Age: 90.0
Sex: M
Vaccine: FLU4
Symptoms: Computerised tomogram spine normal, Computerised tomogram thorax abnormal, Condition aggravated, Creatinine renal clearance decreased, Electrocardiogram normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 03, 2023 22:09 EDT   Verified By: MD on November 03, 2023 22:09 EDT   Encounter Info: Hospital, Inpatient, 11/03/23 -     * Final Report *        Chief Complaint   Fall  History of Present Illness/Subjective     This is a 90-year-old male with past medical history aortic stenosis, hyperlipidemia, BPH, presenting  with complaint of chest pain.  Apparently, the patient had a mechanical fall at home last night and spent a good portion of the evening on the ground because he was unable to get up.  Creatinine kinase mildly elevated, less than 1000.     The patient is typically active, ambulatory with the use of an assist device, lives at home with no significant cognitive impairment.  Actually, was anticipating stress testing next week electively and asymptomatically for preparation for possible knee arthroplasty due to osteoarthritis.  Does not typically experience anginal pains and denies chest pain at this time.  No prior cardiac history.    CBC unremarkable, D-dimer elevated, renal function good, blood sugar mildly elevated, LFTs good.   Troponin 1090 and reasonably flat, BNP 589, creatinine kinase 963.   All imaging including CT of the head, CT cervical spine, CT PE protocol, all grossly unremarkable.  There is an age-indeterminate mild endplate vertebral compression deformity in the cervical spine.   EKG shows normal sinus rhythm, no ST elevation or depression, no arrhythmia or ectop  Review of Systems     Denies palpitations, syncope, near syncope, headache, visual changes, numbness, shortness of air, diaphoresis, nausea, vomiting.  Remaining 10 point review of systems negative except as noted above.  Physical Exam/Objective Vitals & Measurements most recent past 24 hours   Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported     Constitutional:  No acute distress,  well-nourished 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. NSTEMI (non-ST elevated myocardial infarction)   I21.4   Telemetry.  Serial cardiac enzymes.  Heparin, aspirin, statin, blood pressure is up so we will add transdermal nitroglycerin, as needed morphine.  Dr. aware and will see patient in the morning.  Transthoracic echocardiogram in the morning as well.  We will check a lipid panel and hemoglobin A1c for risk stratification as well.   2. Hyperlipidemia   E78.5   Statin   3. BPH (benign prostatic hyperplasia)   N40.0   Monitor for signs of retention   4. Rhabdomyolysis   M62.82   Mild and generally inconsequential   5. Accidental fall   W19.XXXA   PT/OT when appropriate   Full code   Heparin  Code Status   Full code   Chronic Problem List    Anemia  Aortic stenosis  Arthritis of knee  BPH (benign prostatic hyperplasia)  Encounter for long-term (current) use of medications  Familial tremor  Hyperglycemia  Hyperlipidemia  Impingement syndrome, shoulder, left  Left carpal tunnel syndrome  Low back pain  Memory changes  Seasonal allergies       Medications   Home Medications (11) Active  aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily  donepezil 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime  gabapentin 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID, 1 capusule in the morning and afternoon; continue with your 300 mg capsule at bedtime  gabapentin 300 mg oral capsule 300 mg = 1 Capsule, Orally, At Bedtime, TAKE 1 CAPSULE BY MOUTH ONCE DAILY AT BEDTIME  lisinopril 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Mysoline 50 mg oral tablet 100 mg = 2 Tablet, Orally, BID  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily  Vitamin B-12   Vitamin C , Orally, Daily  Zetia 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Zinc 140 mg, Orally, Daily  Active Scheduled Inpatient Medications  Heparin PREMIX + Sodium Chloride 0.45% IV Continuous Per Nomogram 830 Units/hr      One-Time Medications Given 11/02/23 00:00:00 TO 11/03/23 22:08:47  None Reported  PRN Medications (0600 - 0559) from 11/02 - 11/03  None Reported  Allergies   No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Colon cancer stage 1: Brother.  Melanoma: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.4 k/cumm (11/03/23 17:12:00)  RBC: 3.78 million/cumm Low (11/03/23 17:12:00)  Hgb: 12.2 GM/dL Low (11/03/23 17:12:00)  Hct: 36.3 % Low (11/03/23 17:12:00)  MCV: 96 fL (11/03/23 17:12:00)  MCH: 32.3 pg (11/03/23 17:12:00)  MCHC: 33.7 GM/dL (11/03/23 17:12:00)  RDW: 13 % (11/03/23 17:12:00)  Platelet: 251 k/cumm (11/03/23 17:12:00)  MPV: 6.8 fL Low (11/03/23 17:12:00)  Neutrophils %: 76 % (11/03/23 17:12:00)  Lymphocytes %: 9 % (11/03/23 17:12:00)  Monocytes %: 3 % (11/03/23 17:12:00)  Eosinophils %: 0 % (11/03/23 17:12:00)  Basophils %: 0 % (11/03/23 17:12:00)  Absolute Neutrophil: 5.7 k/cumm (11/03/23 17:12:00)  Absolute Lymphocyte: 0.7 k/cumm Low (11/03/23 17:12:00)  Absolute Monocyte: 1 k/cumm (11/03/23 17:12:00)  Absolute Eosinophil: 0 k/cumm (11/03/23 17:12:00)  Absolute Basophil: 0 k/cumm (11/03/23 17:12:00)  Chemistry:  Sodium SerPl QN: 134 mmol/L Low (11/03/23 17:12:00)  Potassium SerPl QN: 4.8 mmol/L (11/03/23 17:12:00)  Chloride SerPl QN: 99 mmol/L (11/03/23 17:12:00)  Carbon Dioxide SerPl QN: 27 mmol/L (11/03/23 17:12:00)  Anion Gap: 8 mmol/L (11/03/23 17:12:00)  BUN SerPl QN: 27 mg/dL High (11/03/23 17:12:00)  Creatinine SerPl QN: 1.06 mg/dL (11/03/23 17:12:00)  Estimated GFR (CKD-EPI, no race): 67 mL/min/1.73m2 (11/03/23 17:12:00)  Estimated CRCL (CG): 45 mL/min Low (11/03/23 17:12:00)  Glucose SerPl QN: 124 mg/dL High (11/03/23 17:12:00)  Calcium Total SerPl QN: 9 mg/dL (11/03/23 17:12:00)  Alkaline Phos SerPl QN: 111 Units/L (11/03/23 17:12:00)  ALT SerPl QN: 22 Units/L (11/03/23 17:12:00)  AST SerPl QN: 40 Units/L High (11/03/23 17:12:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (11/03/23 17:12:00)  Total Protein SerPl QN: 6.8 GM/dL (11/03/23 17:12:00)  Albumin SerPl QN: 4 GM/dL (11/03/23 17:12:00)  Magnesium SerPl QN: 1.7 mg/dL (11/03/23 17:12:00)  CK SerPl QN: 963 Units/L High (11/03/23 17:12:00)  Troponin-I High Sensitivity: 1116 ng/L High (11/03/23 18:01:00)  BNP Pl QN: 589 pg/mL High (11/03/23 17:12:00)  Coagulation:  aPTT: 30.8 seconds (11/03/23 17:57:00)  D-Dimer Pl QN: 2415 ng/mL DDU High (11/03/23 17:56:00)  Urine Studies:  Color: Light-Yellow (11/03/23 17:12:00)  Clarity: Clear (11/03/23 17:12:00)  Specific Gravity: 1.021 (11/03/23 17:12:00)  pH: 7 (11/03/23 17:12:00)  Protein: 50 Abnormal (11/03/23 17:12:00)  Glucose: Normal (11/03/23 17:12:00)  Ketones: NEGATIVE (11/03/23 17:12:00)  Bilirubin: NEGATIVE (11/03/23 17:12:00)  Hgb Ur: Small 1+ Abnormal (11/03/23 17:12:00)  Nitrite: NEGATIVE (11/03/23 17:12:00)  Urobilinogen: Normal (11/03/23 17:12:00)  Leukocyte Esterase Ur: NEGATIVE (11/03/23 17:12:00)  WBC: 0-5 (11/03/23 17:12:00)  RBC: 6-10 Abnormal (11/03/23 17:12:00)  Bacteria: NONE (11/03/23 17:12:00)  Squamous Epithelial: NONE (11/03/23 17:12:00)  Hyaline Casts: 0-2 (11/03/23 17:12:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/03/23 21:03:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (11/03/23 21:03:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/03/2023 17:24 - XR Chest PA or AP Portable  IMPRESSION:1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    11/03/2023 17:39 - CT Head W/o IV Contrast  IMPRESSION: 1.  No acute intracranial abnormality within technical limitations.-Thank you for consulting our team radiologists Radiology. Please contact us with any questions.    11/03/2023 17:40 - CT Cervical Spine W/o IV Contrast  IMPRESSION: 1.  No acute fracture or traumatic malalignment of the cervicalspine.2.  Mild age-indeterminate T1 superior endplate compression fracture.-Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    11/03/2023 19:24 - CTA Chest Pulm Embolism W/IV Contrast  IMPRESSION:1.  Negative for pulmonary embolism. No acute findings in the chest.2.  Atherosclerotic disease and dense aortic valvular calcifications. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 11/03/23 22:09 EDT ________________________________________________________ MD