Age: 66.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Alanine aminotransferase increased, Angiogram, Anion gap, Anticoagulant therapy, Arrhythmia
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: on November 22, 2022 06:49   Verified By: on November 22, 2022 06:49   Encounter Info: Hospital, Observation, 11/21/22 -     * Final Report *        Chief Complaint   Palpitations  History of Present Illness/Subjective     This is a 66-year-old man with an extensive past medical history noted fully below, significant for liver transplant earlier this year secondary to HCC/hep C cirrhosis, and recent hospital admission at Hospital for introduction of Epclusa which is known to cause bradycardia, earlier this month the patient began having episodes of SVT and was seen by cardiology during this admission, they wanted him to continue to take flecainide twice daily however the patient states to me that he he doesn't see the reason for having to take a medication when he is not having arrhythmia and chooses to take it only when he is having the arrhythmia however today he did not do this and just came to the emergency room instead.   In the ED he was found to have COVID 19, however he is not requiring any supplemental O2.  He arrived in SVT with rates in the 170s converted to sinus rhythm with 1 dose of adenosine.  Since that he says he has not felt any palpitations and feels much better.  We will place him in observation overnight and possibly have cardiology evaluate in the a.m.  Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.0 (36.1-38)  Temp (FAHR) 98.6 (97.0-100.4), BP 138/85 (115-138)/(63-94), HR 58 (55-174), RR 18 (17-22), O2Sat 95 (95-95) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    72.7 kg    11/21/22  Previous Daily Weight:    72.7 kg    11/21/22  BMI:    26.7    11/21/22    Overweight (BMI 25-29.9) Patient Height  Current Height:    165.1 cm    11/21/22        Constitutional:  No acute distress,  well-nourished Eyes:  PERRL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB, no respiratory distress, no wheezes or rales Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended, large well-healed surgical incision consistent with liver transplant  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     Place in observation in MedSurg   1. SVT (supraventricular tachycardia)    Maintain telemetry, repeat troponin in a.m. initial trop is negative  Monitor and replete electrolytes as needed  Consider cardiology evaluation  Resume home meds as appropriate   2. COVID-19     Given patient is not requiring supplemental O2 will provide supportive care, no role for steroids or remdesivir at this time   3. Liver transplant status     4. Immunocompromised patient    Noted continue home medications and monitor LFTs   5. Chronic hepatitis C     Noted.  Continue home medications monitor for bradycardia secondary to Epclusa   6. Primary hypertension   Noted.  Continue home medications   7. DVT prophylaxis   Noted.  SCDs and Lovenox   Orders:   enoxaparin, 40 mg, Subcutaneous, Injection, Q24H, Routine, 11/21/22 21:00:00   2000 mg Sodium, 20 gm Saturated Fat Diet  Assign To  Auto Diff  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  CBC w/Differential  Comp Metabolic Panel  Fall Precautions  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Level of Care  Magnesium SerPl QN  Medical Service  OT Evaluation and Treatment  Phosphorus SerPl QN  PT Evaluation and Treatment  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Telemetry Class III 24hr Recommendation  Troponin-I High Sensitivity  Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 11/21/22 20:58:00 , Full Code   Chronic Problem List    Anemia  Anxiety  Chronic hepatitis C  Coronary artery disease  HCC (hepatocellular carcinoma)  Immunosuppression due to drug therapy  Impingement syndrome of right shoulder  Liver transplanted  Primary hypertension  Supraventricular tachycardia  Procedure/Surgical History  ?Complete resection of colon ?gall bladder ?liver cancer ?Liver Transplant ?Sebaceous cyst removal   Surgical History Internal  07/24/2022    Liver Transplant      02/25/2022    Angiogram      06/03/2021    Angiogram      05/06/2021    Angiogram      03/30/2021    Colonscpy Diagnostic/Screen      03/26/2021    EGD Diagnostic      03/20/2021    EGD Diagnostic      Medications   Home Medications (8) Active  Epclusa 400 mg-100 mg oral tablet 1 Tablet, Orally, Daily  flecainide 50 mg oral tablet 50 mg = 1 Tablet, Orally, Q12H  hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q6H  magnesium oxide 400 mg oral tablet 800 mg = 2 Tablet, Orally, BID  methocarbamol 750 mg oral tablet 1,500 mg = 2 Tablet, PRN, Orally, TID  multivitamin Therapeutic oral tablet 1 Tablet, Orally, Daily  mycophenolic acid 360 mg oral delayed release tablet 360 mg = 1 Tablet, Orally, BID  tacrolimus 1 mg oral capsule 2 mg = 2 Capsule, Orally, BID, Z 94.4  Active Scheduled Inpatient Medications  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 11/21/22 21:00:00    One-Time Medications Given 11/21/22 00:00:00 TO 11/22/22 06:48:50  adenosine, Injection, 6 mg, IV Push, ONCE, (1 DOSE 11/21/22 15:38:00)  metoPROLOL (metoPROLOL succinate), Tab, Extended Rel, 25 mg, Orally, ONCE, (1 DOSE 11/21/22 16:09:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 11/21/22 15:50:00)  PRN Medications (0600 - 0559) from 11/21 - 11/22  None Reported  Allergies   Bee Stings (SOB)  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   Dementia: Mother.  Diabetes mellitus: Father.  Heart attack: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 3.5 k/cumm Low (11/22/22 04:00:00)  RBC: 4.36 million/cumm (11/22/22 04:00:00)  Hgb: 12.6 GM/dL Low (11/22/22 04:00:00)  Hct: 38.1 % Low (11/22/22 04:00:00)  MCV: 87 fL (11/22/22 04:00:00)  MCH: 28.8 pg (11/22/22 04:00:00)  MCHC: 33 GM/dL (11/22/22 04:00:00)  RDW: 14.2 % (11/22/22 04:00:00)  Platelet: 88 k/cumm Low (11/22/22 04:00:00)  MPV: 10.6 fL (11/22/22 04:00:00)  Neutrophils %: 64 % (11/22/22 04:00:00)  Lymphocytes %: 15 % (11/22/22 04:00:00)  Monocytes %: 18 % (11/22/22 04:00:00)  Eosinophils %: 2 % (11/22/22 04:00:00)  Basophils %: 1 % (11/22/22 04:00:00)  Absolute Neutrophil: 2.2 k/cumm (11/22/22 04:00:00)  Absolute Lymphocyte: 0.5 k/cumm Low (11/22/22 04:00:00)  Absolute Monocyte: 0.6 k/cumm (11/22/22 04:00:00)  Absolute Eosinophil: 0.1 k/cumm (11/22/22 04:00:00)  Absolute Basophil: 0 k/cumm (11/22/22 04:00:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (11/22/22 04:00:00)  Potassium SerPl QN: 4.5 mmol/L (11/22/22 04:00:00)  Chloride SerPl QN: 103 mmol/L (11/22/22 04:00:00)  Carbon Dioxide SerPl QN: 25 mmol/L (11/22/22 04:00:00)  Anion Gap: 7 mmol/L (11/22/22 04:00:00)  BUN SerPl QN: 20 mg/dL (11/22/22 04:00:00)  Creatinine SerPl QN: 1.09 mg/dL (11/22/22 04:00:00)  Estimated GFR (CKD-EPI, no race): 75 mL/min/1.73m2 (11/22/22 04:00:00)  Estimated CRCL (CG): 62 mL/min (11/22/22 04:00:00)  Glucose SerPl QN: 76 mg/dL (11/22/22 04:00:00)  Calcium Total SerPl QN: 8.8 mg/dL (11/22/22 04:00:00)  Phosphorus SerPl QN: 5 mg/dL High (11/22/22 04:00:00)  Alkaline Phos SerPl QN: 105 Units/L (11/22/22 04:00:00)  ALT SerPl QN: 70 Units/L High (11/22/22 04:00:00)  AST SerPl QN: 71 Units/L High (11/22/22 04:00:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (11/22/22 04:00:00)  Total Protein SerPl QN: 5.8 GM/dL Low (11/22/22 04:00:00)  Albumin SerPl QN: 3.6 GM/dL (11/22/22 04:00:00)  Magnesium SerPl QN: 1.9 mg/dL (11/22/22 04:00:00)  Troponin-I High Sensitivity: 18 ng/L (11/21/22 16:00:00)  BNP Pl QN: 70 pg/mL (11/21/22 16:00:00)  Coagulation:  PT: 12.1 seconds (11/21/22 16:00:00)  INR: 1.06 (11/21/22 16:00:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/21/22 15:44:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (11/21/22 15:44:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (11/21/22 15:44:00)  Rapid Influenza A PCR: Not Detected (11/21/22 15:44:00)  Rapid Influenza B PCR: Not Detected (11/21/22 15:44:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/21/2022 16:23 - XR Chest PA or AP  IMPRESSION:1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact the Cardiothoracic Reading Room. For after-hours or emergency department cases, pleasecall.                Signature Line Electronically Signed on 11/22/22 06:49  ________________________________________________________