Age: 92.0
Sex: M
Vaccine: RSV
Symptoms: Haemoglobin decreased, Hyperlipidaemia, Hypertension, Inguinal hernia, Interstitial lung disease
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on January 14, 2025 22:48 EST   Verified By: MD on January 14, 2025 22:48 EST   Encounter Info: Observation, 01/14/25 -     * Final Report *        Chief Complaint   L arm pain  History of Present Illness/Subjective     Patient is a 92 year old man who presents to the ER w/ intermittent pain in his L arm. Patient states that earlier today he had a sharp shooting pain in his L arm. The pain occurs every 15 minutes and only lasts for a second or two. He denies any aggravating or alleviating factors. He denies any associated symptoms such as chest pain, palpitations and diaphoresis. Upon arrival to the ER his BP was 149/82. Temp was normal. HR was 91. He was satting normally on RA. Labs were notable for a Hgb of 12. Trop was 31 then repeat was 34 and 41. EKG showed no acute ST-T changes. CxR showed some chronic interstitial changes. L arm XR showed osteoarthritis. CT abd/pelvis showed no acute findings. Given c/f L arm pain as a possible anginal equivalent and uptrending trop patient was admitted to the medicine service for further management.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.4 °C (Temporal Artery)  BP: 149/82  HR: 91 (Monitored)  HR: 89 (Peripheral)  RR: 16  SpO2: 98%  Oxygen Therapy: Room air  WT: 60.90 kg (WFC)  BMI: 21   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    60.9 kg    01/14/25  BMI:    21    01/14/25    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    170.18 cm    01/14/25        Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  CTAB Cardiovascular:  Regular rate and rhythm, no MGR Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan      1. Elevated troponin   R79.89  -Serial troponin  -Ensure patient is CP free  -Telemetry  -TTE  -Consider Cardiology consultation and stress testing      2. Left arm pain   M79.602  -Likely MSK but will rule out cardiac cause  -See problem #1      3. Left upper quadrant pain   R10.12  -Possible due to constipation or inguinal hernia  -Now resolved      4. Constipation   K59.00  -CT noted large stool burden however patient reports having regular BMs and had two earlier today      5. Hyperlipidemia   E78.5  -Continue statin       6. Hypertension   I10  -Relatively normotensive and stable, continue to trend, continue home regimen with titration as appropriate      7. Anemia   D64.9  -The patient presents with anemia chronic and normocytic due to other chronic disease at present is stable.  Continue to trend serial analysis as appropriate with nutritional or blood product supplementation as required.    Code Status  Full Code   Chronic Problem List    Arthropathy  Chronic renal disease, stage III  Constipation  Diffuse abdominal pain  Hyperlipidemia  Hypertension  Lumbar back pain  OA (osteoarthritis) of knee  Upper abdominal pain  Procedure/Surgical History  ?colonoscopy (04/20/2018) ?Appendectomy ?Hernia repair   Surgical History Internal  04/20/2018    Colonoscopy Diagnostic/Screen    MD  Medications   Home Medications (5) Active  gabapentin 100 mg oral capsule See Instructions, 1 PO QHS PRN with food  lisinopril 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  magnesium oxide 250 mg, Orally, Daily  Vitamin C 250 mg, Orally, Daily  Vitamin D3 (cholecalciferol) 125 mCg, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 01/13/25 00:00:00 TO 01/14/25 22:40:51  aspirin, Tab, Chewable, 324 mg, Orally, ONCE, (1 DOSE 01/14/25 21:00:00)  PRN Medications (0600 - 0559) from 01/13 - 01/14  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   MARRIED, 4 CHILDREN, Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   CVA (cerebral vascular accident)...: Father.  Hypertension..: Mother.   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 7.5 k/cumm (01/14/25 15:51:00)  RBC: 4.56 million/cumm (01/14/25 15:51:00)  Hgb: 12.8 GM/dL Low (01/14/25 15:51:00)  Hct: 38.6 % Low (01/14/25 15:51:00)  MCV: 85 fL (01/14/25 15:51:00)  MCH: 28.1 pg (01/14/25 15:51:00)  MCHC: 33.2 GM/dL (01/14/25 15:51:00)  RDW: 13.4 % (01/14/25 15:51:00)  Platelet: 271 k/cumm (01/14/25 15:51:00)  MPV: 8.1 fL (01/14/25 15:51:00)  Neutrophils %: 69 % (01/14/25 15:51:00)  Lymphocytes %: 22 % (01/14/25 15:51:00)  Monocytes %: 8 % (01/14/25 15:51:00)  Eosinophils %: 1 % (01/14/25 15:51:00)  Basophils %: 0 % (01/14/25 15:51:00)  Absolute Neutrophil: 5.1 k/cumm (01/14/25 15:51:00)  Absolute Lymphocyte: 1.7 k/cumm (01/14/25 15:51:00)  Absolute Monocyte: 0.6 k/cumm (01/14/25 15:51:00)  Absolute Eosinophil: 0.1 k/cumm (01/14/25 15:51:00)  Absolute Basophil: 0 k/cumm (01/14/25 15:51:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (01/14/25 15:51:00)  Potassium SerPl QN: 4.1 mmol/L (01/14/25 15:51:00)  Chloride SerPl QN: 100 mmol/L (01/14/25 15:51:00)  Carbon Dioxide SerPl QN: 31 mmol/L High (01/14/25 15:51:00)  Anion Gap: 4 mmol/L (01/14/25 15:51:00)  BUN SerPl QN: 16 mg/dL (01/14/25 15:51:00)  Creatinine SerPl QN: 1.3 mg/dL (01/14/25 15:51:00)  Estimated GFR (CKD-EPI, no race): 52 mL/min/1.73m2 Low (01/14/25 15:51:00)  Estimated CRCL (CG): 31 mL/min Low (01/14/25 15:51:00)  Glucose SerPl QN: 115 mg/dL High (01/14/25 15:51:00)  Calcium Total SerPl QN: 9.9 mg/dL (01/14/25 15:51:00)  Alkaline Phos SerPl QN: 72 Units/L (01/14/25 15:51:00)  ALT SerPl QN: 9 Units/L (01/14/25 15:51:00)  AST SerPl QN: 18 Units/L (01/14/25 15:51:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (01/14/25 15:51:00)  Total Protein SerPl QN: 6.8 GM/dL (01/14/25 15:51:00)  Albumin SerPl QN: 4.1 GM/dL (01/14/25 15:51:00)  Lipase SerPl QN: 21 Units/L (01/14/25 15:51:00)  Troponin-I High Sensitivity: 41 ng/L High (01/14/25 19:15:00)  Urine Studies:  Color: Light-Yellow (01/14/25 15:59:00)  Clarity: Clear (01/14/25 15:59:00)  Specific Gravity: 1.007 (01/14/25 15:59:00)  pH: 7 (01/14/25 15:59:00)  Protein: NEGATIVE (01/14/25 15:59:00)  Glucose: Normal (01/14/25 15:59:00)  Ketones: NEGATIVE (01/14/25 15:59:00)  Bilirubin: NEGATIVE (01/14/25 15:59:00)  Hgb Ur: NEGATIVE (01/14/25 15:59:00)  Nitrite: NEGATIVE (01/14/25 15:59:00)  Urobilinogen: Normal (01/14/25 15:59:00)  Leukocyte Esterase Ur: NEGATIVE (01/14/25 15:59:00)  WBC: 0-5 (01/14/25 15:59:00)  RBC: 0-2 (01/14/25 15:59:00)  Bacteria: NONE (01/14/25 15:59:00)  Squamous Epithelial: NONE (01/14/25 15:59:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 01/14/2025 18:21 - XR Radius/Ulna Left  IMPRESSION:1.  Severe radiocarpal osteoarthritis. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at xxx-xxx-xxxx with any questions.    01/14/2025 18:21 - XR Chest PA or AP Portable  IMPRESSION: 1.  Bilateral infrahilar interstitial thickening, right more thanleft, which could be due to atypical infection or chronicinterstitial lung changes. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at xxx-xx-xxxx(xxx-xxx-xxxx) with any questions.    01/14/2025 18:46 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  No acute findings in the abdomen or pelvis.2.  Left inguinal hernia containing short segment of nonobstructedcolonic segment.3.  Significant amount of diffuse colonic and rectal stool burden. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at xxx-xx-xxxx(xxx-xxx-xxxx) with any questions.             Signature Line Electronically Signed on 01/14/25 22:48 EST ________________________________________________________ MD