Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Urine analysis, Urine analysis abnormal, Urine ketone body absent, Urine leukocyte esterase, Urobilinogen urine
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on July 19, 2022 15:24 EDT   Verified By: MD on July 20, 2022 12:35 EDT   Encounter Info: Hospital, Emergency, 07/19/22 - 07/19/22    * Final Report *        Basic Information  Time Seen:  MD / 07/19/2022 15:23  Chief Complaint  L arm tingling  History of Present Illness     Pt seen: 07/19/22 16:18:43 A 76 year old male presents to the ED via private vehicle c/o left arm tingling/aching onset last night. Pt states he was out in the heat for 1-2 hours yesterday before onset. He states there is not tingling in his hand.  Says it feels almost like when your arm goes to sleep but it is only involving his forearm.  He also endorses increased urinary frequency.  No hematuria, dysuria or flank pain.  Denies neck pain, neck trauma, difficulty swallowing or vision changes. Pt has had SHx of heart bypass surgery and stent placement.  Review of Systems     Constitutional:  no fever, no chills ENMT:  no sore throat, no difficulty swallowing Respiratory:  no shortness of breath, no cough Cardiovascular: no chest pain, no edema Gastrointestinal: no abdominal pain, no vomiting, no diarrhea Genitourinary:  no dysuria Musculoskeletal: no myalgias Neurologic: no weakness,  no numbness, +tingling in LUE Integumentary: no rash Hematologic/Lymphatic: no bleeding 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:       60 bpm  Resp Rate:       18 br/min  BP #1:       142 / 63 mmHg  SpO2 (%):       98 %  O2 Device:       Room air     Height CM: 172.7 cm  Weight KG: 80.5 kg  Ideal Body Weight: 68.38 kg      Constitutional: No acute distress, Well nourished Eyes: no scleral icterus, no conjunctival injection HENT: no edema, atraumatic Neck:  normal ROM Cardiovascular: regular rate, regular rhythm, No edema Pulmonary: no respiratory distress, clear to auscultation bilaterally, no wheezes, no rales, no rhonchi Abdomen: nondistended, no tenderness, no rebound, noguarding MSK: atraumatic, no deformities, no cyanosis Neurologic: motor function grossly intact, sensation grossly intact, 5/5 strength in all nerve distributions, normal sensation bilaterally, full ROM of all extremities Skin: dry, warm Psych: calm and cooperative  Medical Decision Making     Patient presents with left arm aching/tingling.  No neck pain or obvious dermatomal distribution to suggest cervical radiculopathy.  He is without any neurological findings on exam or distribution of symptoms to suggest CVA.  Considering atypical presentation of acute coronary syndrome but seems overall unlikely.  However, also has no obvious areas of tenderness of the extremity or or pain with range of motion to suggest musculoskeletal etiology.  Palpable pulses and no history or symptoms suggestive of vascular pathology.  Patient also complains of urinary frequency so will evaluate for urinary tract infection.  No associated flank pain or systemic symptoms to suggest pyelonephritis.   ED nursing documentation reviewed  Diagnostic Results:   EKG: sinus bradycardia at 57 bpm with 1st degree AV block. T-wave inversion in AVL and possibly lead I. No QRS widening or QT prolongation, appears overall unchanged from previous.  Labs for this visit: reviewed  Imaging studies for this visit: reviewed          Re-Assessment  07/19/22 17:36:31  UA shows for UTI. Pt states that his left arm is no longer tingling. Informed patient that he will be discharged with abx for his UTI. Patient is agreeable to plan and all questions have been addressed.  Condition     Stable  Counseled  Counseled patient regarding diagnosis, regarding diagnostic results, regarding treatment plan. Patient indicated understanding of instructions.  Disposition: 07/19/22 17:39:13 discharged to home  Scribe Attestation  I, acting as a scribe for Dr. on 07/19/22 16:25:38. Signed, 07/19/22 16:25:38. I, acting as scribe for Dr. at 7/19/2022 at 1800  Signed by, Scribe, at 7/19/2022 at 1800   I, MD, attest that the scribes documentation has been prepared under my direction in person and by me in its entirety.  I confirm that the note above accurately reflects all the work, treatment, procedures, and medical decision-making performed by me.     Assessment/Plan       1. Left arm pain   M79.602    2. Urinary frequency   R35.0    3. Cystitis   N30.90    Prescriptions:       nitrofurantoin 100 mg, = 1 Capsule, Orally, BID, for 5 Days, Acute, Dispense: 10 Capsule, Refills: 0, Total Refills: 1, 07/19/22 17:38:00 EDT, 07/24/22 17:38:00 EDT, Pharmacy: Pharmacy, 1 Capsule Orally BID,x5 Days, 172.7, cm, 07/19/22 14:44:00 EDT, Hei...  Patient Education   BLADDER INFECTION, Male (Adult) (MCRITTE1)  Follow Up        With  When  Contact Information        NP, MED Within 3 to 5 days Medical Clinic 1     Additional Instructions:          Chronic Problem List    Diabetes mellitus  Health care maintenance  Heart disease  Hyperlipidemia  Hypertension  Malignant melanoma of face  Tobacco use  Procedure/Surgical History  ?3 bypass heart (02/09/2016) ?Endoscopy (04/28/2014) ?back surgery ?Colonoscopy ?Coronary Artery Bypass Graft ?skin cancer removal 2021 ?Tracheostomy  Surgical History Internal  02/09/2016    Coronary Artery Bypass Graft    MD  Medications  Home Medications (14) Active albuterol HFA MDI 90mCg/puff inhalation aerosol 2 Puff, PRN, Inhalation, Q4H amLODIPine 10 mg, Orally, At Bedtime aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Daily atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, QHS carvedilol 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, BID clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily fenofibrate 160 mg oral tablet 160 mg = 1 Tablet, Orally, Daily gabapentin 300 mg oral capsule 300 mg = 1 Capsule, Orally, TID glimepiride 4 mg oral tablet 4 mg = 1 Tablet, Orally, Daily lisinopril 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily metFORMIN 500 mg (Eqv-Fortamet) oral tablet, extended release 1,000 mg = 2 Tablet, Orally, BID With Meals montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily sertraline 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily  Medication Administration   Given  ceftRIAXone, 2 GM, IV Push  Allergies   penicillins (servere)  Social History    Alcohol   Past   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   Skin cancer: Brother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  07/19/22 16:47  6.2  07/07/22  6.3          RBC  07/19/22 16:47  4.53  07/07/22  4.74          Hgb  07/19/22 16:47  13.4  07/07/22  14.1          Hct  07/19/22 16:47  40.4  07/07/22  42.5          MCV  07/19/22 16:47  89  07/07/22  90          MCH  07/19/22 16:47  29.6  07/07/22  29.8          MCHC  07/19/22 16:47  33.2  07/07/22  33.2          RDW  07/19/22 16:47  13.3  07/07/22  13.4          Platelet  07/19/22 16:47  220  07/07/22  218          MPV  07/19/22 16:47  8.3  07/07/22  8.7          Neutrophils %  07/19/22 16:47  51  07/07/22  62          Lymphocytes %  07/19/22 16:47  39  07/07/22  29          Monocytes %  07/19/22 16:47  8  07/07/22  8          Eosinophils %  07/19/22 16:47  1  07/07/22  1          Basophils %  07/19/22 16:47  1  07/07/22  1          Absolute Neutrophil  07/19/22 16:47  3.2  07/07/22  3.9          Absolute Lymphocyte  07/19/22 16:47  2.5  07/07/22  1.8          Absolute Monocyte  07/19/22 16:47  0.5  07/07/22  0.5          Absolute Eosinophil  07/19/22 16:47  0.0  07/07/22  0.1          Absolute Basophil  07/19/22 16:47  0.1  07/07/22  0.0           Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  07/19/22 16:47  136  07/07/22  137          Potassium SerPl QN  07/19/22 16:47  4.3  07/07/22  4.3          Chloride SerPl QN  07/19/22 16:47  103  07/07/22  101          Carbon Dioxide SerPl QN  07/19/22 16:47  22  07/07/22  26          Anion Gap  07/19/22 16:47  11  07/07/22  10          BUN SerPl QN  07/19/22 16:47  13  07/07/22  16          Creatinine SerPl QN  07/19/22 16:47  0.81  07/07/22  1.03          Estimated GFR (CKD-EPI)  07/19/22 16:47  86  07/07/22  70          Estimated GFR (CKD-EPI, no race)  07/19/22 16:47  >90  07/07/22  75          Estimated CRCL (CG)  07/19/22 16:47  88  07/07/22  69          Glucose SerPl QN  07/19/22 16:47  123  High  07/07/22  230  High          Calcium Total SerPl QN  07/19/22 16:47  9.1  07/07/22  10.0          Troponin-I High Sensitivity  07/19/22 16:47  8               Urinalysis FS  LATEST RESULTS  HISTORICAL RESULTS          Color  07/19/22 16:36  Orange  07/14/21  Yellow          Clarity  07/19/22 16:36  Clear  07/14/21  Clear          Specific Gravity  07/19/22 16:36  1.010  07/14/21  1.020          pH  07/19/22 16:36  7.0  07/14/21  6.5          Protein  07/19/22 16:36  Trace Abnormal  07/14/21  Trace Abnormal          Glucose  07/19/22 16:36  250 Abnormal  07/14/21  250 Abnormal          Ketones  07/19/22 16:36  Negative  07/14/21  Negative          Bilirubin  07/19/22 16:36  Negative  07/14/21  See Comment Abnormal          Hgb Ur  07/19/22 16:36  Negative  07/14/21  Large Abnormal          Nitrite  07/19/22 16:36  Positive Abnormal  07/14/21  Negative          Urobilinogen  07/19/22 16:36  2.0 Abnormal  07/14/21  Normal          Leukocyte Esterase Ur  07/19/22 16:36  Negative  07/14/21  Trace Abnormal          WBC  07/19/22 16:36  0-5  07/14/21  11-20 Abnormal          RBC  07/19/22 16:36  0-2  07/14/21  21-50 Abnormal          Bacteria  07/19/22 16:36  Trace  07/14/21  Few Abnormal          Squamous Epithelial  07/19/22 16:36  Few  07/14/21  Few      Diagnostic Results  XR Chest PA or AP Portable    07/19/22 17:17:03  IMPRESSION:  1. No acute findings in the chest. Chronic changes, as above.   Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss  this case further can contact the Room at. For after-hours or emergency department cases, please  call.   Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 07/25/22 13:57 EDT ________________________________________________________   Electronically Signed on 07/19/22 17:40 EDT ________________________________________________________   Electronically Signed on 07/20/22 12:35 EDT ________________________________________________________ MD