Notes

WriteSUBJECTIVE: Feels much better this morning. SOB much improved, He is in a good mod . Denies any chest tightness. No fever no chills.

PHYSICAL EXAM:
VITALS: as below
General Exam: Positive: Alert, Cooperative
Eye Exam: Positive: PERRLA
ENT Exam: Positive: Atraumatic
Neck Exam: Positive: Supple, No JVD
Chest Exam: Positive: diminished breath sounds, bilateral basal crackles a few decreased.
Heart Exam: Positive: Irregular Rhythm, rate low, s1 ,s2 normal, no rub, murmur or gallop.
Telemetry: Positive: Atrial fibrillation
Abdomen Exam: Positive: Normal bowel sounds
Extremity Exam: Positive: Clubbing;
Negative: Cyanosis
Skin Exam: Positive: Nl turgor and temperature
Neuro Exam: Positive: Strength at 5/5 X4 ext, Cranial Nerves 3-12 NL

LABS and Radiology : reviewed.

Assessment and Plan: Patient is 83 years old male with past medical history of hypertension, CHF, morbid obesity, obstructive sleep apnea, prostate cancer presented to the hospital with increased shortness of breath. Patient stated for past 3 days he has developed progressive shortness of breath with increased orthopnea and leg swelling to the extend that he has been using his CPAP round the clock without any relief .Also patient complained of substernal chest tightness and heaviness yesterday which lasted the whole they then slowly was relieved at night. On arrival to the ED he was in Florid CHF, severely hypoxic. He was also in afib and had an NSTEMI.

Acute respiratory failure with Hypoxia
Due to Acute CHF
continue BIPAP support with oxygen.

Acute on Chronic CHF
Continue BIPAP with oxygen bleed in.
continue lasix
Cardiology consulted.
Echo ordered.

AKI on CKD 3 with hyperkalemia
due to Acute CHF
creatinine still rising but k better.
continue lasix
nephrology following.

NSTEMI
Patient refused to go to Syracuse for cardiac intervention. Wanted only medical management
He opted to be DNR and DNI.
Continue ASA, PlaviX, stain high dose and heparin infusion.

CHRONIC ATRIAL FIBRILLATION
continues to be in a fib rate controlled
continue metoprolol with hold parameters.

PROSTATE CANCER
s/p radiation in 2003 follows with urology.

DIABETES
continue lispro.

HYPERTENSION
now Bp in low normal range, continue metoprolol with hold parameters.

MORBID OBESITY
complicating care

DEPRESSION/ANXIETY

SLEEP APNEA
presently on BIPAP

Code: DNR/DNI

VS, Fishbone, I+O
VS,Fishbone, I+O
VS, Fishbone, I+O
Laboratory Tests
2/17/20 15:53

[Image 0]

2/18/20 04:20

[Image 1]


Vital Signs
Date Time Temp Pulse Resp B/P (MAP) Pulse Ox O2 Delivery O2 Flow Rate FiO2
2/18/20 09:00 50
2/18/20 08:00 96.3 22 139/89 (106) 92 Nasal Cannula 2.0
2/18/20 04:45 45

I&O- Last 24 Hours up to 6 AM
2/18/20
06:00
Intake Total 1159 ml
Output Total 2150 ml
Balance -991 ml




RAY,ARUNA MD Feb 18, 2020 10:09
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