Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on June 05, 2023 21:34   Verified By: MD on June 05, 2023 21:34   Encounter Info: Hospital, Inpatient, 06/05/23 -     * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     Chief complaint: Generalized weakness   History of present illness:    82-year-old female with past medical history of hypertension, diabetes mellitus, hyperlipidemia presented with generalized weakness.  Family is at bedside assisting with history   Patient is fairly active for her age, she works in the garden and is very independent of her ADLs.  She was doing fine until the last 2 days when she started to have generalized weakness.  Initially she had headache and neck pain and then felt very weak and was not able to walk.  Today when family came from outside the found her sitting in the chair and was not able to move or use the bathroom.  She was wearing a diaper which is very unusual for her.   Patient complains of lower abdominal pain, low back pain without any radiation.  This is better now   She denies shortness of breath or cough.  No fever or chills   No vomiting or diarrhea   She denies dysuria but has some urgency and frequency   In the ED, she was given amlodipine 5 mg for uncontrolled hypertension and ceftriaxone  Review of Systems      Pertinent positives/negatives as noted in HPI. All other systems were reviewed and are negative.  Physical Exam/Objective Vitals & Measurements most recent past 24 hours   Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported     06/05/23 16:48    (L) 36.1 DegC  75 bpm   15 br/min  97 %   4   (H) 157 mmHg  67 mmHg  97 mmHg   55 kg  Stand up   General: Alert, in no acute cardiopulmonary distress.  Mental Status: Oriented to person, place and time. Normal affect.  Head: Normocephalic.  Eyes: Pupils are equal, round and reactive to light. Extraocular muscles intact.  Throat: Oropharynx clear, mucous membranes moist.   Neck: Supple, Full range of motion.  Respiratory: Clear to auscultation and percussion. No wheezing, rales or rhonchi.  Cardiovascular: Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops.  Gastrointestinal: Abdomen soft, non-tender, non-distended. Normal bowel sounds. No pulsatile mass. No hepatosplenomegaly.  Genitourinary: No costovertebral angle tenderness.  Neurologic: Cranial nerves II-XII grossly intact. No focal neurological deficits. Deep tendon reflexes +2 bilaterally. Flexor plantar response. Moves all extremities spontaneously. Sensation intact bilaterally.  Skin: No rashes or lesions. No petechiae or purpura. No edema.  Musculoskeletal: No cyanosis or clubbing. No gross deformities. Normal range of motion.       Assessment/Plan     82-year-old female with past medical history of hypertension, diabetes mellitus, hyperlipidemia presented with generalized weakness   1. Generalized weakness   R53.1  PT/OT  -Likely from UTI  -Check TSH and B12  -COVID-19 is pending  -CT head showed generalized cerebral atrophy without acute intracranial abnormality ? Chest x-ray showed no acute findings ? CT abdomen/pelvis showed no acute findings, liver hemangiomas, proximal SMA atherosclerotic narrowing, mild fatty liver  -Her weakness is more in the lower legs but she does not have any weakness in the upper extremities or facial droop/dysphagia or dysarthria.  We will hold off on MRI of the brain.  She denies having any trauma to her back.  Denies any fall   2. Acute UTI   N39.0  UA showed WBC of 21-50 and moderate leukocyte esterase  -Continue ceftriaxone and follow urine cultures   3. Leukocytosis   D72.829  Leukocytosis with WBC of 12.6.  Patient does not have sepsis.  No tachycardia or tachypnea  -Chest x-ray and CT abdomen/pelvis showed no acute issues   4. Chronic kidney disease (CKD)   N18.9  stage 3. Baseline creatinine is less than 1.  Monitor   5. Diabetes mellitus   E11.9  Hold metformin due to recent contrast exposure and start on low sliding scale insulin.  Her A1c's have been less than 7   6. Gastroesophageal reflux disease   K21.9  Awaiting reconciliation.  Plan to continue Protonix   7. Hypertension   I10  On hydralazine as needed.  She received amlodipine 5 mg in ED   8. Liver hemangioma   D18.03  Noted and stable from previous CT scans   9. Hyperlipidemia   E78.5  On statin   10. On deep vein thrombosis (DVT) prophylaxis   Z79.899  On Lovenox   Orders:   Status Order Acknowledgement   Code Status   None Recorded   Chronic Problem List    Anxiety  Atrophic vaginitis  B12 deficiency  Chronic kidney disease (CKD)  Cognitive decline  Dementia  Diabetes mellitus  Encounter for vitamin deficiency screening  Encounter for vitamin deficiency screening  Foot pain, left  Gastroesophageal reflux disease  Hypertension  Hypokalemia  Insomnia  Liver hemangioma  Long term use of drug  Annual wellness visit, subsequent  Pain of left lower leg  Procedure/Surgical History  ?Diabetic retinal eye exam (11/22/2021) ?colonoscopy (10/12/2016) ?CT of abdomen and pelvis (10/19/2015) ?Appendectomy ?Cesarean section ?Cystocele ?Hysterectomy   Surgical History Internal  10/12/2016    Colonscpy Diagnostic/Screen    MD  Medications   Home Medications (12) Active  amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  Blood Glucose Test Strips See Instructions, Test Blood Sugar once a day  Dx: DM  E11.9  Claritin 10 mg oral tablet 10 mg, Orally, Daily  lancets See Instructions, use to test blood sugar once daily.Dx: E11.9  Lancets See Instructions, use to check blood sugar once dailywhat brand ins covers dx E11.9  Melatonin 10 mg, Orally, At Bedtime  metFORMIN 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  multivitamin , Orally, Daily  pravastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  Strips - Glucose Test See Instructions, use to check blood sugar once daily dx: E11.9  Systane Ultra Preservative Free 1 Drop, Eyes, Both, BID  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 06/04/23 00:00:00 TO 06/05/23 21:32:05  None Reported  PRN Medications (0600 - 0559) from 06/04 - 06/05  None Reported  Allergies   Centrum Silver (unknown)  Fish (unknown)  Premarin (unknown)  Tagamet (unknown)  aspirin (unknown)  penicillins (unknown)  terfenadine derivatives (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   Asthma: Mother.  Depression: Sister.  Diabetes...: Father.  Heart disease..: Grandmother (M).  Hypertension..: Father.  Stroke: Grandmother (M).  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12.6 k/cumm High (06/05/23 18:04:00)  RBC: 4.75 million/cumm (06/05/23 18:04:00)  Hgb: 13.4 GM/dL (06/05/23 18:04:00)  Hct: 40.7 % (06/05/23 18:04:00)  MCV: 86 fL (06/05/23 18:04:00)  MCH: 28.3 pg (06/05/23 18:04:00)  MCHC: 33 GM/dL (06/05/23 18:04:00)  RDW: 14.6 % High (06/05/23 18:04:00)  Platelet: 395 k/cumm (06/05/23 18:04:00)  MPV: 7.6 fL (06/05/23 18:04:00)  Neutrophils %: 83 % (06/05/23 18:04:00)  Lymphocytes %: 8 % (06/05/23 18:04:00)  Monocytes %: 10 % (06/05/23 18:04:00)  Eosinophils %: 0 % (06/05/23 18:04:00)  Basophils %: 0 % (06/05/23 18:04:00)  Absolute Neutrophil: 10.4 k/cumm High (06/05/23 18:04:00)  Absolute Lymphocyte: 0.9 k/cumm Low (06/05/23 18:04:00)  Absolute Monocyte: 1.2 k/cumm (06/05/23 18:04:00)  Absolute Eosinophil: 0 k/cumm (06/05/23 18:04:00)  Absolute Basophil: 0 k/cumm (06/05/23 18:04:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (06/05/23 18:04:00)  Potassium SerPl QN: 3.6 mmol/L (06/05/23 18:04:00)  Chloride SerPl QN: 101 mmol/L (06/05/23 18:04:00)  Carbon Dioxide SerPl QN: 22 mmol/L (06/05/23 18:04:00)  Anion Gap: 15 mmol/L High (06/05/23 18:04:00)  BUN SerPl QN: 30 mg/dL High (06/05/23 18:04:00)  Creatinine SerPl QN: 0.92 mg/dL (06/05/23 18:04:00)  Estimated GFR (CKD-EPI, no race): 62 mL/min/1.73m2 (06/05/23 18:04:00)  Estimated CRCL (CG): 41 mL/min Low (06/05/23 18:04:00)  Glucose SerPl QN: 169 mg/dL High (06/05/23 18:04:00)  Calcium Total SerPl QN: 10.1 mg/dL (06/05/23 18:04:00)  Alkaline Phos SerPl QN: 66 Units/L (06/05/23 18:04:00)  ALT SerPl QN: 12 Units/L (06/05/23 18:04:00)  AST SerPl QN: 15 Units/L (06/05/23 18:04:00)  Bilirubin Total SerPl QN: 1.2 mg/dL High (06/05/23 18:04:00)  Total Protein SerPl QN: 8.2 GM/dL High (06/05/23 18:04:00)  Albumin SerPl QN: 4.4 GM/dL (06/05/23 18:04:00)  CK SerPl QN: 124 Units/L (06/05/23 18:04:00)  Troponin-I High Sensitivity: 10 ng/L (06/05/23 18:04:00)  BNP Pl QN: 67 pg/mL (06/05/23 18:04:00)  Ammonia Pl QN: 32 mCmol/L (06/05/23 18:04:00)  Lactate Venous Pl QN: 1.4 mmol/L (06/05/23 18:04:00)  Coagulation:  PT: 13.1 seconds (06/05/23 18:04:00)  INR: 1.14 (06/05/23 18:04:00)  Urine Studies:  Color: Yellow (06/05/23 18:33:00)  Clarity: Slightly Cloudy (06/05/23 18:33:00)  Specific Gravity: 1.027 (06/05/23 18:33:00)  pH: 5.5 (06/05/23 18:33:00)  Protein: 200 Abnormal (06/05/23 18:33:00)  Glucose: 50 Abnormal (06/05/23 18:33:00)  Ketones: 20 Abnormal (06/05/23 18:33:00)  Bilirubin: NEGATIVE (06/05/23 18:33:00)  Hgb Ur: Small 1+ Abnormal (06/05/23 18:33:00)  Nitrite: NEGATIVE (06/05/23 18:33:00)  Urobilinogen: Normal (06/05/23 18:33:00)  Leukocyte Esterase Ur: Moderate250 Abnormal (06/05/23 18:33:00)  WBC: 21-50 Abnormal (06/05/23 18:33:00)  RBC: 6-10 Abnormal (06/05/23 18:33:00)  Bacteria: TRACE. (06/05/23 18:33:00)  Yeast Ur: PRESENT. Abnormal (06/05/23 18:33:00)  Squamous Epithelial: Few (06/05/23 18:33:00)  Mucous: PRESENT. (06/05/23 18:33:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 06/05/2023 18:08 - XR Chest PA or AP Portable  IMPRESSION:1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.    06/05/2023 19:58 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  No acute findings in the abdomen or pelvis.2.  Multiple hypoechoic liver lesions are similar to decreased insize from the patient's prior study and are compatible withhemangiomas.3.  Mild to moderate atherosclerotic narrowing of the proximal SMAfor 2.5 cm.4.  Mild fatty liver.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us  with any questions.    06/05/2023 19:58 - CT Head W/o IV Contrast  IMPRESSION:  1.  Stable generalized cerebral atrophy without CT evidence of acuteintracranial abnormalities.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 06/05/23 21:34  ________________________________________________________ MD  Electronically Signed on 06/05/23 23:19  ________________________________________________________ MD  Reviewed by MD