mg 1 tab, PO, Daily
PNEUMOVAX VACCINE 0.5 mL Inj 0.5 mL, IM, Daily+
rivaroxaban 10 mg Tab 10 mg 1 tab, PO, Daily w/Supper
SALINE (NS) FLUSH 1 syringe, IV Flush, Q8HR
Tegretol tab 200mg 1 EA, PO, Q8HR
Continuous: (0)
PRN: (9)
acetaminophen 325 mg Tab 650 mg 2 tab, PO, Q6HR
atropine 0.5 mg/5 mL Pre Fill Syringe 0.5 mg 5 mL, IV Pus h, Daily
magnesium hydroxide 8% UD Oral Sus 30 mL, PO, Daily
metoprolol 5 mg/5 mL Inj 5 mg 5 mL, IV Slow Push, Q4HR
morphine 2 mg Inj 2 mg 1 mL, IV Push, Daily
nitroGLYCERIN 0.4 mg Tab SL 0.4 mg 1 tab, SubLingual, Q5Min
ondansetron 4 mg Tab ODT 4 mg 1 tab, PO, Q8HR
ondansetron 4 mg/2 mL Inj 4 mg 2 mL, IV Slow Pus h, Q8HR
tramadol 50 mg Tab 50 mg 1 tab, PO, Q12HR

Labs
Labs (Last four charted values)
WBC 4.3 (JAN 02) 5.1 (JAN 01)
Hgb L 10.5 (JAN 02) L 11.9 (JAN 01)
Hct L 33.2 (JAN 02) 37.1 (JAN 01)
Plt 277 (JAN 02) 312 (JAN 01)
Na 141 (JAN 02) 138 (JAN 01)
K 4.1 (JAN 02) 4.5 (JAN 01)
Cl 106 (JAN 02) 106 (JAN 01)
Cr 1.1 (JAN 02) 1.0 (JAN 01)
BUN H 27 (JAN 02) H 26 (JAN 01)
Glucose 97 (JAN 02) H 110 (JAN 01)
Mg 2.1 (JAN 01)
Ca L 8.0 (JAN 02) 8.8 (JAN 01)
PT 14.0 (JAN 01)
INR 1.1 (JAN 01)
PTT 28.7 (JAN 01)
Troponin <0.05 (JAN 01) <0.05 (JAN 01) <0.05 (JAN 01)

Impression and Plan

Assessment and Plan: Diagnosis
.
85-year-old female past medical history significant for hypertension, dyslipidemia, hypothyroidism, CAD/stent ,A. fib
on Xarelto presents to the ER for evaluation of chest pain. Patient reports onset of chest pain prior to arrival
described as substernal chest tightness radiating to her right arm. Associated diaphoresis. At time of exam she is
chest pain-free. She denies any new leg pain or swelling. She has facial and upper torso bruising. States that she
fell a week ago after standing up and becoming lightheaded. She denies any loss of consciousness. She reports

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Hospitalist Progress Notes SCHMIDT, ADDIE - 1622826

history of CAD with a stent placed however is unsure of when the stent was placed. She does not have a local
cardiologist.

Hospital course:

1. Acute chest pain with multiple risk factors

Ruled out MI

Continue telemetry

Aspirin, used to take Plavix

1/2/20: Ordered stress test, to be done in a 2 day protocol per cards. No chest pain now

2. Paroxysmal A. fib/flutter

On and off afib, rate controlled with BB

On Xarelto

3. Syncope

Bruised her face, might not be a candidate for Xarelto

PT/OT ordered 1/2/20

Ordered orthostatic vital signs

Continue telemetry

3. Congestive heart failure unknown ejection fraction

Follow echo, pending results

4. Hypertension

OK vitals

5. Dyslipidemia

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Hospitalist Progress Notes SCHMIDT, ADDIE - 1622826

Statins

6. Hypothyroidism

Continue home meds

7. Elevated d-dimer

CTA chest:. Normal CTA chest examination, without a demonstrated pulmonary embolism or arterial dissection. COPD.
Cardiomegaly.

8. History of CAD/stent
ASA

9. Disposition
Home needs depending on PT/OT eval
Lives with son

Signature Line
Electronically Signed By: Soto, MD, Adolfo
Date / Time Signed: 01/02/20 12:56 PM

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