Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 21, 2023 15:49 EST   Verified By: MD on February 21, 2023 15:49 EST   Encounter Info: Hospital, Observation, 02/21/23 -     * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     This is a 79-year-old female with past medical history of asthma, type 2 diabetes, hyperlipidemia, anemia and hypothyroidism presented with complaints of extreme fatigue that has been happening since last couple of months.  To the point that it is difficult for her to get up from the bed the patient had her appointment with primary care physician Dr. She endorsed having chest pressure cough and shortness of breath due to which she was referred here.  The patient had a recent ED visit on 02/11/2023 at that time she was treated with bronchitis and UTI.  Patient tells me that she does not smoke but everyone around her smokes.  She has been drinking a lot of fluid.  She lives with her son and usually takes care of her her blood pressure is noted to be slightly elevated from the vitals.  She is saturating 93% on room air.  Her white count is mildly elevated to 11.2.  EKG showed lateral leads T wave inversion troponins are slightly 25-29.  Her BNP is 318 and she does not have an echocardiogram in the system  X-ray suggestive of edema/atypical infection or interstitial lung disease.  Review of Systems     13 point review systems negative except for what is mentioned above  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.2 (36.2-36.2)  Temp (FAHR) 97.2 (97.2-97.2), BP 142/79 (135-165)/(62-83), HR 97 (80-108), RR 20 (20-33), O2Sat 93 (92-93)     Patient Weight  Current Daily Weight:    52.2 kg    02/21/23    Patient Height  Current Height:    154.9 cm    02/21/23        Constitutional:  No acute distress,  Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus  ENMT:  Moist oral mucosa  Neck:  Supple, non-tender, intact range of motion  Respiratory: Slight expiratory wheezing  Cardiovascular:  Regular rate and rhythm  Gastrointestinal:  Soft, non-tender, non-distended  Musculoskeletal:  No joint swelling, no deformity, intact ROM, no edema  Integumentary:  Intact, warm, dry no rashes  Neurologic: Alert & Oriented  Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan     #Lethargy  - the patient has chronic anemia, i don't see a colonoscopy in the system.  - anemia workup, b12, thyroid profile, folate,  - needs more PT   ???????#chest pain  - mild trop elevation,  - ekg lateral t wave inversion  - follow trops q 6 until downtrending  - echo cardiogram , she does have risk factors   #Asthma  - her home meds,  - duonebs PRN   #Hypertension  -resume home meds   #Type 2 diabetes  - resume home meds   #Hypothyroidism  -thyroid profile , given weakness   #Pneumonia  - she has recently been treatment, i will continue treatment for now  - obtain pneumonia workup   #Passive smoking  - monitor for withdrawal  can give lung changes    #Diabetic nephropathy  - noted   1. Asthma   J45.909    2. Diabetes mellitus type 2, uncontrolled   E11.65    3. Hypertension   I10    4. Hypothyroidism   E03.9    5. Microalbuminuric diabetic nephropathy   E11.21    6. Normocytic anemia   D64.9    Dyspnea   R06.00    Weakness   R53.1    Code Status   None Recorded   Chronic Problem List    Asthma  Diabetes mellitus type 2, uncontrolled  Encounter for medication management  Gout  Hyperlipidemia  Hypertension  Hypothyroidism  Major depression  Microalbuminuric diabetic nephropathy  Normocytic anemia  Procedure/Surgical History  ?Diabetic retinal eye exam (01/02/2019) ?back surgery     Medications   Home Medications (11) Active  allopurinol 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  amLODIPine 5 mg oral tablet 5 mg, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, QHS  cyanocobalamin 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  DME Spacer for MDI Not Applicable, Other, Unscheduled  glipiZIDE XL 2.5 mg oral tablet, extended release 2.5 mg = 1 Tablet, Orally, Daily  levothyroxine 125 mCg (0.125 mg) oral tablet 125 mCg = 1 Tablet, Orally, Daily  lisinopril 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  ProAir HFA 90 mCg/inh inhalation aerosol 1 Puff, PRN, Inhalation, 4 Times Daily  Requip 0.5 mg oral tablet 0.5 mg = 1 Tablet, Orally, QHS  sertraline 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/20/23 00:00:00 TO 02/21/23 15:49:19  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 02/21/23 09:51:00)  PRN Medications (0600 - 0559) from 02/20 - 02/21  None Reported  Allergies   NKA  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   Heart attack: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 11.2 k/cumm High (02/21/23 09:39:00)  RBC: 4.16 million/cumm (02/21/23 09:39:00)  Hgb: 10.4 GM/dL Low (02/21/23 09:39:00)  Hct: 33.7 % Low (02/21/23 09:39:00)  MCV: 81 fL (02/21/23 09:39:00)  MCH: 25.1 pg Low (02/21/23 09:39:00)  MCHC: 31 GM/dL Low (02/21/23 09:39:00)  RDW: 14.8 % High (02/21/23 09:39:00)  Platelet: 379 k/cumm (02/21/23 09:39:00)  MPV: 7.8 fL (02/21/23 09:39:00)  Neutrophils %: 76 % (02/21/23 09:39:00)  Lymphocytes %: 14 % (02/21/23 09:39:00)  Monocytes %: 8 % (02/21/23 09:39:00)  Eosinophils %: 3 % (02/21/23 09:39:00)  Basophils %: 0 % (02/21/23 09:39:00)  Absolute Neutrophil: 8.5 k/cumm High (02/21/23 09:39:00)  Absolute Lymphocyte: 1.5 k/cumm (02/21/23 09:39:00)  Absolute Monocyte: 0.8 k/cumm (02/21/23 09:39:00)  Absolute Eosinophil: 0.3 k/cumm (02/21/23 09:39:00)  Absolute Basophil: 0 k/cumm (02/21/23 09:39:00)  Chemistry:  Sodium SerPl QN: 134 mmol/L Low (02/21/23 09:39:00)  Potassium SerPl QN: 4 mmol/L (02/21/23 09:39:00)  Chloride SerPl QN: 97 mmol/L Low (02/21/23 09:39:00)  Carbon Dioxide SerPl QN: 29 mmol/L (02/21/23 09:39:00)  Anion Gap: 8 mmol/L (02/21/23 09:39:00)  BUN SerPl QN: 13 mg/dL (02/21/23 09:39:00)  Creatinine SerPl QN: 0.81 mg/dL (02/21/23 09:39:00)  Estimated GFR (CKD-EPI, no race): 74 mL/min/1.73m2 (02/21/23 09:39:00)  Estimated CRCL (CG): 44 mL/min Low (02/21/23 09:39:00)  Glucose SerPl QN: 194 mg/dL High (02/21/23 09:39:00)  Calcium Total SerPl QN: 9.7 mg/dL (02/21/23 09:39:00)  Alkaline Phos SerPl QN: 80 Units/L (02/21/23 09:39:00)  ALT SerPl QN: 20 Units/L (02/21/23 09:39:00)  AST SerPl QN: 34 Units/L (02/21/23 09:39:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (02/21/23 09:39:00)  Total Protein SerPl QN: 7.9 GM/dL (02/21/23 09:39:00)  Albumin SerPl QN: 3.6 GM/dL (02/21/23 09:39:00)  Troponin-I High Sensitivity: 29 ng/L High (02/21/23 09:39:00)  BNP Pl QN: 318 pg/mL High (02/21/23 09:39:00)  Urine Studies:  Color: Yellow (02/21/23 10:16:00)  Clarity: Clear (02/21/23 10:16:00)  Specific Gravity: 1.010 (02/21/23 10:16:00)  pH: 6.5 (02/21/23 10:16:00)  Protein: >=300 Abnormal (02/21/23 10:16:00)  Glucose: NEGATIVE (02/21/23 10:16:00)  Ketones: NEGATIVE (02/21/23 10:16:00)  Bilirubin: SC Small Abnormal (02/21/23 10:16:00)  Hgb Ur: NEGATIVE (02/21/23 10:16:00)  Nitrite: NEGATIVE (02/21/23 10:16:00)  Urobilinogen: NormalUro (02/21/23 10:16:00)  Leukocyte Esterase Ur: NEGATIVE (02/21/23 10:16:00)  WBC: 0-5 (02/21/23 10:16:00)  RBC: None Seen (02/21/23 10:16:00)  Bacteria: TRACE. (02/21/23 10:16:00)  Squamous Epithelial: NONE (02/21/23 10:16:00)  Mucous: PRESENT. (02/21/23 10:16:00)  Hyaline Casts: 3-5 (02/21/23 10:16:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (02/21/23 10:06:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/21/23 10:06:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/21/2023 09:24 - XR Chest PA or AP  IMPRESSION:Slight interval improvement in extensive bilateral interstitialchanges when compared to 11/20/2023. This may still be edema,atypical infection and/or interstitial lung disease or somecombination of the above.                Signature Line Electronically Signed on 02/21/23 15:49 EST ________________________________________________________ MD  Electronically Signed on 02/21/23 15:50 EST ________________________________________________________ MD