Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Chest X-ray normal, Coagulation test, Computerised tomogram abdomen abnormal, Computerised tomogram abdomen normal, Creatinine renal clearance decreased
Clinical narrative: Basic Information  Time Seen:  05/31/2022 09:12  Chief Complaint  Weakness or fatigue (Complaint of)  Supporting Nursing Comments:    pt reports worsening fatigue and weakness over the last month. pt was walking 1 mile a day 1month ago and now cannot walk. Denies SOA or pain anywhere. No change in appetite. "Feels achy"   History of Present Illness     Pt is an 84 y/o male who presents to the ED secondary to increased weakness and fatigue for the past month that has gradually worsened. Pt states that he used to be able to walk a mile a day but now struggles with 50 feet. Notes having some nausea, decreased appetite, and myalgias; denies dyspnea, CP, abd pain, NVD, and urinary sx. Wife states that pt has had very limited PO intake; mostly eats Jello sporadically over the past week. Denies any acute changes at time of onset such as falls, trauma, or illnesses. Pt notes thought that he had a single fall last week due to the weakness; bent over to pick something up when he fell on his shoulder. Did not hit head or have LOC. pt states that he was able on the ground for 15 minutes and wife was able to get him up; then proceeded to mow the lawn. Denies any changes in medications; compliant with meds.   Hx includes DM, HLD, HTN, Aortic regurgitation, ascending aorta dilation, and neuropathy.  Review of Systems  Constitutional:  no fever, no chills, no sweats, mild weakness, + fatigue Skin:  no jaundice, no rash, no lesions, no petechiae ENMT:  no ear pain, no sore throat, no congestion, no hoarseness Respiratory:  no shortness of breath, no cough, no orthopnea, no wheezing Cardiovascular: no chest pain, no palpitations, no edema Gastrointestinal:  mild nausea, no vomiting, no diarrhea, no GI bleeding, + decreased PO intake Genitourinary:  no dysuria, no hematuria, no discharge, no pain Musculoskeletal:  no back pain, no trauma, + myalgias Neurologic:  no headache, no dizziness, no numbness, no weakness Psychiatric:  no sleeping problems, no irritability, no mood swings/depression Heme/Lymph:  no bleeding tendency, no bruising tendency, no petechiae, no swollen nodes Allergy/Immunologic:  no seasonal allergies, no food allergies, no recurrent infections, no impaired immunity Additional ROS info:  Except as noted in the above Review of Systems and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.5 DegC  Heart Rate:       72 bpm  Resp Rate:       16 br/min  BP #1:       135 / 81 mmHg  SpO2 (%):       96 %     Height CM: 177 cm  Weight KG: 80.2 kg  Ideal Body Weight: 72.28 kg     General:  alert, no acute distress Skin:  warm, dry Head:  no trauma, normocephalic Neck:  trachea midline, no adenopathy, no tenderness Eye:  normal conjunctiva, clearsclera  ENMT: Dry oral mucosa Cardiovascular:  regularrate and rhythm, normalperipheral perfusion, soft systolic murmur best heard at apex Respiratory:  Lungs CTA, respirations non-labored Chest wall:  no deformity Gastrointestinal:  soft, non-distended, no tenderness _, no guarding _ Extremities:  no deformity, no trauma Neurological:  oriented x4  , LOC appropriate for age, CNII-XII intact, motor strength equal and normal bilaterally, sensation equal and normal bilaterally  , speech normal Psychiatric:  Cooperative ,  appropriate for ageaffect  , normal  judgement,  normal psychiatric thoughts  Medical Decision Making     ED Nurse's Notes, Previous Records, and Vital Signs Reviewed   DDx includes but is not limited to: dehydration vs electrolyte abnormality vs COVID vs UTI   Ordered: Labs, EKG, and Imaging   Labs: Reviewed Images: Reviewed  05/31/22 13:23:12 Update: Labs show leukopenia at 1.3 but otherwise baseline blood counts. PTINR is normal. Baseline electrolytes. Baseline renal function. Normal LFTs. Negative Trop, BNP, and lactate. Lipase is elevated at 65. TSH is negative. COVID and Flu negative. CXR and CT abdomen are normal. UA is normal. Will reassess the pt.  05/31/22 13:56:51 Pt is resting on bed comfortably. Updated pt on results of labs and images and recommended admission at this time for observation. Pt is agreeable to be admitted.    Dr. Hospitalist, agrees to admit to obs MS w/ tele     Condition     Stable  Disposition    05/31/22 13:57:30 Admitted under Dr.   Counseled I have currently counseled the  Patient regarding diagnosis, diagnostic results, and treatment plan.  Patient indicated understanding of instructions.  Scribe Attestation I,  acting as scribe for Dr. 05/31/22 09:13:39 . Signed by:  05/31/22 09:13:39  I, DO, attest that the scribe's documentation has been prepared under my direction in person and by me in its entirety. I confirm that the note above accurately reflects all work, treatments, procedures, and medical decision-making performed by me.  Assessment/Plan       1. Leukopenia     2. Generalized weakness       3. History of prostate cancer         Follow Up  No qualifying data available