Age: 85.0
Sex: F
Vaccine: FLU3
Symptoms: Epigastric discomfort, Gastrooesophageal reflux disease, Glomerular filtration rate normal, Haematocrit normal, Haemoglobin normal
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Performed By: MD on October 21, 2024 09:55 EDT   Verified By: MD on October 21, 2024 09:55 EDT   Encounter Info: Hospital, Inpatient, 10/20/24 -     * Final Report *  Document Has Been Revised        Subjective     85-year-old female with a history of CHF, prediabetes, hypertension, Takotsubo cardiomyopathy, anxiety presents to the ER due to epigastric discomfort after consuming a taco salad.   ???????Admitted for NSTEMI  No new complaints today  VSS  Cannot get a stress test till Wednesday  Cardiology on board  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 36.4 °C (Oral)  TMIN: 36.4 °C (Oral)  TMAX: 36.9 °C (Route Not Specified)  BP: 119/49  HR: 77 (Monitored)  RR: 16  SpO2: 94%  Oxygen Therapy: Room air  Oxygen Flow Rate: 2 (L/min)  WT: 57.72 kg (WFC)    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    57.72 kg    10/20/24    Patient Height  Current Height:    165.9 cm    10/20/24      Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 10/20 - 10/21  Total Intake 88.96 mL    Total Output 6400.00 mL     Balance -6311.04 mL     Physical Exam     General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: Lungs are clear to auscultation, Respirations are non-labored. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling, ???????  Assessment/Plan       1. Chest pain   R07.9   Presents with epigastric burning. No real chest pain. associated with rising troponin which is downtrending  No ST changes on EKG   -Continue serial enzyme analysis, telemetry, trend electrolytes with goal of K+ greater than 4 and Mg 2+ greater than 2.   -Monitor closely with telemetry for any developing arrhythmias and obtain EKG STAT if chest pain recurs  -Stress test treadmill/Lexiscan pending, though if troponin cont to uptrend may consider deferring Lexiscan and starting treatment for NSTEMI and consider transfer for cardiac catheterization if recommended by cardiology. Pt is open to cardiac cath  -Echocardiogram pending for evaluation of regional wall motion abnormalities.   -Maximize GDMT.   -Cardiology consulted and on board  -Will continue to monitor closely ???????-Exercise stress ECHO ordered for tomorrow. Metoprolol stooped for the test (Please resume metoprolol when test is done)    2. NSTEMI (non-ST elevated myocardial infarction)   I21.4   Presents with epigastric burning. No real chest pain. associated with rising troponin  No ST changes on EKG   -Continue serial enzyme analysis, telemetry, trend electrolytes with goal of K+ greater than 4 and Mg 2+ greater than 2.   -Monitor closely with telemetry for any developing arrhythmias and obtain EKG STAT if chest pain recurs  -Stress test treadmill/Lexiscan pending, though if troponin cont to uptrend may consider deferring Lexiscan and starting treatment for NSTEMI and consider transfer for cardiac catheterization if recommended by cardiology.   -Echocardiogram pending for evaluation of regional wall motion abnormalities.   -Maximize GDMT.   -Continue Heparin drip??????? and other medical management  -Cardiology consulted in the ER and on board???????  -Will continue to monitor closely     3. Leukocytosis   D72.829   No other SIRS criteria met. Likely stress induced  will trend daily.     4. Hyponatremia   E87.1   mild  will trend.      5. Anxiety   F41.9   chronic  resume home alprazolam [1]   Ordered:   cetirizine, 10 mg, Orally, Tablet, Daily, 10/21/24 9:00:00 EDT     6. Congestive heart failure   I50.9   not in acute exacerbation  resume home meds  Hold Lasix for now  cont tele  f/u ECHO  replete electrolytes PRN   Ordered:   cetirizine, 10 mg, Orally, Tablet, Daily, 10/21/24 9:00:00 EDT     7. GERD (gastroesophageal reflux disease)   K21.9  PPI [2]     8. HTN (hypertension)   I10  resume home meds [3]   Ordered:   cetirizine, 10 mg, Orally, Tablet, Daily, 10/21/24 9:00:00 EDT     9. Hyperlipidemia   E78.5  started high intensity atorvastatin [4]     10. Lung mass   R91.8   not new, Pt is aware of it.  She endorsed that it was diagnosed about 3 years ago but decided not to pursue treatment due to her advanced age and feared non-tolerance for chemo.     11. Prediabetes   R73.03  has a recent HBa1c confirming.     12. Takotsubo cardiomyopathy   I51.81   History of Takotsubo diagnosed 6 years ago  f/u ECHO  keep on tele  Trend troponin [5]     Greater than 35 minutes total with greater than 50% of time face-to-face with patient reviewing course, plan of care, and in care coordination  Code Status  Resuscitation Status (Code Status) - Ordered    -- 10/20/24 12:17:00 EDT, DNR/DNI/Comprehensive Care   Medications   Active Scheduled Inpatient Medications  ALprazoLAM, Tablet, 0.5 mg, Orally, TID, Start: 10/20/24 15:00:00  aspirin (Aspirin Enteric Coated), Tab, Delayed Rel, 81 mg, Orally, Daily, Start: 10/21/24 09:00:00  atorvastatin, Tablet, 40 mg, Orally, At Bedtime, Start: 10/20/24 21:00:00  cetirizine (Zyrtec), Tablet, 10 mg, Orally, Daily, Start: 10/21/24 09:00:00  lisinopril, Tablet, 10 mg, Orally, Daily, Start: 10/20/24 12:26:00  metoPROLOL (metoPROLOL succinate), Tab, Extended Rel, 50 mg, Orally, Daily, Start: 10/21/24 09:00:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, Daily, Start: 10/21/24 09:00:00  Heparin PREMIX + Sodium Chloride 0.45% IV Continuous Per aPTT LOW Dose Nomogram 520 Units/hr  10/21/24    One-Time Medications Given 10/20/24 00:00:00 TO 10/21/24 09:53:31  Al hydroxide-Mg hydroxide-simethicone (aluminum hydroxide-magnesium hydroxide-simethicone  200 mg-200 mg-20 mg/5 mL oral suspension), Oral Susp, 30 mL, Orally, ONCE, (1 DOSE 10/20/24 20:00:00)  lidocaine topical (lidocaine 2% mucous membrane solution), Oral Solution, 15 mL, Orally, ONCE, (1 DOSE 10/20/24 20:00:00)  metoPROLOL (metoPROLOL tartrate), Tablet, 25 mg, Orally, ONCE, (1 DOSE 10/20/24 12:08:00)  PRN Medications (0600 - 0559) from 10/20 - 10/21  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   heparin infusion bolus dose, aPTT LOW Dose Nomogram , Via Infusion Pump, Unscheduled, 0  Dose(s)   nitroGLYCerin, 0.4 mg, Sublingually, Q5min, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   polyethylene glycol 3350, 17 GM, Orally, Daily, 0  Dose(s)   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 11.9 k/cumm High (10/20/24 12:04:00)  RBC: 4.58 million/cumm (10/20/24 12:04:00)  Hgb: 13.4 GM/dL (10/20/24 12:04:00)  Hct: 41.2 % (10/20/24 12:04:00)  MCV: 90 fL (10/20/24 12:04:00)  MCH: 29.4 pg (10/20/24 12:04:00)  MCHC: 32.6 GM/dL (10/20/24 12:04:00)  RDW: 13.5 % (10/20/24 12:04:00)  Platelet: 221 k/cumm (10/20/24 12:04:00)  MPV: 8.4 fL (10/20/24 12:04:00)  Chemistry:  Sodium SerPl QN: 131 mmol/L Low (10/21/24 04:03:00)  Potassium SerPl QN: 4 mmol/L (10/21/24 04:03:00)  Chloride SerPl QN: 96 mmol/L Low (10/21/24 04:03:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (10/21/24 04:03:00)  Anion Gap: 5 mmol/L (10/21/24 04:03:00)  BUN SerPl QN: 12 mg/dL (10/21/24 04:03:00)  Creatinine SerPl QN: 0.64 mg/dL (10/21/24 04:03:00)  Estimated GFR (CKD-EPI, no race): 87 mL/min/1.73m2 (10/21/24 04:03:00)  Estimated CRCL (CG): 59 mL/min (10/21/24 04:03:00)  Glucose SerPl QN: 113 mg/dL High (10/21/24 04:03:00)  Calcium Total SerPl QN: 9.2 mg/dL (10/21/24 04:03:00)  Cholesterol SerPl QN: 160 mg/dL (10/21/24 04:03:00)  Triglyceride SerPl QN: 80 mg/dL (10/21/24 04:03:00)  HDL SerPl QN: 63 mg/dL (10/21/24 04:03:00)  LDL Calculated QN: 81 mg/dL (10/21/24 04:03:00)  Total Chol/HDL Ratio: 3 (10/21/24 04:03:00)  Troponin-I High Sensitivity: 125 ng/L High (10/21/24 04:03:00)  TSH 3rd Gen SerPl QN: 2.591 mcU/mL (10/20/24 12:04:00)  Coagulation:  aPTT: 62.9 seconds High (10/21/24 08:38:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.            [1] History & Physical Note; MD 10/20/2024 12:20 EDT  [2] History & Physical Note; MD 10/20/2024 12:20 EDT  [3] History & Physical Note; MD 10/20/2024 12:20 EDT  [4] History & Physical Note; MD 10/20/2024 12:20 EDT  [5] History & Physical Note; MD 10/20/2024 12:20 EDT   Signature Line Electronically Signed on 10/21/24 09:55 EDT ________________________________________________________ MD  Electronically Signed on 10/21/24 13:48 EDT ________________________________________________________ MD