Age: 57.0
Sex: M
Vaccine: PNC20
Symptoms: Urine ketone body absent, Urine leukocyte esterase, Urine osmolarity, Urobilinogen urine, White blood cell count increased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on February 04, 2023 18:21  Verified By: NP on February 04, 2023 18:21    Encounter Info: Hospital, Emergency, 02/04/23 - 02/04/23    * Final Report *  Document Contains Addenda          History of Present Illness/Subjective     Patient is a 57-year-old male with past medical history of morbid obesity, diabetes, depression, GERD, hypertension, hyperlipidemia, who presented to the ER with chest pain and shortness of breath for the past 1 week.  Patient mentions that his shortness of breath and coughing worsens his chest pain.  He has a temperature of 100.1 degrees before coming to the ER.  Patient was recently put on Lasix by his primary care provider.  Patient did not go for follow-up lab work.   ???????Upon ER evaluation EKG showed mild ST elevation does not meet criteria for STEMI.  This was reviewed by Dr. cardiology recommended monitoring tropes.  After patient arrived to the ER he did not complain of any more chest pain.  No significant rise in troponins.  Temperature was 99.3, heart rate was 117, respiratory rate was 20 room air sat was 100% and blood pressure was 140/108.  Lab work was obtained showed white blood cell count of 10.3, hemoglobin is 13.3, sodium was down to 125, creatinine was elevated 2.87, GFR was down to 25 patient's baseline renal function is creatinine of 1.2.  Glucose was 298, lipase was 121, troponin initially was 5 repeat was 4, BNP was 33 no acute findings on UA, COVID-19 and flu testing were negative.  Due to elevated lipase CT abdomen pelvis were completed did not show any acute findings in the abdomen or pelvis.  We will bring patient in for further evaluation management of AKI, hyponatremia and dehydration.  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the System  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.4 (37.4-37.4)  Temp (FAHR) 99.3 (99.3-99.3), BP 114/91 (100-140)/(59-108), HR 112 (105-119), RR 16 (14-25), O2Sat 98 (95-98)     Patient Weight  Current Daily Weight:    173.5 kg    02/04/23    Patient Height  Current Height:    177.8 cm    02/04/23        Constitutional:  No acute distress,  well-nourished, obese Eyes:  PEERL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  + Dry 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. Hyponatremia   E87.1   Serum and urine osmolality and urine sodium pending. ? Likely due to dehydration we will continue with IV fluids normal saline at 100 mL an hour   2. AKI (acute kidney injury)   N17.9   Likely due to dehydration and recent diuretic use as an outpatient without lab work follow-up ? Continue IV fluid resuscitation and monitor labs daily   3. Dehydration   E86.0   As above   4. Chest pain   R07.9   Chest pain was discussed with Dr. patient had some ST elevation on EKG but not STEMI.  No significant rise in troponins ? Chest pain has resolved upon admission to the hospital   5. Morbid obesity   E66.01   Noted   6. Diabetes mellitus without complication   E11.9   Sliding scale and basal Lantus coverage ? Carb controlled diet   7. GERD (gastroesophageal reflux disease)   K21.9   Continue PPI   8. HTN (hypertension)   I10   Continue home meds   9. Hyperlipidemia   E78.5   Continue statin   10. Elevated liver transaminase level   R74.01   Will monitor and if no improvement can do ultrasound on Monday of the right upper quadrant   11. Severe obesity   E66.01    12. Obstructive sleep apnea on CPAP   G47.33   RT protocol, continue CPAP   13. Depression   F32.A   Resume home meds   14. SIRS without infection or organ dysfunction   R65.10  HR elevated, RR 25, likely dehydration   Cough   R05.9    Dyspnea   R06.00    Renal failure   N19    Code Status   None Recorded   Chronic Problem List    AKI (acute kidney injury)  Bilateral patellofemoral syndrome  Chronic right maxillary sinusitis  Chronic serous otitis media  Conductive hearing loss of left ear with restricted hearing of right ear  Cubital tunnel syndrome on left  Dehydration  Depression  Diabetes mellitus without complication  Diabetes with neurologic complications  Elevated liver transaminase level  Gastric nodule  GERD (gastroesophageal reflux disease)  Helicobacter pylori (H. pylori) infection  History of DVT in adulthood  History of sinus surgery  HTN (hypertension)  Hyperlipidemia  Hypertrophy of both inferior nasal turbinates  Hyponatremia  Impingement syndrome, shoulder, left  Left carpal tunnel syndrome  Mixed hyperlipidemia  Nasal septal deviation  Neuropathy  Obstructive sleep apnea on CPAP  Onychogryphosis  Onychomycosis  Primary osteoarthritis of knees, bilateral  Severe obesity  SIRS without infection or organ dysfunction  Tobacco use  Procedure/Surgical History  ?Appendectomy (08/08/2022) ?EGD - Esophagogastroduodenoscopy (12/11/2020) ?EGD - Esophagogastroduodenoscopy (09/10/2020) ?Colonoscopy (07/22/2019) ?Diabetic retinal eye exam (07/17/2019) ?Diabetic retinal eye exam (05/14/2018) ?Bilateral carpal tunnel release ?cyst removal ?Deviated septum ?ear tube ?knee ?Sinus Surgery ?Tonsillectomy ?Uvulectomy   Surgical History Internal  08/09/2022    Appendectomy Laparoscopic      10/19/2021    Carpal Tunnel Decompression   10/05/2021    Carpal Tunnel Decompression    01/11/2021    EGD ENDO Ultrasound      12/11/2020    EGD Bx      09/10/2020    EGD Diagnostic      07/22/2019    Colonscpy Diagnostic/Screen      12/06/2018    Hernia Repair Umbilical Laparoscopic    12/27/2017    Abscess I and D.      Medications   Home Medications (22) Active  Accu-Chek Guide Test Strips Check up to 3 times daily, Other, Unscheduled, Dispense 30 day supply  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  albuterol HFA MDI 90mCg/puff inhalation aerosol 180 mCg = 2 Puff, PRN, Inhalation, Q6H  Aldactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, QAM  BD Ultra-Fine Nano (4mm x 32G) Pen Needle Use 4 per day, Other, Unscheduled, Use 4 a dayDx: E11.22  cloNIDine 0.1 mg oral tablet 0.1 mg = 1 Tablet, Orally, BID  Coreg 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID, stop metoprolo  Cymbalta 60 mg oral delayed release capsule 60 mg = 1 Capsule, Orally, QAM, do not crush or chew  DME Rollator Walker w/ Hand Brakes Not Applicable, Other, Unscheduled, bariatric rollator walkerE66.1  Fiasp (insulin aspart) FlexTouch 100 units/mL injectable solution 38 Units, Subcutaneous, With Meals, per endocrine  Hyzaar 100 mg-25 mg oral tablet 1 Tablet, Orally, Daily  Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, BID  metFORMIN 500 mg oral tablet 1,000 mg = 2 Tablet, Orally, BID  Misc Supplies See Instructions, BIPAP machine with supplies99 moG47.33  Misc Supplies See Instructions, CPAP supplies including mask, tubing, etcG47.33  Neurontin 600 mg oral tablet 600 mg = 1 Tablet, Orally, TID  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  Ozempic 2 mg/1.5 mL (0.25 mg or 0.5 mg dose) subcutaneous solution See Instructions, 2 mg sc weekly  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  Spiriva 18 mCg inhalation capsule 18 mCg = 1 Capsule, Inhalation, Daily, Use two inhalations of one capsule each dose  Tresiba (insulin degludec) FlexTouch 100 units/mL subcutaneous solution 85 Units, Subcutaneous, Unscheduled  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/03/23 00:00:00 TO 02/04/23 18:21:10  albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 5 mg, Neb Inhal, ONCE, (1 DOSE 02/04/23 15:40:00)  aspirin, Tab, Chewable, 324 mg, Orally, ONCE, (1 DOSE 02/04/23 14:09:00)  hydroCODONE-acetaminophen (Norco 5 mg-325 mg oral tablet), Tablet, 2 Tablet, Orally, ONCE, (1 DOSE 02/04/23 17:49:00)  methylPREDNISolone (methylPREDNISolone sodium succinate), Injection, 60 mg, IV Push, ONCE, (1 DOSE 02/04/23 14:22:00)  promethazine (Phenergan), Tablet, 25 mg, Orally, ONCE, (1 DOSE 02/04/23 17:49:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 02/04/23 14:09:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 02/04/23 15:45:00)  PRN Medications (0600 - 0559) from 02/03 - 02/04  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   The patient is currently trying to obtain disability coverage., Work/School description: The patient drove a truck for many years and was exposed to dust and fumes.. Workplace hazards: Hazardous materials, Heavy lifting/twisting.   Exercise   Exercise duration: 30. Exercise frequency: 3-4 times/week. Self assessment: Fair condition. Exercise type: Walking, The patient tries to help around the house..   Home/Environment   Lives with Spouse. Home equipment: Respiratory treatments. Injuries/Abuse/Neglect in household: No. Feels unsafe at home: No. Safe place to go: Yes. Agency(s)/Others notified: No. Family/Friends available for support: Yes.   Nutrition/Health   Type of diet: The patient tries to limit his intake of refined carbohydrates and also tries to include fresh fruits and vegetables.. Diet: Diabetic. Wants to lose weight: Yes.   Other   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. 1.5 packs per day. 23 year(s). Started age 16.0 Years. Stopped age 39 Years.  Family History   Arthritis: Mother, Father and Sister.  Asthma: Mother and Sister.  Breast cancer: Negative: Father.  Cancer: Mother and Father.  Dementia: Negative: Father.  Diabetes mellitus: Mother.  Diabetes mellitus type 2: Mother.  Endocrine disease: Negative: Mother.  Heart disease: Mother.  Heart failure: Mother.  High cholesterol: Father.  Hypertension: Mother, Father and Sister.  Insomnia: Negative: Mother and Father.  Narcolepsy: Negative: Mother and Father.  Obesity: Sister.  Restless legs: Negative: Mother and Father.  Seizure disorder: Sister.  Sleep apnea: Negative: Mother and Father.  Sleep problem: Negative: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.3 k/cumm (02/04/23 14:10:00)  RBC: 4.42 million/cumm (02/04/23 14:10:00)  Hgb: 13.3 GM/dL Low (02/04/23 14:10:00)  Hct: 38.9 % Low (02/04/23 14:10:00)  MCV: 88 fL (02/04/23 14:10:00)  MCH: 30.1 pg (02/04/23 14:10:00)  MCHC: 34.1 GM/dL (02/04/23 14:10:00)  RDW: 13.5 % (02/04/23 14:10:00)  Platelet: 233 k/cumm (02/04/23 14:10:00)  MPV: 9.2 fL (02/04/23 14:10:00)  Neutrophils %: 46 % (02/04/23 14:10:00)  Lymphocytes %: 42 % (02/04/23 14:10:00)  Monocytes %: 11 % (02/04/23 14:10:00)  Eosinophils %: 0 % (02/04/23 14:10:00)  Basophils %: 1 % (02/04/23 14:10:00)  Absolute Neutrophil: 4.7 k/cumm (02/04/23 14:10:00)  Absolute Lymphocyte: 4.3 k/cumm High (02/04/23 14:10:00)  Absolute Monocyte: 1.1 k/cumm (02/04/23 14:10:00)  Absolute Eosinophil: 0 k/cumm (02/04/23 14:10:00)  Absolute Basophil: 0.1 k/cumm (02/04/23 14:10:00)  Chemistry:  Sodium SerPl QN: 125 mmol/L Low (02/04/23 14:10:00)  Potassium SerPl QN: 5.1 mmol/L (02/04/23 14:10:00)  Chloride SerPl QN: 95 mmol/L Low (02/04/23 14:10:00)  Carbon Dioxide SerPl QN: 20 mmol/L Low (02/04/23 14:10:00)  Anion Gap: 10 mmol/L (02/04/23 14:10:00)  BUN SerPl QN: 70 mg/dL High (02/04/23 14:10:00)  Creatinine SerPl QN: 2.87 mg/dL High (02/04/23 14:10:00)  Estimated GFR (CKD-EPI, no race): 25 mL/min/1.73m2 Low (02/04/23 14:10:00)  Estimated CRCL (CG): 45 mL/min Low (02/04/23 14:10:00)  Glucose SerPl QN: 298 mg/dL High (02/04/23 14:10:00)  Calcium Total SerPl QN: 8.5 mg/dL (02/04/23 14:10:00)  Alkaline Phos SerPl QN: 168 Units/L High (02/04/23 14:10:00)  ALT SerPl QN: 42 Units/L (02/04/23 14:10:00)  AST SerPl QN: 48 Units/L High (02/04/23 14:10:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (02/04/23 14:10:00)  Total Protein SerPl QN: 7.1 GM/dL (02/04/23 14:10:00)  Albumin SerPl QN: 3.5 GM/dL (02/04/23 14:10:00)  Lipase SerPl QN: 121 Units/L High (02/04/23 14:10:00)  Troponin-I High Sensitivity: 4 ng/L (02/04/23 15:30:00)  BNP Pl QN: 33 pg/mL (02/04/23 14:10:00)  Coagulation:  PT: 11 seconds (02/04/23 14:10:00)  INR: 0.97 (02/04/23 14:10:00)  aPTT: 35.4 seconds (02/04/23 14:10:00)  Urine Studies:  Color: Yellow (02/04/23 15:59:00)  Clarity: Clear (02/04/23 15:59:00)  Specific Gravity: 1.015 (02/04/23 15:59:00)  pH: 5.5 (02/04/23 15:59:00)  Protein: 30 Abnormal (02/04/23 15:59:00)  Glucose: 250 Abnormal (02/04/23 15:59:00)  Ketones: NEGATIVE (02/04/23 15:59:00)  Bilirubin: NEGATIVE (02/04/23 15:59:00)  Hgb Ur: TRACE. Abnormal (02/04/23 15:59:00)  Nitrite: NEGATIVE (02/04/23 15:59:00)  Urobilinogen: NormalUro (02/04/23 15:59:00)  Leukocyte Esterase Ur: NEGATIVE (02/04/23 15:59:00)  WBC: 0-5 (02/04/23 15:59:00)  RBC: 0-2 (02/04/23 15:59:00)  Bacteria: TRACE. (02/04/23 15:59:00)  Squamous Epithelial: Few (02/04/23 15:59:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/04/23 14:20:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/04/23 14:20:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/04/23 14:20:00)  Rapid Influenza A PCR: Not Detected (02/04/23 14:20:00)  Rapid Influenza B PCR: Not Detected (02/04/23 14:20:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/04/2023 14:43 - XR Chest PA or AP Portable  IMPRESSION:1.  No acute findings in the chest. Please contact us with any questions.    02/04/2023 15:13 - CT Abd/Pelvis W/O IV Contrast  IMPRESSION:1.  No acute findings in the abdomen or pelvis.2.  Hepatosplenomegaly and wedge-shaped a proteinaceous splenicregion probably a vascular compromised area. Please contact us  with any questions.                Signature Line Electronically Signed on 02/04/23 18:21       Addendum, MD on February 04, 2023 18:57:01 (Verified)    i agree with the above medical documentation and assessment   Signature Line Electronically Signed on 02/04/23 18:57