Union Memorial Hospital 201 East University Parkway Baltimore, MD, 21218 Chief Complaint Pr c/o SOB since the weekend * Preliminary Report * History of Present Iliness Mrs. Smith isa 67 Y.O. female with a past medical history of diabetes (on metformin-glimepiride, last Alc 6.5% 8/2017), asthma, hyperlipidemia, HTN, hypothyroidism, dysrhythmias (hx of multiple SVTs and VTS, no history of Afib, no known codes in the past who presented to ED 5/2/18 complaining of progressively ‘worsening SOB for the past week. History was taken from patient, ED and urgent care notes. She was in a usual state Cf health until 7 days ago when she started experiencing upper respiratory symptoms of sneezing, dry cough although occasionally productive of yellow ‘sputum, and runny nose. She tried flonase without relief. Over the next 5 days her ‘symptoms progressively worsened to shortness of breath to the extent that ste ‘cannot speak in full sentences, productive cough, fatigue, sweats, myalgias and headaches. As a result on 5/1/2018 she went to urgent care, was seen by Dr. Dixon and placed on prednisone + albuterol with mild improvement. She states that she {does occasionally experience shortness of breath outside her current iliness and these are not associated with palpitations. After discharge the cough and SOB persisted and she went to ED on 5/2/18. In the ED, along with upper resp symptoms, she had new onset Afb with RVR. She was placed on Cardizem drip. She reported recent fever, no chills. Denied chest pain, edema, PND or Orthopnea. Denied vomiting or nausea. Denied abdominal pain, diarrhea, constipation. Denied pain on urination, changes in frequency or color. Reported body aches that began 4 days ago. In ED her vitals were T 37.9, HR 117, RR 22, BP 200/139, Sp02 92% Room air. Labs revealed slightly elevated glucose 142. CXR showed unremarkable findings, no infiltrates or consolidation. She received duonebs in the ED. She was admitted to IMCU for SOB and afib with RVR. Review of Systems 8 point ROS negative unless stated in HPT. Physical Exam i ements 1237.6 °C (Oral) TMIN: 37.6 °C (Oral) TMAX: 37.9 °C (Oral) HR: 124 (Monitored) RR: 28 BP: 186/87 SpO2: 95% WT: 108.3 kg (Oxygen Delivery Device: Other: neb bx (05/03/18 03:42:00 EDT) Pain Assessment Primary: Numeric Pain Score: 0 (05/02/18 23:43:51) Pain Present: Yes actual or suspected pain (05/02/18 23:20:51) General: Patient resting in bed, dlaphoretic, answering questions appropriately but tunable to speak in full sentences Lungs: Diffuse wheezing throughout all lung spaces with decreased breath sounds in the right lower lung. No crackles. Unable to speak in full sentences, no tripoding retractions, SMITH, MAXIZINE BROWN UMH-05036234614 Printed on: 05/03/2018 7:01 EDT Medical Student Note Type Registration Date: 05/03/2018 Problem List/Past Medical History ‘Ongoing. Allergic rhinitis ‘Asthma Diabetes melitus GLAUCOMA Hyperlipidemia Hypertension Hypothyroidism Obesity PAROXYSMAL ATRIAL TACHYCARDIA Preventative health care Urge incontinence VITAMIN D DEFICIENCY Historical No qualifying data re/ Surgical His ‘breast reduction (01/01/1977) Medications Inpatient albuterol 2.5 mg/3 mi. (0.083%) NEB, 2.5 mg= 3 mL, Neb, adh, PRN dlitiazem additive 125 mg (5 mg/h] + 0.9% NaCl premix 125 ml. heparin (PRN bolus for protocol), ‘Standard (0.3-0.7) Protocol, IV Push, AS Indicated, PRN heparin additive 25,000 units (18 ‘nits/ka/hr] + 0.45% NaCl premix 500 mL. methylPREDNISolone IV, 60 mg= 1.5 mL, IV Push, Daily ‘normal saline 1,000 mt, 1000 mt, 1V Synthroid, 125 meg= 1 tab, PO, Daily Home "ACCU-CHEK AVIVA DEVICE AMB ‘ACCU-CHEK AVIVA PLUS STRIPS - 'AMB, See Instructions, 11 refill dispense 100 test strips For blood glucose testing TID E11.9 ‘ACCU-CHEK SOFTCLIX LANCETS - ‘AMB, See Instructions, 11 refll, for blood glucose testing TID, dispense 100 lancets E11.9 ‘Advair Diskus 250 meg-50 meg inhalation powder, 1 puff, Inhalation, 2x/day, 5 refs EMPI: 1398977 Page t of 4Union Memorial Hospital Medical Student Note Type Heart or Cardiovascular: Tachycardic rate, egular rhythm, no murmurs, rubs, oF gallops, radial and DP pulses 2+ bilaterally Abdomen: Hypoactive bowel sounds, soft, nontender, nondistended, no masses organomegaly Musculoskeletal: No gross deformities, no lower extremity edema Neurologic: Alert and oriented x3 Assessment/Plan Mrs. Smith is a 67 Y.O. female with a past medical history of diabetes (on ‘metformin+ glimepiride, last Aic 6.5% 8/2017), asthma, hyperlipidemia, HTN, hypothyroidism, dysrhythmias (hx of multiple SVTs and VTS, no history of Afb, no known codes in the past who presented to ED 5/2/18 complaining of progressively worsening SOB for the past week. 1, Shortness of breath RO6.02, SOB (shortness of breath) RO6.02 ‘SOB began 7 days ago and progressively worsened. Pt was given one time Duoneb in ED. Currently on nebulizer albuterol ¢4, PRN, LUkely multifactorial; likely due to viral URI which may have precipitated the afib with RVR. Event study via Holter monitor in 8/8/2015 described 278 SVTS and suggested presence of episodes similar to Afib. Less likely PE considering no recent history of prolonged immobility. Less likely thyroid related considering recent TSH level normal 0.722 Plan: + continue albuterol -Solu-Medrol 60 mg dally with titration as tolerated = monitor pulse ox - Therapeutic heparin drip for Afb will also address PE if present 2. Rapid atrial fibrillation 148.91, New onset. Previous Holter Monitor analysis report on 7/26/18 stated presence of AFib 3% burden. CHA2DS2-VASc Score of 4, at high risk for stroke. Hemodynamically stable. Plan: + continue ditiazem drip Smg/hr for rate control, wean as tolerated - anticoagulation with heparin drip with bridging to PO anticoagulation as covered by insurance = telemetry monitoring = Regular vital signs to assess hemodynamic stability 3. HTN (hypertension) 110 With hypertensive urgency. Patient was considerably hypertensive on admission to a peak of 200/138. Shortness of breath unlikely secondary to hypertensive emergency as there is no evidence of pulmonary edema on chest x-ray, no altered mental status or chest. pain. Review of vitals from previous admissions shows consistently elevated systolic BP ranging 140-180. Home medications include Metoprolol 25mg daily, HTZD 12.5mg daily. Plan: Goal SBP 150 mmHg and first 24 hours Holding home antihypertensives as the patient is on diltiazem drip 4. Viral URI with cough 306.9 ‘SMITH, MAXIZINE BROWN DOB: 02/02/1951 UMH-05036234614 Printed on: 05/03/2018 7:01 EDT Registration Date: 05/03/2018 aspirin 81 mg oral tablet, 81 mg= 1 tab, PO, Daily, 6 refills dorzolamide 2% ophthalmic solution, 1 drop, Eye Lt, Daily Flonase 50 mcg/inh nasal spray, 50 ‘mog= 1 spray, Inhale-nasal, 2x/day, PRN, 3 refs glimepiride 4 mg oral tablet, 4 mg= 1 tab, PO, Daily, 1 refills hydrochlorothiazide 12.5 mg oral tablet, 12.5 mg= 1 tab, PO, Dally, refills hydrochlorothiazide-irbesartan 12.5 'mg-300 mg oral tablet, 1 tab, PO, Dally, 1 refs latanoprost 0.005% ophthalmic solution, 1 drop, Eye Lt, Daly metFORMIN 500 mg oral tablet, extended release, See Instructions, 1 refills metoprolol tartrate 25 mg oral tablet, 25 mg= 1 tab, PO, Daily, 1 refills ‘Synthroid 125 meg (0.125 mg) oral tablet, See Instructions, 5 reflls Ventolin HFA 90 mcg/inh inhalation ‘aerosol with adapter, 1 putt, Inhalation, 4x/day, PRN, 3 refls Allergies codeine Ery-Tab Norvasc Pollen | lisinoprit Social History ‘Smoking Status - 05/02/2018 Never smoker Alcohol - Denies Alcohol Use, (05/26/2015 Use: Denies., 04/13/2017 Status: Retired. Previous femployment/school: nanny., 4/11/2017 Exercise Frequency: Less Than Weekly., 04/13/2017 Sexval ‘Sexually active: No., 04/13/2017 ‘Substance Use - Denies Substance ‘Abuse, 05/26/2015 Use: Denies., 04/13/2017 ‘Tobacco{Nicotine - Denies Tobacco Use, 05/26/2015 Use: Denies., 04/13/2017 Family History EMPI: 1398977 Page 2 of 4Union Memorial Hospital Medical Student Note Type Pt has had productive cough, fever, myalgias. No requirement for antibiotics at this time, 5. Diabetes melitus E11.9 History of Diabetes. Globin Atc 6.5% on 8/2017 indicating good control. Home ‘medications include glimepiride miligrams daily and metformin 500 mg daily. Plan: High-dose sliding scale insulin with addition of standing Lantus and prandial insulin as required by sliding scale coverage 6. Asthma 345.909 Home medications Advair Diskus 250-50 mog and albuterol inhaler as needed. Duo nebs standing every 4 hours as noted in problem #1. FEN: NS @ 125 ce/hr DVT prophylaxis: heparin drip Code: DNR/DNI Communication: Patient clearly stated she wants no resuscitative or intubation ‘measures to be taken even if deemed temporary and life saving. Patient isin agreement with the treatment plan as stated above. All ofthe patient's questions and concerns were answered. ‘SMITH, MAXIZINE BROWN DOB: 02/02/1951 UMH-05036234614 Printed on: 05/03/2018 7:01 EDT MI- Mom @57, sister Brain cancer - brother Lung cancer - father CBC Het: :00 EDT) Platelet: 260 k/ul (05/03/18 00:07:00 EDT) BMP Sodium Lvl: 135 mmol/L Low (05/03/18 00:07:00 EDT) Potassium Lvl: 3.8 mmol/L (05/03/18 00:07:00 EDT) Chloride: 100 mmol/L. (05/03/18 00:07:00 EDT) C02: 27 mmol/L (05/03/18 00:07:00 £0T) BUN: 17 mg/dl. (05/03/18 00:07:00 EDT) Creatinine: 1.01 mg/dl (05/03/18 (00:07:00 EDT) Glucose Lvl Random: 142 mg/dl High (05/03/18 00:07:00 EDT) Electrolytes Magnesium Lvi: 1.7 mg/dL. (05/03/18 (00:07:00 EDT) Phosphorus Li (00:07:00 EDT) Calcium Lvl: 9.2 mg/dl. (05/03/18 (00:07:00 EDT) mg/dl. (05/03/18 No LFT results in past 72 hours Coag Panel Platelet: 260 Kut (05/03/18 00:07:00 EDT) PT: 13.2 sec (05/03/18 03:36:00 EDT) INR: 1 (05/03/18 03:36:00 EDT) PTT: 26.4 sec (05/03/18 03:36:00 EDT) RR (5/3) Offical read still pending EKG (5/3) Atrial fibrillation with rapid ventricular response ST and T wave abnormality, consider inferolateral ischemia ‘Abnormal ECG ‘When compared with ECG of 26-MAY- 2015 16:16, Arial fibrillation has replaced Sinus rhythm MPI: 1398977 Page 3 of 4