Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 03, 2023 18:05 EDT   Verified By: MD on November 03, 2023 18:05 EDT   Encounter Info: Hospital, Inpatient, 11/03/23 -     * Final Report *        Chief Complaint   Rapid HR  History of Present Illness/Subjective     Patient is an 85 year old man w/ T2DM and a fib who presents to the ER w/ a rapid HR. The patient was found to be in rapid a flutter. He is a poor historian and can't tell me much about his past medical history or what meds he takes. Labs at the Facility were notable for a normal trop. WBC count was 10. Cr was 1.6 which is around his baseline. CT head and neck showed no acute findings or fractures. Synchronized cardioversion was attempted twice in the ER at 200J however patient failed this. His case was discussed w/ Cardiology on call who recommended starting an amiodarone infusion and admitting him to the ICU. Upon arrival his HR remains in the 110s to 120s. He has no complaints at this time. Telemetry shows a flutter. BP is normal.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours      Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Increased WOB Cardiovascular:  Tachycardic, irregularly irregular rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan     Patient is an 85 year old man admitted w/ rapid a flutter.       1. Atrial flutter   I48.92  -Failed cardioversion in the ER x 2   -Amio gtt for now  -TTE  -Cardiology consultation if refractory  -Continue apixaban   -Continue coreg  -TSH  -Telemetry      2. CAD (coronary artery disease)   I25.10  -Continue home ASA and statin      3. Stage 3 chronic kidney disease   N18.30  -Serum creatinine is at baseline  -Renally dose medications  -Avoid nephrotoxic agents  -Monitor with daily CMP      4. Type 2 diabetes mellitus with hyperglycemia   E11.65  -CDA in place  -Carb controlled diet  -Hypoglycemia protocol  -Hold oral DM meds      5. Dyslipidemia   E78.5  -Continue statin       6. Gout   M10.9  -Continue allopurinol      7. Hypertension   I10  -Continue home antihypertensive regimen      8. Diabetic neuropathy   E11.40  -Continue gabapentin      Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent 40 minutes of critical care time directly and personally managing the patient. This critical care time included obtaining a history, examining the patient, pulse oximetry, ordering and reviewing the studies, arranging urgent treatment with development of a management plan, evaluation of the patient?s response to treatment, frequent reassessment, and discussions with other clinicians. The critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see the MDM section and the rest of this note for further information on patient assessment and treatment.     Code Status   Resuscitation Status - Ordered    -- 11/03/23 17:58:00 EDT, Full Code   Chronic Problem List    AKI (acute kidney injury)  CAD (coronary artery disease)  Diabetes type 2, controlled  Diabetic neuropathy  Dyslipidemia  GERD (gastroesophageal reflux disease)  Gout  Hypertension  Primary osteoarthritis of both knees  Stage 3 chronic kidney disease  Procedure/Surgical History  ?EGD and Colonoscopy with biopsy (08/11/2008) ?back ?shoulder-right     Medications   Home Medications (20) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  allopurinol 100 mg oral tablet 100 mg = 1 Tablet, Orally, TID  apixaban 2.5 mg oral tablet 2.5 mg = 1 Tablet, Orally, BID  aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, QHS  Cinnamon 1,000 mg, Orally, QAM  Coreg 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, Daily  finasteride 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  Fish Oil 1200 mg oral capsule 1,200 mg = 1 Capsule, Orally, QHS  FLUoxetine 20 mg oral capsule 20 mg = 1 Capsule, Orally, QAM  Garlic oral capsule 1,000 mg, Orally, QAM  glimepiride 2 mg oral tablet 2 mg = 1 Tablet, Orally, Every Afternoon  Lantus (insulin glargine) SoloStar Pen 100 units/mL subcutaneous solution See Instructions, Inject 40 units SubQ in the morning and 80 units at bedtime.  Lutein 20 mg oral capsule 20 mg = 1 Capsule, Orally, QAM  meloxicam 15 mg oral tablet   NovoLOG (insulin aspart) FlexPen 100 units/mL subcutaneous solution   omeprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, At Bedtime  pravastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, At Bedtime  sodium bicarbonate 325 mg oral tablet 1,300 mg = 4 Tablet, Orally, BID  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  amiodarone infusion bolus dose, Infusion, 150 mg, Via Infusion Pump, ONCE, Start: 11/03/23 18:00:00  apixaban, Tablet, 2.5 mg, Orally, BID, Start: 11/03/23 21:00:00  insulin glargine (insulin glargine (Core Diabetes App)), Injection, 20 Units, Subcutaneous, BID, Start: 11/03/23 21:00:00  Amiodarone PREMIX + Dextrose 5% in Water PREMIX IV Continuous See Comments 15 mg/min    Amiodarone PREMIX + Dextrose 5% in Water PREMIX IV Continuous  See Comments     Dextrose 10% in Water  500 mL IV Continuous  Per Core Diabetes App - See Comments       One-Time Medications Given 11/02/23 00:00:00 TO 11/03/23 18:01:35  None Reported  PRN Medications (0600 - 0559) from 11/02 - 11/03  glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Core Diabetes App , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Per Core Diabetes App , Subcutaneous, Unscheduled, 0  Dose(s)   Allergies   Neurontin  Social History    Alcohol   Past   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smokeless tobacco user, quit more than 30 days ago.  Family History   Cancer....: Mother.  Father: History is unknown  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.7 k/cumm High (11/03/23 09:56:00)  RBC: 4.46 million/cumm (11/03/23 09:56:00)  Hgb: 12.3 GM/dL Low (11/03/23 09:56:00)  Hct: 37.8 % Low (11/03/23 09:56:00)  MCV: 85 fL (11/03/23 09:56:00)  MCH: 27.7 pg (11/03/23 09:56:00)  MCHC: 32.7 GM/dL (11/03/23 09:56:00)  RDW: 17.1 % High (11/03/23 09:56:00)  Platelet: 170 k/cumm (11/03/23 09:56:00)  MPV: 6.9 fL Low (11/03/23 09:56:00)  Neutrophils %: 87 % (11/03/23 09:56:00)  Lymphocytes %: 5 % (11/03/23 09:56:00)  Monocytes %: 7 % (11/03/23 09:56:00)  Eosinophils %: 0 % (11/03/23 09:56:00)  Basophils %: 1 % (11/03/23 09:56:00)  Absolute Neutrophil: 9.3 k/cumm High (11/03/23 09:56:00)  Absolute Lymphocyte: 0.5 k/cumm Low (11/03/23 09:56:00)  Absolute Monocyte: 0.8 k/cumm (11/03/23 09:56:00)  Absolute Eosinophil: 0 k/cumm (11/03/23 09:56:00)  Absolute Basophil: 0.1 k/cumm (11/03/23 09:56:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (11/03/23 09:56:00)  Potassium SerPl QN: 5.4 mmol/L (11/03/23 09:56:00)  Chloride SerPl QN: 96 mmol/L Low (11/03/23 09:56:00)  Carbon Dioxide SerPl QN: 25 mmol/L (11/03/23 09:56:00)  Anion Gap: 14 mmol/L High (11/03/23 09:56:00)  BUN SerPl QN: 23 mg/dL High (11/03/23 09:56:00)  Creatinine SerPl QN: 1.68 mg/dL High (11/03/23 09:56:00)  Estimated GFR (CKD-EPI, no race): 40 mL/min/1.73m2 Low (11/03/23 09:56:00)  Estimated CRCL (CG): 43 mL/min Low (11/03/23 09:56:00)  Glucose SerPl QN: 344 mg/dL High (11/03/23 09:56:00)  Calcium Total SerPl QN: 8.7 mg/dL (11/03/23 09:56:00)  Troponin-I High Sensitivity: 16 ng/L (11/03/23 09:56:00)  BNP Pl QN: 125 pg/mL High (11/03/23 09:56:00)  Gluc-Strip, POC: 246 mg/dL High (11/03/23 15:42:00)  Urine Studies:  Color: Yellow (11/03/23 10:22:00)  Clarity: Clear (11/03/23 10:22:00)  Specific Gravity: >=1.030 (11/03/23 10:22:00)  pH: 6.0 (11/03/23 10:22:00)  Protein: >=300 Abnormal (11/03/23 10:22:00)  Glucose: >=1000 Abnormal (11/03/23 10:22:00)  Ketones: 15 Abnormal (11/03/23 10:22:00)  Bilirubin: NEGATIVE (11/03/23 10:22:00)  Hgb Ur: MODERATE. Abnormal (11/03/23 10:22:00)  Nitrite: NEGATIVE (11/03/23 10:22:00)  Urobilinogen: NormalUro (11/03/23 10:22:00)  Leukocyte Esterase Ur: NEGATIVE (11/03/23 10:22:00)  WBC: 11-20 Abnormal (11/03/23 10:22:00)  RBC: 3-5 Abnormal (11/03/23 10:22:00)  Bacteria: Moderate Abnormal (11/03/23 10:22:00)  Squamous Epithelial: Few (11/03/23 10:22:00)  Hyaline Casts: 0-2 (11/03/23 10:22:00)  Granular Casts: 0-2 Abnormal (11/03/23 10:22:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/03/2023 10:43 - XR Chest PA or AP Portable  IMPRESSION:1.  Possible minimal congestion with no focal infiltrateThank you for consulting our team of subspecialty radiologists at Radiology.    11/03/2023 12:14 - CT Cervical Spine W/o IV Contrast  IMPRESSION:1.  No acute fracture or traumatic subluxation.2.  Congenital spinal canal stenosis with superimposed degenerativechanges resulting in  moderate to severe spinal canal stenosis atC5-C6 and C6-C7 levels. Multilevel moderate to severe neuralforaminal narrowing. Recommend MRI cervical spine without intravenouscontrast if clinical concern for spondylitic myelopathy.Thank you for consulting our team of subspecialty radiologists at Radiology.      11/03/2023 12:14 - CT Head W/o IV Contrast  IMPRESSION:1.  No acute intracranial findings, specifically no intracranialhemorrhage, hydrocephalus or herniation.2.  Sequela of advanced chronic small vessel ischemic disease whichlimits evaluation for small foci of acute ischemia.Thank you for consulting our team of subspecialty radiologists at Radiology.               Signature Line Electronically Signed on 11/03/23 18:05 EDT ________________________________________________________ MD