Age: 14.0
Sex: M
Vaccine: COVID19
Symptoms: Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Blood albumin normal, Blood alkaline phosphatase increased
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on December 10, 2022 12:45 EST   Encounter Info: Hospital, Emergency, 12/10/22 - 12/10/22    * Preliminary Report *        Basic Information  Time Seen:  DO / 12/10/2022 12:18  Chief Complaint  Heart rate slow (Complaint of), Heartburn or indigestion (Complaint of)  History of Present Illness     Patient Seen: 12/10/22 12:41:48 16 year old male presents to the ED with mother and grandmother complaining of irregular EKG. Pt explains he was seen in urgent care earlier today for intermittent GERD symptoms, described as burning in his throat after eating, for the past few weeks. He notes he frequently has these GERD symptoms after eating fast food, and has not had them in the last few days. Pt was then referred to ED due to irregular EKG tracing. He denies chest pain, chest pressure, palpitations, recent fevers, chills, vomiting, diarrhea. Denies Hx of HLD, HTN, pneumonia, bronchitis. Surgical history of tonsillectomy, no other surgical history.   Reviewed EKG tracing completed at urgent care, it shows sinus bradycardia with occasional PVCs, rate of 54 bpm.  Review of Systems     Constitutional: -fevers, -chills ENMT: +intermittent burning in throat Respiratory: -shortness of breath Cardiovascular: -chest pain, -chest pressure, -palpitations Gastrointestinal: -nausea, -vomiting, -diarrhea Additional review of systems information: All other systems reviewed and otherwise negative.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.4 DegC  Heart Rate:       100 bpm  Resp Rate:       16 br/min  BP:       153 / 80 mmHg  SpO2 (%):       97 %  O2 Device:       Room air  Height/Length (%):          56.10     Height CM: 175.3 cm  Weight KG: 115.9 kg  Percentile Height/Length: 56.1     General: Alert, no acute distress Skin: Warm, dry Head: Normocephalic, atraumatic Eyes: Pupils equal, round, and reactive to light, extraocular movements are intact ENMT: Tongue midline, uvula midline Neck: Supple, trachea midline, no tenderness Cardiovascular: Regular rate and rhythm, no murmur, normal peripheral perfusion Respiratory: Lungs clear to auscultation, non-labored respirations, breath sounds equal Chest wall: No tenderness, no deformity Gastrointestinal: Soft, nontender, non-distended, normal bowel sounds, no rebound, no guarding Back: Nontender, normal range of motion, normal alignment Musculoskeletal: Normal range of motion, normal strength, no tenderness, no swelling, no deformity Neurological: No focal neurological deficits, cranial nerves II-XII intact, normal sensory, normal motor, normal speech Psychiatric: Cooperative, appropriate mood and affect  Medical Decision Making     Documents Reviewed:  ED nurse notes, prior records  Diagnostic Results:  Labs: Reviewed Imaging: Reviewed  12/10/22 14:39:15 Reassessment: Pt is still feeling asymptomatic. Reassured Pt and mother about normal EKG. Discussed with Pt and mother results of workup, they are agreeable to discharge and PCP followup for further eval. Will give Rx for Pepcid, instructed Pt and mother to eat less fast food and spicy food which will likely improve symptoms. Requests school note.            Condition     Stable Disposition: 12/10/22 14:43:42 Discharged home Counseled: Patient and mother regarding diagnosis, regarding diagnostic studies, regarding treatment plan. Patient and family indicated understanding of instructions. All questions answered.  Attestations:  I, serving scribe for Dr, 12/10/22 12:43:06 Signed by, Scribe, 12/10/22 12:43:06  Assessment/Plan       Bradycardia   R00.1    GERD (gastroesophageal reflux disease)   K21.9      Prescriptions:       famotidine 20 mg, = 1 Tablet, Orally, Daily, Maintenance, Dispense: 14 Tablet, Refills: 0, Total Refills: 1, avoid eating and drinking for 10 minutes after each dose, for acid reflex, 12/10/22 14:44:00 EST, Pharmacy: Pharmacy, 1 Tablet Orally Daily...  Patient Education   Medicines for GERD  GERD (Adult)  Follow Up        With  When  Contact Information        NP, PED Within 1 to 2 weeks     Additional Instructions:          Chronic Problem List    BMI (body mass index), pediatric, greater than or equal to 95% for age  Hypertrophy tonsils  Procedure/Surgical History  ?Tonsillectomy (2015)    Medications  Home Medications (2) Active Pepcid 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily, avoid eating and drinking for 10 minutes after each dose, for acid reflex Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily    Allergies   NKA  Social History    Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Parents, Siblings.    Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Asthma: Negative: Mother and Father.  Diabetes mellitus type 1: Negative: Mother and Father.  Diabetes mellitus type 2: Negative: Mother and Father.  Heart disease: Negative: Mother and Father.  High cholesterol: Negative: Mother and Father.  Hypertension: Negative: Mother and Father.  Lab Results      Routine Chemistry Tests FS  LATEST RESULTS        Sodium SerPl QN  12/10/22 13:37  137        Potassium SerPl QN  12/10/22 13:37  5.5        Chloride SerPl QN  12/10/22 13:37  103        Carbon Dioxide SerPl QN  12/10/22 13:37  24        Anion Gap  12/10/22 13:37  10        BUN SerPl QN  12/10/22 13:37  14        Creatinine SerPl QN  12/10/22 13:37  0.90        Glucose SerPl QN  12/10/22 13:37  90        Calcium Total SerPl QN  12/10/22 13:37  9.5        Alkaline Phos SerPl QN  12/10/22 13:37  183        ALT SerPl QN  12/10/22 13:37  13        AST SerPl QN  12/10/22 13:37  26        Bilirubin Total SerPl QN  12/10/22 13:37  0.5        Total Protein SerPl QN  12/10/22 13:37  7.3        Albumin SerPl QN  12/10/22 13:37  4.4        Magnesium SerPl QN  12/10/22 13:37  2.1        Troponin-I High Sensitivity  12/10/22 13:37  3      Diagnostic Results  XR Chest PA and Lateral    12/10/22 13:01:00  IMPRESSION:  1. No acute findings.   Thank you for choosing our subspecialized team of radiologists at  Physicians. Healthcare providers wishing to discuss this case  further can contact our Hospital for pediatric  radiologists or our emergency radiology team at  Hospital.   Electronically Signed by:     Signed By: MD  EKG  Time: 12/10/22 1228 Rate: 81 bpm Rhythm: sinus rhythm with marked sinus arrhythmia Axis: normal ST-T segments: no changes T waves: normal Ectopy: none P waves and PR interval: within normal limits QT/QTc interval: within normal limits QRS interval: within normal limits Previous EKG: none available EP Interpretation      Signature Line Electronically Signed on 12/10/22 15:09 EST ________________________________________________________    ________________________________________________________  DO