Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Alanine aminotransferase normal, Anxiety, Arthralgia, Aspartate aminotransferase normal, Atrial fibrillation
Clinical narrative: ED to Hosp-Admission Discharged  6/18/2021 - 6/19/2021 (17 hours) Hospital  MD Last attending ? Treatment team Musculoskeletal chest pain Principal problem     Hospitalist Medicine   History and Physical         Date: 6/18/2021 Admission Date: 6/18/2021 PCP: MD DOB: 3/16/1940 Hospitalist: MD       Assessment/Plan     Medical Problems     Hospital Problems        POA   * (Principal) Atrial fibrillation with RVR (CMS/HCC) Yes       COVID toes Yes       Angina of effort (CMS/HCC) Yes       Atrial fibrillation (CMS/HCC) Yes            Medical Problems        Plan:  1. Will be admitted to icu because of angina like smptoms montor 2.repat tropon 3. Check bmp bnp and echo in am 3.check tsh mag 4.covid precautions5. Cardiology and ID consut in am if needed   VTE prophylaxis: already on eliquis avoid nsaids because he is on eliquis will try tylenol if needed morphine for severe pain Full Code     History of Present Illness      Pt. is an 81yr male.    Very pleasant male with history of choronic afi on eliquis history of hypertenson hyperchol  Had ultrasound of the carotid arteris which showed stenosis  Today he was mowing lawn developed left sided cheestpain pressure with no radiation to the neck arm s shoulder he was not diaphoretic. No fever chills or cough his covid is postive denies nausea vomiting or abdominal pain   Came to the ER initially he was tachycardic with heart rate of 136 ekg showed right bundle with A-fib  His initial troponin is negative less than 0.03   Has wbc cont of 11.8 hb 14.3 hct  Normal platelets 188 na 142 k4.0 cl 110 c02 223 bun 17 cr 1.07  ast 15 alt 16 blood sugar of 148    Continue with chestpressure little anxious sats stable   Considered his multiple risk factors and rapid a fib on arrival therefore he will be admitted in icu  And montor his oxygen sats in case if it get rapid may need iv blocker or amiodarone     Family history father died at the age of 63 from cAD /MI Mother died of old age at 93     Assessment     Review of Systems  Constitutional: Negative for activity change, appetite change, chills, diaphoresis, fatigue, fever and unexpected weight change.  HENT: Positive for trouble swallowing. Negative for congestion, ear discharge, mouth sores, sinus pressure, sinus pain, sore throat and voice change.   Eyes: Positive for visual disturbance. Negative for photophobia, pain and redness.  Respiratory: Positive for chest tightness and shortness of breath. Negative for apnea, cough, choking and wheezing.   Cardiovascular: Positive for chest pain and palpitations. Negative for leg swelling.  Gastrointestinal: Negative for blood in stool, diarrhea, nausea and vomiting.  Endocrine: Negative for cold intolerance, heat intolerance, polydipsia and polyphagia.  Genitourinary: Negative for difficulty urinating, flank pain and hematuria.  Musculoskeletal: Positive for arthralgias. Negative for back pain, gait problem, joint swelling, myalgias, neck pain and neck stiffness.  Skin: Negative for color change, pallor and rash.  Neurological: Positive for headaches. Negative for dizziness, tremors, seizures, syncope, facial asymmetry, speech difficulty, weakness and numbness.  Psychiatric/Behavioral: Negative for agitation and behavioral problems.        Past Medical, Social and Family History     Medical History No past medical history on file.    Surgical History No past surgical history on file.    Social History     Socioeconomic History ? Marital status: Married     Spouse name: Not on file ? Number of children: Not on file ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Not on file Tobacco Use ? Smoking status: Not on file Substance and Sexual Activity ? Alcohol use: Not on file ? Drug use: Not on file ? Sexual activity: Not on file Other Topics Concern ? Not on file Social History Narrative ? Not on file    Social Determinants of Health    Financial Resource Strain:  ? Difficulty of Paying Living Expenses:  Food Insecurity:  ? Worried About Running Out of Food in the Last Year:  ? Ran Out of Food in the Last Year:  Transportation Needs:  ? Lack of Transportation (Medical):  ? Lack of Transportation (Non-Medical):  Physical Activity:  ? Days of Exercise per Week:  ? Minutes of Exercise per Session:  Stress:  ? Feeling of Stress :  Social Connections:  ? Frequency of Communication with Friends and Family:  ? Frequency of Social Gatherings with Friends and Family:  ? Attends Religious Services:  ? Active Member of Clubs or Organizations:  ? Attends Club or Organization Meetings:  ? Marital Status:  Intimate Partner Violence:  ? Fear of Current or Ex-Partner:  ? Emotionally Abused:  ? Physically Abused:  ? Sexually Abused:       No family history on file.   Allergies and Medications     No Known Allergies   Prior to Admission medications  Medication Sig Start Date End Date Taking? Authorizing Provider apixaban (ELIQUIS) 5 mg tablet Take 5 mg by mouth 2 (two) times a day     Yes Provider, Historical, MD atorvastatin (LIPITOR) 10 mg tablet Take 10 mg by mouth at bedtime 5/20/21   Yes Provider, Historical, MD clonazePAM (KlonoPIN) 0.5 mg tablet Take 0.5 mg by mouth at bedtime 6/14/21   Yes Provider, Historical, MD metoprolol succinate XL (TOPROL-XL) 25 mg 24 hr tablet Take 12.5 mg by mouth daily 6/2/21   Yes Provider, Historical, MD NIFEdipine XL (PROCARDIA XL) 30 mg 24 hr tablet Take 30 mg by mouth daily 6/12/21   Yes Provider, Historical, MD omeprazole (PriLOSEC) 40 mg capsule Take 40 mg by mouth daily 5/26/21   Yes Provider, Historical, MD tamsulosin (FLOMAX) 0.4 mg capsule Take 0.4 mg by mouth daily 4/26/21   Yes Provider, Historical, MD      Objective   Objective   Current Min/Max Temperature: 36.1 °C (97 °F) Temp  Min: 36.1 °C (97 °F)  Max: 36.1 °C (97 °F) Heart Rate: 99 Pulse  Min: 80  Max: 116 Resp: 18 Resp  Min: 18  Max: 18 BP: (!) 148/89 BP  Min: 121/103  Max: 148/89 SpO2: 96 % SpO2  Min: 94 %  Max: 98 %   No intake/output data recorded.   Weight:   Wt Readings from Last 1 Encounters: 06/18/21 75.8 kg (167 lb 1.7 oz)       Physical Exam     Physical Exam Vitals reviewed.  Constitutional:      Appearance: He is well-developed. He is not ill-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No hepatojugular reflux or JVD.     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Rhythm irregular.  Pulmonary:     Effort: Pulmonary effort is normal. No accessory muscle usage.     Breath sounds: Normal breath sounds. No stridor.  Abdominal:     General: Bowel sounds are normal. There is no abdominal bruit.     Palpations: Abdomen is soft. There is no splenomegaly.     Tenderness: There is no abdominal tenderness. There is no rebound.  Musculoskeletal:     Cervical back: Normal range of motion and neck supple.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not cyanotic or pale.     Findings: No rash.     Nails: There is no clubbing.  Neurological:     General: No focal deficit present.     Mental Status: He is alert.     Cranial Nerves: No cranial nerve deficit.     Motor: Weakness present.  Psychiatric:        Mood and Affect: Mood is anxious.        Signed, MD Hospitalist Medicine 6/18/2021 10:08 PM