Age: 78.0
Sex: F
Vaccine: FLU3
Symptoms: Chromaturia, Coma scale normal, Computerised tomogram head abnormal, Creatinine renal clearance decreased, Diplopia
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on November 11, 2024 17:37    Verified By: NP on November 11, 2024 17:37    Encounter Info: Hospital, Observation, 11/11/24 -     * Final Report *  Document Contains Addenda        Chief Complaint   unresponsive  History of Present Illness/Subjective     This is a 78 year old patient with a past medical history significant for  CAD s/p LHC in 2019, COPD on baseline 2LNC???????, OSA on CPAP, type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, chronic PE on Xarelto, sinus node dysfunction s/p PPM implantation 2013, paroxysmal supraventricular tachycardia, that presented to hospital on 11/11/2024 from home via EMS with c/o weakness and is being admitted to observation for UTI and stroke work up???????.    Patient reports that this morning she went to the bathroom and states that her daughter-in-law evidently was talking to her and she was briefly unresponsive.  Patient reports that she did not fall off the commode, and does not have any preceding/prodromal symptoms.  Denies any chest pain or palpitations.  Denies any headache.  Does report that last night while watching the game she had a few seconds of seeing brief double vision as the game was ending, wherein she saw 2 different players standing side-by-side and duplicate.  No current double vision, no facial droop, no slurred speech, no numbness or tingling or weakness in her face or arms or legs.  Reports that she feels a little bit weak but denies any chest pain or abdominal pain.  Denies any vomiting or diarrhea.  Denies any bloody stools or dark tarry stools.     Review of Systems     Constitutional:  No fevers,  no chills Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No sore throat Respiratory:  No shortness of breath,  no cough Cardiovascular:  No chest pain,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea Genitourinary:  No dysuria,  no hematuria Endocrine:  No polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash Neurologic:  No headache,  no focal weakness +double vision   Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.9 °C (Oral)  BP: 122/62  HR: 90 (Monitored)  HR: 88 (Peripheral)  RR: 20  SpO2: 98%  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 2 (L/min)  WT: 87.70 kg (WFC)    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    87.7 kg    11/11/24    Patient Height  Current Height:    170.2 cm    11/11/24         Constitutional:  No acute distress Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect???????    Assessment/Plan      1. Unresponsive episode R40.4  e/o unknown   symptoms have resolved.   CT head completed in ED   Unable to complete an MRI due to pacemaker, if neuro concerns develop can repeat a head CT and consider transfer to another location for MRI if pacemaker is compatible  Daily Aspirin and Atorvastatin  Lipid panel, Hgb A1c, Folate, Tsh, Vitamin B12, and sed rate pending  Carotid Doppler pending  Telemetry  PT/OT eval  SCDs for VTE prophylaxis  echo pending   2. Weakness R53.1   as above   pt/ot   3. UTI (urinary tract infection) N39.0  urine culture pending   iv ceftx      inpatient???????, medical floor  Daily labs - CBC, CMP Daily   Low Sodium Diet  IV fluids 100ml/hr  Telemetry  Full Code Status  VTE Prophylaxis - Fully anticoagulated with xarelto      Code Status  Full code   Chronic Problem List    Arthritis  Atrial fibrillation  Cardiovascular disease  Chronic kidney disease stage 3 (disorder)  Chronic respiratory failure  Degenerative arthritis of knee, bilateral  Diabetes  Emphysema/COPD  GERD (gastroesophageal reflux disease)  History of aortic dissection  HTN (hypertension)  Hx of diverticulitis of colon  Hyperlipidemia  Hypothyroidism  IBS (irritable bowel syndrome)  OSA on CPAP  Osteoarthritis of right shoulder  Pain in left hand  Right shoulder pain  Shoulder impingement syndrome  Procedure/Surgical History  ?Colonoscopy (02/01/2024) ?Colonoscopy (10/04/2023) ?Diabetic retinal eye exam (05/05/2023) ?Left heart catherization (02/25/2019) ?colonoscopy (05/16/2017) ?egd (07/01/2014) ?Appendectomy ?Cardiac pacemaker ?Cholecystectomy ?Hysterectomy ?rebuilt thumb joint right hand   Surgical History Internal  02/01/2024    Colonoscopy Diagnostic/Screen    MD  10/04/2023    Colonoscopy Diagnostic/Screen   MD  Medications   Home Medications (28) Active  albuterol (Eqv-ProAir HFA) 90 mCg/inh inhalation aerosol 1 Puff, PRN, Inhalation, Q4H, every 4-6h PRN  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, Neb Inhal, TID  Allegra 24 Hour Allergy oral tablet 180 mg = 1 Tablet, Orally, Daily  amitriptyline 10 mg oral tablet 20 mg = 2 Tablet, Orally, At Bedtime  atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily  Dexcom G7 Mobile CGM Receiver Not Applicable, Other, Unscheduled  Dexcom G7 Mobile CGM Sensor Not Applicable, Other, Unscheduled, Replace every 10 days  diclofenac 1.5% topical solution 40 Drop, Topical, 4 Times Daily  dicyclomine 20 mg oral tablet 20 mg = 1 Tablet, Orally, TID, Take 30 minutes before meals.  digoxin 125 mCg (0.125 mg) oral tablet 125 mCg = 1 Tablet, Orally, Every Other Day  DME (Vendor) CPAP and Supplies See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) Miscellaneous See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME Incontinence Briefs dme, Other, Unscheduled, Size large Adult Pull ups 2 daily Medical Supply fax  docusate-senna tablet 50 mg-8.6 mg 2 Tablet, Orally, BID, Take as needed for constipation.  Available over-the-counter.  famotidine 20 mg oral tablet 20 mg = 1 Tablet, Orally, BID  fluticasone 50 mCg/inh nasal spray 2 Spray, Nostrils, Both, Daily  Lantus (insulin glargine) SoloStar Pen 100 units/mL subcutaneous solution See Provider Instructions, Subcutaneous, Unscheduled, Use up to a total of 35 units daily, SEE INSTRUCTIONS FROM YOUR PROVIDER  levothyroxine 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Daily  metoPROLOL succinate 100 mg oral capsule, extended release 1 Tablet, Orally, Daily  Pen Needles - Insulin (4mm x 32G) Use daily, Other, Unscheduled, Dispense QS 90 days  potassium chloride 10 mEq oral capsule, extended release 1 Capsule, Orally, BID  PreserVision AREDS oral capsule 1 Tablet, Orally, BID  traMADOL 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  Trulicity Pen 0.75 mg/0.5 mL subcutaneous solution 0.75 mg = 0.5 mL, Subcutaneous, Every Week  Vitamin D3 (cholecalciferol) 50 mCg, Orally, Daily  Xarelto 20 mg, Orally, Every PM  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 11/10/24 00:00:00 TO 11/11/24 17:35:57  None Reported  PRN Medications (0600 - 0559) from 11/10 - 11/11  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Sexual Orientation and Gender Identity   Which of the following do you identify most closely with? (check all that apply) Heterosexual (or straight). What is your current gender identity? (check all that apply) Female.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Alzheimer's disease: Mother.  Arthritis: Mother.  COPD - Chronic obstructive pulmonary disease: Aunt/Uncle.  Crohn's disease: Child.  Dementia: Mother and Sister.  Depression: Child.  Diabetes mellitus: Mother.  Heart attack: Father.  Heart disease: Grandfather (P).  Hyperlipidemia: Sister and Sister.  Hypertension: Sister and Sister.  Suicide: Father and Child.   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 13.9 k/cumm High (11/11/24 09:24:00)  RBC: 3.92 million/cumm (11/11/24 09:24:00)  Hgb: 12.6 GM/dL (11/11/24 09:24:00)  Hct: 38.2 % (11/11/24 09:24:00)  MCV: 98 fL (11/11/24 09:24:00)  MCH: 32.2 pg (11/11/24 09:24:00)  MCHC: 33 GM/dL (11/11/24 09:24:00)  RDW: 12.9 % (11/11/24 09:24:00)  Platelet: 233 k/cumm (11/11/24 09:24:00)  MPV: 8.1 fL (11/11/24 09:24:00)  Neutrophils %: 71 % (11/11/24 09:24:00)  Lymphocytes %: 18 % (11/11/24 09:24:00)  Monocytes %: 9 % (11/11/24 09:24:00)  Eosinophils %: 2 % (11/11/24 09:24:00)  Basophils %: 0 % (11/11/24 09:24:00)  Absolute Neutrophil: 9.8 k/cumm High (11/11/24 09:24:00)  Absolute Lymphocyte: 2.5 k/cumm (11/11/24 09:24:00)  Absolute Monocyte: 1.3 k/cumm (11/11/24 09:24:00)  Absolute Eosinophil: 0.3 k/cumm (11/11/24 09:24:00)  Absolute Basophil: 0 k/cumm (11/11/24 09:24:00)  Chemistry:  Sodium SerPl QN: 137 mmol/L (11/11/24 09:24:00)  Potassium SerPl QN: 4.2 mmol/L (11/11/24 09:24:00)  Chloride SerPl QN: 102 mmol/L (11/11/24 09:24:00)  Carbon Dioxide SerPl QN: 22 mmol/L (11/11/24 09:24:00)  Anion Gap: 13 mmol/L High (11/11/24 09:24:00)  BUN SerPl QN: 18 mg/dL (11/11/24 09:24:00)  Creatinine SerPl QN: 0.89 mg/dL (11/11/24 09:24:00)  Estimated GFR (CKD-EPI, no race): 66 mL/min/1.73m2 (11/11/24 09:24:00)  Estimated CRCL (CG): 59 mL/min (11/11/24 09:24:00)  Glucose SerPl QN: 139 mg/dL High (11/11/24 09:24:00)  Calcium Total SerPl QN: 9.1 mg/dL (11/11/24 09:24:00)  Alkaline Phos SerPl QN: 55 Units/L (11/11/24 09:24:00)  ALT SerPl QN: 31 Units/L (11/11/24 09:24:00)  AST SerPl QN: 28 Units/L (11/11/24 09:24:00)  Bilirubin Direct SerPl QN: 0.1 mg/dL (11/11/24 09:24:00)  Bilirubin Total SerPl QN: 0.7 mg/dL (11/11/24 09:24:00)  Total Protein SerPl QN: 6.5 GM/dL (11/11/24 09:24:00)  Albumin SerPl QN: 3.8 GM/dL (11/11/24 09:24:00)  Magnesium SerPl QN: 1.5 mg/dL Low (11/11/24 12:32:00)  Troponin-I High Sensitivity: 4 ng/L (11/11/24 09:24:00)  Urine Studies:  Color: Yellow (11/11/24 11:05:00)  Clarity: Slightly Cloudy (11/11/24 11:05:00)  Specific Gravity: 1.022 (11/11/24 11:05:00)  pH: 6 (11/11/24 11:05:00)  Protein: NEGATIVE (11/11/24 11:05:00)  Glucose: Normal (11/11/24 11:05:00)  Ketones: NEGATIVE (11/11/24 11:05:00)  Bilirubin: NEGATIVE (11/11/24 11:05:00)  Hgb Ur: NEGATIVE (11/11/24 11:05:00)  Nitrite: NEGATIVE (11/11/24 11:05:00)  Urobilinogen: Normal (11/11/24 11:05:00)  Leukocyte Esterase Ur: Moderate250 Abnormal (11/11/24 11:05:00)  WBC: 21-50 Abnormal (11/11/24 11:05:00)  RBC: None Seen (11/11/24 11:05:00)  Bacteria: TRACE. (11/11/24 11:05:00)  Yeast Ur: PRESENT. Abnormal (11/11/24 11:05:00)  Squamous Epithelial: Moderate (11/11/24 11:05:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/11/2024 09:44 - CT Head W/o IV Contrast  IMPRESSION:1.  Diffuse cortical atrophy. 2.  No acute intracranial findings.                Signature Line Electronically Signed on 11/11/24 17:37  ________________________________________________________ NP     Addendum by MD on November 11, 2024 18:08:02  (Verified)     This note was dictated using Dictation. If any errors with dictation, please contact me for clarification.   I personally reviewed the patient and have reviewed the NP's Note. I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care with the following additions/ exceptions/ observations:   Briefly, this is a 78-year-old female with a history of CAD with a prior left heart catheterization, COPD on baseline 2 L nasal cannula, type 2 diabetes, hypertension, OSA on CPAP, hypothyroidism, history of PE on Xarelto, sinus node dysfunction, SVT, pacemaker, arthritis who presented to Hospital on 11/11/2024 with concerns for loss of consciousness at home.  Her daughter reports that the patient was found on the toilet and was not responding to her despite multiple attempts.  When the patient came to she was still weak and had to be put in her wheelchair.  She also reported double vision at that time.  Denies any headache.  Denies any dizziness or lightheadedness.  Denies any facial droop or slurred speech.  At this time her double vision has resolved.  She has no chest pain or shortness of breath.  No vomiting.  No GI complaints.  Does report some dysuria at times.  Denies any loss of bowel or bladder.  Cognition is at baseline at this time.  Does not smoke at this time.  Denies illicit substance or alcohol abuse. Daughter in law is present at the bedside.  At this time we will admit her to MedSurg observation for further evaluation of this unresponsive episode to potentially determine any underlying etiology.  Constitutional:  No acute distress Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple Respiratory:  Lungs CTAB, on 2LNC Cardiovascular:  Regular rate, pacemaker Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No acute deformities noted Integumentary:  Warm, dry Neurologic: Alert and oriented, no acute deficits on exam Psychiatric:  Cooperative, appropriate mood and affect   #Unresponsive episode: Seems unlikely that this was an acute neurological event especially given the negative head imaging.  Her mentation is at her baseline.  Neurological exam is unremarkable.  Holding off on MRI at this time but if she has any acute changes in mental status she will need a repeat head CT stat and may need to consider transfer for MRI at that point.  Seems that this may have all potentially been due to underlying orthostatic hypotension.  Daughter-in-law does report a history of positive orthostatics in the past.  Would recommend that these be obtained on 11/12/2024. Telemetry ordered. Will need PT/OT.  Agree with echocardiogram and carotid duplex.   #UTI: Urinalysis seems to be consistent with UTI.  Rocephin ordered.   #Chronic medical conditions: Chronic respiratory failure, COPD, hypertension, hyperlipidemia, hypothyroidism, OSA, cardiovascular disease, chronic kidney disease all appear to be stable and around her baseline at this time.  Will continue with routine management.   Her medication history reconciliation is pending at this time.  Please notify MD once this is completed so that her med rec can be done.   Signature Line Electronically Signed on 11/11/24 18:10  ________________________________________________________ MD