Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin urine absent, Hiatus hernia, Hypertensive emergency, Infection, Lipase
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: Nurse Practitioner on October 26, 2022 18:52  Verified By: Nurse Practitioner on October 26, 2022 18:52  Encounter Info: Hospital, Emergency, 10/26/22 - 10/26/22    * Final Report *        Basic Information  Time Seen:  Nurse Practitioner / 10/26/2022 15:45  Chief Complaint  Chest pain (Complaint of)  History of Present Illness     Patient presents via private vehicle due to chest pain described as burning and heavy x 2 hours. On arrival he vomited x 1. Denies SOB, fever or cough. Patient is poor historian due to dementia. He was seen by his PCP today for a routine visit and no complaints at that time.  Add'l medical hx includes: HTN, HLD, CAD, dementia, GERD,   Social hx:  non smoker, lives at home with spouse who is caregiver, DNI, comprehensive care  Review of Systems     Constitutional:  Negative, No weakness, No fatigue, No decreased activity.   Eye:  Negative.   Ear/Nose/Mouth/Throat:  Negative.   Respiratory:  Negative.   Cardiovascular:  chest pain Gastrointestinal:  vomiting 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:       36.1 DegC  Heart Rate:       53 bpm  Resp Rate:       31 br/min  BP #1:       127 / 70 mmHg  SpO2 (%):       94 %  O2 Device:       Room air     Height CM: 178 cm  Weight KG: 84.2 kg  Ideal Body Weight: 73.18 kg     General:  Poor historian, no acute distress Eye:  Pupils are equal, round and reactive to light, Normal conjunctiva.   HENT:  Normocephalic, atraumatic Neck:  Non-tender, No jugular venous distention, Cardiovascular:  Regular rate, Normal rhythm, S1, S2.  No LE edema Respiratory:  Lungs are clear to auscultation, Respirations are non-labored.   Gastrointestinal:  Soft, Non-tender, Non-distended, Normal bowel sounds, Integumentary:  Warm, Dry, Intact.   Neurologic:  Alert, Oriented, Normal sensory, Normal motor function, Psychiatric:  Cooperative, Appropriate mood & affect.    Medical Decision Making     Diff: ACS, HTN emergency, gastritis, pancreatitis, hiatal hernia, esophageal spasm, GERD,  Covid 19, costochondritis, pneumonia   EKG   Time completed: 1543  Rhythm: SB with 1st degree AV block  Interp: SB with 1st degree AV block; RBBB, no STEMI; interpreted by doctor  rate: 57  QT/QTC: 446/434    Med records reviewed: abnormal stress test in March 2021, cardiac cath completed in March 2021 40 % LAD, no intervention needed. Patient has been maintained on Metoprolol, asa 81 and Statin. Patient also maintained on omeprazole due to frequent complaint of lower chest pain v. epigastric pain that does not appear to be cardiac.   Today his EKG is non ischemic, trop negative x 2, BNP unremarkable, ACS or cardiac etiology of current symptoms unlikely.   Patient was hypertensive on arrival but BP normalized in department. Patient cannot recall if he has had his BP medication today.   CXR suspicious for atypical infection v. pulmonary edema. Covid is negative. Collateral hx from spouse reveals worsening cough x 2-3 days without fever. Will DC to home with antibiotic coverage for atypical pneumonia and encourage medication compliance for GERD. Given patient's unremarkable labs and stable VS admission is not indicated.            Condition     stable  Assessment/Plan       1. Pneumonia   2. HTN (hypertension)   3. GERD (gastroesophageal reflux disease)   Orders:   doxycycline, 100 mg, = 1 Capsule, Orally, BID, for 10 Days, Acute, Dispense: 20 Capsule, Refills: 0, Total Refills: 1, 10/26/22 17:19:00, 11/05/22 17:19:00  ketoROLAC, 15 mg, IV Push, Injection, ONCE, NOW, 10/26/22 18:51:00, 10/26/22 18:51:00  ondansetron, 4 mg, = 1 Tablet, Orally, Q6H, Maintenance, Dispense: 10 Tablet, Refills: 0, Total Refills: 1, 10/26/22 17:19:00  **Coronavirus SARS-CoV2 Rapid  Auto Diff  BNP Pl QN  Cardiac Monitor  CBC w/Differential  Comp Metabolic Panel  COVID 19 PCR  Discharge Patient  Electrocardiogram  Lipase SerPl QN  Peripheral IV Insertion  Troponin-I High Sensitivity  Troponin-I High Sensitivity  UA Microscopic  Urinalysis w Culture Rflx  Urine CX  XR Chest PA or AP   Patient Education   PNEUMONIA, ADULT  Follow Up        With  When  Contact Information        doctor Within 3 to 5 days  Additional Instructions: Antibiotics as prescribed for atypical pneumonia. Zofran as needed for nausea. Please be sure to continue your omeprazole as prescribed for GERD daily and continue all blood pressure medications as prescribed. If you develop any new or worsening symptoms please return to the ER.        Chronic Problem List    B12 deficiency  Coronary artery disease  Dementia  DNI (do not intubate)  Encounter for long-term current use of medication  Erectile dysfunction  GERD (gastroesophageal reflux disease)  Hyperlipidemia  Hypertension  Kidney stones  Ventral hernia  Procedure/Surgical History  ?cardiac catheterization (03/19/2021) ?History of kidney stones.. (2015) ?colonoscopy (09/24/2010) ?Appendectomy ?hernia  Surgical History Internal  02/08/2022    Foreign Body Retrieval  Medications  Home Medications (11) Active aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Daily diclofenac sodium 50 mg oral delayed release tablet 50 mg = 1 Tablet, Orally, BID, with food doxycycline monohydrate 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID hydroCHLOROthiazide 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, Daily memantine 10 mg oral tablet 10 mg = 1 Tablet, Orally, BID metoPROLOL succinate 25 mg oral tablet, extended release 25 mg = 1 Tablet, Orally, Daily omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily rosuvastatin 5 mg oral tablet 5 mg = 1 Tablet, Orally, QHS Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily, sublingual Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, Orally, Q6H  Medication Administration   Given  aluminum hydroxide-magnesium hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral suspension, 30 mL, Orally  aspirin, 324 mg, Orally  doxycycline, 100 mg, Orally  lidocaine 2% mucous membrane solution, 15 mL, Orally  nitroGLYCerin, 0.4 mg, 0.4 mg, 0.4 mg, Sublingually  ondansetron, 4 mg, IV Push  Allergies   Zocor (Unknown)  sulfa drugs (Unknown)  Social History    Alcohol   Current, Beer, 3-5 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Home/Environment   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Heart attack..: Father.  Skin cancer..: Grandfather.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  10/26/22 16:03  8.5  10/26/22  7.5          RBC  10/26/22 16:03  5.66  High  10/26/22  5.72  High          Hgb  10/26/22 16:03  16.5  10/26/22  16.6          Hct  10/26/22 16:03  49.6  10/26/22  50.0          MCV  10/26/22 16:03  88  10/26/22  87          MCH  10/26/22 16:03  29.2  10/26/22  29.0          MCHC  10/26/22 16:03  33.3  10/26/22  33.2          RDW  10/26/22 16:03  13.4  10/26/22  13.3          Platelet  10/26/22 16:03  193  10/26/22  197          MPV  10/26/22 16:03  7.9  10/26/22  8.2          Neutrophils %  10/26/22 16:03  57  10/26/22  60          Lymphocytes %  10/26/22 16:03  33  10/26/22  28          Monocytes %  10/26/22 16:03  9  10/26/22  10          Eosinophils %  10/26/22 16:03  2  10/26/22  2          Basophils %  10/26/22 16:03  0  10/26/22  0          Absolute Neutrophil  10/26/22 16:03  4.8  10/26/22  4.5          Absolute Lymphocyte  10/26/22 16:03  2.8  10/26/22  2.1          Absolute Monocyte  10/26/22 16:03  0.7  10/26/22  0.8          Absolute Eosinophil  10/26/22 16:03  0.1  10/26/22  0.1          Absolute Basophil  10/26/22 16:03  0.0  10/26/22  0.0           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  10/26/22 16:03  138  10/26/22  142          Potassium SerPl QN  10/26/22 16:03  3.5  10/26/22  4.3          Chloride SerPl QN  10/26/22 16:03  103  10/26/22  101          Carbon Dioxide SerPl QN  10/26/22 16:03  27  10/26/22  31  High          Anion Gap  10/26/22 16:03  8  10/26/22  10          BUN SerPl QN  10/26/22 16:03  20  10/26/22  18          Creatinine SerPl QN  10/26/22 16:03  1.08  10/26/22  1.00          Estimated GFR (CKD-EPI, no race)  10/26/22 16:03  69  10/26/22  76          Estimated CRCL (CG)  10/26/22 16:03  59  10/26/22  63          Glucose SerPl QN  10/26/22 16:03  137  High  10/26/22  90          Calcium Total SerPl QN  10/26/22 16:03  9.8  10/26/22  9.8          Alkaline Phos SerPl QN  10/26/22 16:03  55  10/26/22  53          ALT SerPl QN  10/26/22 16:03  15  10/26/22  16          AST SerPl QN  10/26/22 16:03  20  10/26/22  19          Bilirubin Total SerPl QN  10/26/22 16:03  0.4  10/26/22  0.7          Total Protein SerPl QN  10/26/22 16:03  7.0  10/26/22  7.3          Albumin SerPl QN  10/26/22 16:03  4.2  10/26/22  4.1          Lipase SerPl QN  10/26/22 16:03  59              Troponin-I High Sensitivity  10/26/22 17:24  5              BNP Pl QN  10/26/22 16:03  53               Urinalysis FS  LATEST RESULTS  HISTORICAL RESULTS          Color  10/26/22 17:43  Yellow  05/31/21  Yellow          Clarity  10/26/22 17:43  Clear  05/31/21  Slightly Cloudy          Specific Gravity  10/26/22 17:43  1.025  05/31/21  1.024          pH  10/26/22 17:43  6.0  05/31/21  5.0          Protein  10/26/22 17:43  30 Abnormal  05/31/21  30 Abnormal          Glucose  10/26/22 17:43  Negative  05/31/21  Normal          Ketones  10/26/22 17:43  Negative  05/31/21  Negative          Bilirubin  10/26/22 17:43  See Comment Abnormal  05/31/21  Negative          Hgb Ur  10/26/22 17:43  Negative  05/31/21  Large Abnormal          Nitrite  10/26/22 17:43  Negative  05/31/21  Negative          Urobilinogen  10/26/22 17:43  Normal  05/31/21  Normal          Leukocyte Esterase Ur  10/26/22 17:43  Trace Abnormal  05/31/21  Trace Abnormal          WBC  10/26/22 17:43  51-100 Abnormal  05/31/21  6-10 Abnormal          RBC  10/26/22 17:43  3-5 Abnormal  05/31/21  51-100 Abnormal          Bacteria  10/26/22 17:43  Few Abnormal  05/31/21  Trace          Squamous Epithelial  10/26/22 17:43  Few  05/31/21  Few          Calcium Oxalate Crystals  10/26/22 17:43  Present               Molecular Diagnostic Tests  LATEST RESULTS  HISTORICAL RESULTS          COVID 19 Specimen Source  10/26/22 16:03  Nasopharyngeal  02/07/22  Nasopharyngeal          Coronavirus SARS-CoV2 Rapid  10/26/22 16:03  Not Detected          Diagnostic Results  XR Chest PA or AP    10/26/22 16:30:24  IMPRESSION:  1. Perihilar and right basilar interstitial opacities. Differential  diagnosis includes atypical infection and pulmonary edema.