PGY1 IM H&P
HPI:
54M w/ MMP incl. COPD, HFrEF, stg. IV SSC (?1°, w/ mets to LLL c/b CAP x 3, mets to L-S c/b LBP), p/w CP x 2hr i/s/o SOB & F/C x 3 d. Tmax 102. ROS neg 4 N/V/D, DVT/PE.
ED: AF BP 99/60 P 120 RR 16, CBC w/ WBC 20 w 90% PMN, Cr 1.4 (b/l 1.0), lact neg, rec’d 2L NS, BCx, 1 g IV vanc, 3.375 g IV pip-tazo.
Add’l PMH:
pAF, AC (CHADS-VASC 4)
DM2 (A1C 9)
HTN (b/l SBP ~160s)
COPD (FEV1/FVC 60%)
HFrEF (EF 15% s/p AICD)
CAD (s/p CABG 2012, LHC w/ PCI x 2, 2014 LAD DES, 2015 RCA DES)
PSH:
LLL Bx 4/2017 w/ VATS
Ex-lap 1990 i/s/o GSW
Lap-Choly 1992
SHx:
Ex-PSA (tob, EtOH, MJ)
FHx:
NC
PE:
T 101 P 99 RR 20 BP 99/56 SO2 91% RA
A&Ox3, NAD
nl S1, S2, RRR, 2/6 SEM
CTAB w/ decr. BS @ LLL
NTND, nl BS, neg H/S/M, no R/G
WWP
CBC 20>15.6<545 (90% PMN)
Lact 0.9
BMP 140/4.0/100/24/25/1.4<250 Mg 1.5
Trop 0.5
A1C 9
LFTs wnl
BCx x 2 pend
SpCx w/ <10 epis, >25 WBC, 2+ GNRs, 2+ GPCs
CTPE: GGO in LLL, neg PE
EKG w/ TWI V4-V6, Qs II/III/AvF
A/P:
56M w MMP, p/w CP i/s/o SOB & F/C x 3d. WBC 20 w ↑PMNs & CXR c/w CAP, w/ EKG ∆s & trop c/w type-2 NSTEMI vs. ACS.
#CAP, COPD
– DC vanc
– DC pip-tazo
– STAT ceftr/azithro
– 1L NS STAT
– CBC qd
– nebs q6h prn
– f/u BCx, SpCx
– I/O
#NSTEMI i/s/o infxn vs. ACS?
– rpt. trop, EKG q8h
– prn SLN
– f/u cards c/s recs
– NPO – LHC AM?
#AKI i/s/o hypoTN
– Cr qd
– DC ARB i/s/o AKI
– FENa
#DM2
– AISS
– FSG TID AC & qAM
#FEN/GI/PPX
– SQH
– 2 g MgSO4
– NPO
