Age: 49.0
Sex: M
Vaccine: COVID19
Symptoms: Tachycardia, Thyroxine free normal, Troponin
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: Doctor on May 14, 2022 00:36   Verified By: Doctor on May 21, 2022 19:41  Encounter Info: Hospital, Observation, 05/14/22 - 05/14/22   Basic Information  Time Seen: Doctor / 05/14/2022 00:13  Chief Complaint  Palpitations (Complaint of)  History of Present Illness     discharged a few hours ago. Started having CP and felt HR was high again.   50-year-old male, recently discharged from the emergency department after diagnosis of new onset atrial flutter, patient was prescribed Cardizem for rate control and apixaban for anticoagulation.  Patient notes he felt his heart race again after discharge and started having chest pressure.  Does endorse anxiety.  Review of Systems     Constitutional: -Chills, -Fever Respiratory: -Cough, -SOB, -Wheezing Cardio: -Chest pain, -Palpitations GI: -Abd pain, -Nausea, -Vomiting, -Diarrhea GU: -Difficulty urinating, -Dysuria Musc: -Arthralgias, -Back pain, -Myalgias, -Gait problem, -Neck pain Neuro: -Headaches, -Lightheadedness, -Numbness, -Weakness Skin: -Lacerations, -Rashes Psych: -Anxiety, -Agitation, -Behavior problem, -Confusion   All other systems reviewed and are negative      Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.7 DegC  Heart Rate:       117 bpm  Resp Rate:       18 br/min  BP #1:       181 / 92 mmHg  SpO2 (%):       98 %  O2 Device:       Room air     Height CM: 188 cm  Weight KG: 141.7 kg  Ideal Body Weight: 82.24 kg     Constitutional: no diaphoresis, no distress CV: Tachycardia, Regular rhythm, Intact distal pulses Pulm: no respiratory distress, no wheezes, no rales GI: Soft, no distention, no tenderness MSK: ROM normal, no edema or tenderness Neuro: AOx3, no focal deficits, no abnormal coordination, no abnormal tone Skin: Warm, Dry, no erythema, no rash Psych: Behavior normal  Medical Decision Making     Full work-up done just hours prior.  EKG and troponin unchanged.  Started on a Cardizem drip given mild tachycardia.  Hospitalist consulted for admission and they accepted pt to their service. Explained findings, interventions as well as plan for admission to pt, who is understanding and agreeable. Pt remained hemodynamically stable the entire ED course and is suitable for transfer to floor at this time.             Condition     Stable  Assessment/Plan       Atrial flutter with rapid ventricular response       Follow Up  No qualifying data available   Chronic Problem List    Atrial flutter with rapid ventricular response  Benign essential HTN  Hyperglycemia  Hyperlipidemia  Lipoma  Obesity  Procedure/Surgical History  ?no previous surgeries    Medications  Home Medications (4) Active Cardizem CD 120 mg/24 hours oral capsule, extended release 120 mg = 1 Capsule, Orally, Daily Eliquis 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily meloxicam 15 mg oral tablet 15 mg = 1 Tablet, Orally, Daily    Allergies   Bee Stings (unknown)  Levaquin (unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Family history is negative  Lab Results       Endo Serum/Plasma Tests FS  LATEST RESULTS  HISTORICAL RESULTS          T4 Free Direct SerPl QN  05/14/22 10:00  1.0  05/13/22  0.9      Diagnostic Results  No qualifying data available.