Age: 74.0
Sex: M
Vaccine: COVID19
Symptoms: Urinary sediment present, Urine analysis, Urine ketone body absent, Urine leukocyte esterase, Urobilinogen urine decreased
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: NP on September 30, 2021 17:39   Verified By: NP on September 30, 2021 17:39    Encounter Info: Hospital, Emergency, 09/30/21 - 09/30/21    * Final Report *        Basic Information  Time Seen: NP / 09/30/2021 15:53     Chief Complaint  SOB  History of Present Illness     Patient presents via private vehicle due to SOB worsening today, weakness and fatigue. States he saw his PCP at the Clinic and was referred to the ER for low iron.   Patient denies chest pain, fever, worsening cough or wheeze. Denies blood thinners, no previous GI bleed, last colonoscopy 2-3 years ago. Patient is fully Covid vaccinated.  Associated medical hx includes:  hx IDA, last hg/hct 9/1 10.6/34.6 Add'l medical hx includes: IDDM II, CKD, HTN, GERD, COPD, prostate ca   Social hx:  former smoker, patient  Review of Systems     Constitutional:  fatigue, weakness Eye:  Negative.   Ear/Nose/Mouth/Throat:  Negative.   Respiratory:  SOB Cardiovascular:  Negative.   Gastrointestinal:  Negative.   Hematology/Lymphatics:  Negative.   Endocrine:  Negative.   Immunologic:  Negative.   Musculoskeletal:  Negative.   Integumentary:  Negative.   Neurologic:  Negative.   Psychiatric:  No anxiety, No depression.   All other systems are negative      Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.8 DegC  Heart Rate:       82 bpm  Resp Rate:       24 br/min  BP #1:       164 / 74 mmHg  SpO2 (%):       100 %     Height CM: 165.1 cm  Weight KG: 76.7 kg  Ideal Body Weight: 61.5 kg     General:  Alert and oriented, increased WOB Eye:  Pupils are equal, round and reactive to light, Normal conjunctiva.   HENT:  Normocephalic, atruamatic Neck:  Non-tender, No jugular venous distention,   Cardiovascular:  Regular rate, Normal rhythm, S1, S2.  no LE edema Respiratory:  Lungs are coarse, scattered rhonchi to auscultation, Respirations are tachy, labored Gastrointestinal:  Soft, Non-tender, Non-distended, Normal bowel sounds, Integumentary:  Warm, Dry, Intact.   Neurologic:  Alert, Oriented, Normal sensory, Normal motor function, No focal defects, Cranial Nerves II-XII are grossly intact.   Psychiatric:  Cooperative, Appropriate mood & affect.       Medical Decision Making     EKG   Time completed: 1621  Rhythm: NSR  Interp: NSR, normal intervals, no ST or T wave abnormalities  rate: 78  QT/QTC: 396/451     Trop, BNP, and D dimer are negative  Hg/hct are consistent with previous and occult stool is negative.  DC to home, F/u with PCP            Condition     stable  Assessment/Plan       1. SOB (shortness of breath)   R06.02    2. Anemia   D64.9    Orders:   **Coronavirus SARS Ag FIA  ABO and Rh  Auto Diff  Blood Gas Venous QN  BNP Pl QN  Cardiac Monitor  CBC w/Differential  Comp Metabolic Panel  Coronavirus SARS Ag  D-Dimer Pl QN  Discharge Patient  Electrocardiogram  Indirect Antiglobulin Test  Lactate Pl Venous QN  Occult Bld  Peripheral IV Insertion  Troponin-I High Sensitivity  UA Microscopic  Urinalysis w Culture Rflx  XR Chest PA or AP   Patient Education   Anemia and Kidney Disease  Follow Up        With  When  Contact Information       NP, FAM, FAM Within As Scheduled Clinic  Additional Instructions: Please follow up with all specialists as scheduled:nephrology 10/5/21GI 10/27/21Heme/onc for IDA 12/23/21        Chronic Problem List    Asthma  Chronic renal insufficiency  Diabetes mellitus  Elevated LFTs  H/O gastroesophageal reflux (GERD)    Medications  Home Medications (11) Active albuterol (Eqv-Proventil HFA) 90 mCg/inh inhalation aerosol 2 Puff, Inhalation, Q6H alogliptin 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, Daily cetirizine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily insulin glargine-lixisenatide 100 units-33 mCg/mL subcutaneous solution  ipratropium 500 mCg, Neb Inhal, 4 Times Daily losartan 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily NovoLOG (insulin aspart) FlexPen 100 units/mL subcutaneous solution , Subcutaneous, ONCE omeprazole 20 mg oral delayed release capsule  prednisoLONE acetate 0.12% ophthalmic suspension 1 Drop, BID sildenafil 100 mg oral tablet 100 mg = 1 Tablet, PRN, Orally, As Directed, Take  30 to 60 minutes before sexual activity. Symbicort   Medication Administration   Given  Sodium Chloride 0.9% - ED Bolus, 1000 mL, IVPB  Allergies   NKA  Social History    Alcohol   Denies   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.    Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  09/30/21 16:15  5.7   01/11/21  6.4          RBC  09/30/21 16:15   3.88  Low   01/11/21  4.69          Hgb  09/30/21 16:15   10.3  Low   01/11/21   12.7  Low          Hct  09/30/21 16:15   30.9  Low   01/11/21   39.3  Low          MCV  09/30/21 16:15   80  Low   01/11/21  84          MCH  09/30/21 16:15   26.5  Low   01/11/21  27.1          MCHC  09/30/21 16:15  33.2   01/11/21  32.3          RDW  09/30/21 16:15   15.1  High   01/11/21   15.2  High          Platelet  09/30/21 16:15  222   01/11/21  225          MPV  09/30/21 16:15  7.7   01/11/21  7.7          Neutrophils %  09/30/21 16:15  68   01/11/21  71          Lymphocytes %  09/30/21 16:15  21   01/11/21  16          Monocytes %  09/30/21 16:15  8   01/11/21  9          Eosinophils %  09/30/21 16:15  2   01/11/21  3          Basophils %  09/30/21 16:15  1   01/11/21  1          Absolute Neutrophil  09/30/21 16:15  3.9   01/11/21  4.5          Absolute Lymphocyte  09/30/21 16:15  1.2   01/11/21  1.0          Absolute Monocyte  09/30/21 16:15  0.4   01/11/21  0.6          Absolute Eosinophil  09/30/21 16:15  0.1   01/11/21  0.2          Absolute Basophil  09/30/21 16:15  0.1   01/11/21  0.1             Routine Coagulation Studies FS  LATEST RESULTS        D-Dimer Pl QN  09/30/21 16:15  <200              Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  09/30/21 16:15   134  Low   01/11/21  142          Potassium SerPl QN  09/30/21 16:15  4.7   01/11/21  4.8          Chloride SerPl QN  09/30/21 16:15  104   01/11/21  106          Carbon Dioxide SerPl QN  09/30/21 16:15   19  Low   01/11/21  27          Anion Gap  09/30/21 16:15  11   01/11/21  9          BUN SerPl QN  09/30/21 16:15   29  High   01/11/21   22  High          Creatinine SerPl QN  09/30/21 16:15   2.32  High   01/11/21   2.10  High          Estimated GFR (CKD-EPI)  09/30/21 16:15   26  Low   01/11/21   30  Low          Estimated CRCL (CG)  09/30/21 16:15   26  Low   01/11/21   29  Low          Glucose SerPl QN  09/30/21 16:15   135  High   01/11/21  98          Calcium Total SerPl QN  09/30/21 16:15  8.9   01/11/21  10.1          Alkaline Phos SerPl QN  09/30/21 16:15  91   04/12/21  78          ALT SerPl QN  09/30/21 16:15  51   04/12/21  44          AST SerPl QN  09/30/21 16:15   46  High   04/12/21   41  High          Bilirubin Total SerPl QN  09/30/21 16:15  1.0   04/12/21  0.9          Total Protein SerPl QN  09/30/21 16:15  6.9   04/12/21  6.6          Albumin SerPl QN  09/30/21 16:15  4.2   04/12/21  4.2          Troponin-I High Sensitivity  09/30/21 16:15  <3              BNP Pl QN  09/30/21 16:15  59              Lactate Venous Pl QN  09/30/21 16:15  1.7                 Blood Gases FS  LATEST RESULTS        pH Bld Venous QN  09/30/21 16:15  7.45        PCO2 Bld Venous QN  09/30/21 16:15   31  Low        PO2 Bld Venous QN  09/30/21 16:15   69  High        Base Excess Bld Venous  09/30/21 16:15  -2        Bicarb Bld Venous Calc  09/30/21 16:15  22        O2 Sat Bld Venous Calc  09/30/21 16:15  94        Patient Temperature  09/30/21 16:15  37.0             Urinalysis FS  LATEST RESULTS        Color  09/30/21 16:18  Yellow        Clarity  09/30/21 16:18  Clear        Specific Gravity  09/30/21 16:18  1.010        pH  09/30/21 16:18  6.0        Protein  09/30/21 16:18  Negative        Glucose  09/30/21 16:18  Negative        Ketones  09/30/21 16:18  Negative        Bilirubin  09/30/21 16:18  Negative        Hgb Ur  09/30/21 16:18  Trace Abnormal        Nitrite  09/30/21 16:18  Negative        Urobilinogen  09/30/21 16:18  Normal        Leukocyte Esterase Ur  09/30/21 16:18  Negative        WBC  09/30/21 16:18  None Seen        RBC  09/30/21 16:18  None Seen        Bacteria  09/30/21 16:18  None        Squamous Epithelial  09/30/21 16:18  None             Fecal Studies FS  LATEST RESULTS        Specimen Type Occult Blood  09/30/21 16:18  Stool        Occult Blood Stool  09/30/21 16:18  Negative             Serology Tests  LATEST RESULTS        Coronavirus SARS Ag FIA  09/30/21 16:15  Not Detected             Blood Bank Testing  LATEST RESULTS        ABO Rh  09/30/21 16:15  B Neg        IAT Interp  09/30/21 16:15  Neg      Diagnostic Results  XR Chest PA or AP    09/30/21 16:45:19  IMPRESSION:   No acute findings.   Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 09/30/21 17:39  ________________________________________________________ NP