Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on January 26, 2023 23:58   Verified By: MD on January 26, 2023 23:58   Encounter Info: Hospital, Observation, 01/26/23 - 01/27/23    * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     71 year old male s/p aortic valve replacement with hx of afib, CHF, CVA, thoracic ascending aortic aneurysm, HLD, HTN COPD, hypothyroidism, IBS, lumbar disc herniation, PAD, cholelithiasis dementia, and schizoaffective disorder presents from the nursing home to the emergency department with complaints of reported chest pain earlier in the day but none at this time.  In fact, no complaints at this time.  Called to bedside, heart rate in the mid 30s, reviewed EKG showing atrial flutter with slow ventricular response.  Denies chest pain, diaphoresis, lightheadedness.  No history of angina, no documented history of coronary artery disease..  Patient has history of mechanical aortic valve replacement, prescribed warfarin, currently INR 2.26.  Chest ray shows no acute cardiopulmonary abnormality, only evidence of mild central vascular congestion, no frank pulmonary edema, prior sternotomy and aortic valve replacement, personally reviewed.  Blood pressure on low side of normal, systolic blood pressure generally in the 90s.  No hypoxia or tachypnea noted.  Minimally elevated white blood cell count with normal differential.  Cardiac enzymes negative x2 sets.   Denies cough, fever.  No chest pain at this time.   At the time of evaluation initially, patient in the emergency department heart rate in the 40s and 50s, worsened upon presentation necessitating immediate transfer to the intensive care unit for closer monitoring.  Review of Systems     Constitutional:  No fevers,  no chills,  no sweats Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No ear pain,  no nasal congestion,  no sore throat Respiratory:  No shortness of breath,  no cough,  no wheeze Cardiovascular:  No chest pain,  bradycardia,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea,  no constipation Genitourinary:  No frequency,  no urgency,  no dysuria,  no hematuria Hematologic/Lymphatic:  No bruising,  no enlarged lymph nodes Allergic/Immunologic:  No hives Endocrine:  No cold intolerance,  no heat intolerance,  no polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash,  no pruritus Neurological:  No headache,  no focal weakness,  no numbness Psychiatric:  No anxiety,  no depression  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.1 (36.1-36.1)  Temp (FAHR) 97.0 (97.0-97.0), BP 111/68 (83-118)/(63-86), HR 34 (30-39), RR 20 (14-24), O2Sat 93 (92-93) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    126.0 kg    01/26/23  Previous Daily Weight:    127.4 kg    01/26/23  Difference from Previous:    -1.400000 kg    Patient Height  Current Height:    188 cm    01/26/23        Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion, no thyromegaly. Respiratory:  Lungs CTAB Cardiovascular: Irregularly irregular rhythm with bradycardia, rate generally in the 30s.  Prominent mechanical valve click over left precordium. Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Symptomatic bradycardia   R00.1  At this point, appears to be more consistent with asymptomatic bradycardia, however, given reported chest pain prior to arrival, will classify as symptomatic.  At this point in time, heart rate in the 30s, blood pressure normal, asymptomatic.  We will moved to the intensive care unit for closer monitoring.  Atropine at bedside.  If symptomatic or worsening bradycardia, will consider low-dose dopamine infusion for positive chronotropic effect.  Obviously will hold metoprolol.  Patient is nursing home patient, they manage his medication, no apparent evidence of overuse.  Check thyroid function.  Cardiology to consult in the morning.  Place pacing pads in the ICU.   Last echocardiogram in September 2022 showing preserved left ventricular ejection fraction, mild concentric left ventricular hypertrophy, moderate left atrial enlargement.  We will hold off on repeating pending cardiology consult.   2. Chest pain   R07.9  The patient tells me that he has prior left heart catheterization.  Vital signs stable, no symptoms at this time.  Monitor.   3. H/O mechanical aortic valve replacement   Z95.2  No evidence of heart failure, good mechanical click.   4. On anticoagulant therapy   Z79.01  Warfarin, monitor INR closely.   5. Hypothyroidism   E03.9  Home medication, check TSH   6. Hypertension   I10  Home medication   7. BPH (benign prostatic hyperplasia)   N40.0  Monitor for signs of retention.   8.  Thoracic ascending aortic aneurysm.  4.8 cm in 2021, stable from 2019, no interval evaluation.  Patient with chest and back pain, seems somewhat intermittent but given presentation, will obtain CT angiography for further evaluation, rule out acute pathology.  Code Status   Full code   Chronic Problem List    Actinic keratosis  Anxiety and depression  Arthritis  Aspiration pneumonia  B12 deficiency  Biliary dyskinesia  BPH (benign prostatic hyperplasia)  Cardiovascular disease  Cholelithiasis  Chronic abdominal pain  Chronic constipation  Chronic pain syndrome  Chronic venous insufficiency  Constipation  COPD (chronic obstructive pulmonary disease)  Depression  Dermatophytosis of groin and perianal area  Dyspepsia  Edema  GERD (gastroesophageal reflux disease)  H/O mechanical aortic valve replacement  Hip joint replacement by other means  Hyperlipidemia  Hypertension  Hypogonadism male  Hypothyroidism  IBS (irritable bowel syndrome)  Impaired gait and mobility  Insomnia  Intermittent claudication  Knee joint replacement status  Lumbar disc herniation with radiculopathy  Lumbar pain with radiation down right leg  Lumbar spinal stenosis  Memory change  On anticoagulant therapy  Osteoarthritis  PAD (peripheral artery disease)  Paroxysmal atrial fibrillation  Pseudodementia  Sepsis  Sepsis with acute hypoxic respiratory failure  Thoracic ascending aortic aneurysm  Tremor  Procedure/Surgical History  ?colonoscopy (08/05/2016) ?egd (09/25/2015) ?lap cholecystectomy (05/21/2015) ?PSA - Prostate specific antigen (03/09/2015) ?knee replacement (01/30/2014) ?left hip replacement (10/20/2009) ?aortic valve replacement (12/15/1986) ?Both eyes   Surgical History Internal  08/05/2016    Colonscpy Diagnostic/Screen    MD  09/25/2015    EGD Bx    MD  Medications   Home Medications (26) Active  Abilify 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q8H  bisacodyl 10 mg, PRN, Orally, Daily  buDESOnide-formoterol 160 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID  cyanocobalamin 1000 mCg/mL injectable solution 1,000 mCg = 1 mL, IM, Every Month  diclofenac sodium   docusate sodium 100 mg oral capsule 100 mg = 1 Capsule, PRN, Orally, BID  Eucerin topical cream 1 App, Topical, At Bedtime  Ferrex-150 oral capsule 150 mg = 1 Capsule, Orally, BID  gabapentin 300 mg oral capsule 300 mg = 1 Capsule, Orally, 4 Times Daily  lamoTRIgine 100 mg oral tablet 100 mg = 1 Tablet, Orally, BID, 50 mg bid  lamoTRIgine 100 mg oral tablet 50 mg = 0.5 Tablet, Orally, At Bedtime  Lasix 40 mg oral tablet 40 mg = 1 Tablet, Orally, BID  Lexapro 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  metoPROLOL succinate 25 mg oral tablet, extended release   metoPROLOL succinate 50 mg oral capsule, extended release   Mysoline 50 mg oral tablet 100 mg = 2 Tablet, Orally, QHS  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  Potassium Chloride (Eqv-K-Tab) 20 mEq oral tablet, extended release 20 mEq = 1 Tablet, Orally, Daily  promethazine 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, Q6H  Refresh ophthalmic solution   Synthroid 0.15 mg (150 mCg) oral tablet 150 mCg = 1 Tablet, Orally, Daily  Tums 500 mg, PRN, Orally, Q4  Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H  Vitamin D3 2,000 intl units (50 mCg) oral capsule 2,000 Units = 1 Capsule, Orally, Daily  warfarin 4 mg oral tablet   Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 01/25/23 00:00:00 TO 01/26/23 23:56:19  atropine, Injection, 0.5 mg, IV Push, ONCE, (1 DOSE 01/26/23 20:26:00)  fentaNYL, Injection, 25 mCg, IV Push, ONCE, (1 DOSE 01/26/23 20:26:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, prn, Nausea/Vomiting IV - Use First, (1 DOSE 01/26/23 20:26:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 01/26/23 20:26:00)  PRN Medications (0600 - 0559) from 01/25 - 01/26  fentaNYL, 25 mCg, IV Push, Q10min, 0  Dose(s)   Allergies   penicillins (Unknown)  aspirin (Unknown)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Resident at nursing home   Other   RHD   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Dementia..: Father.  Sister: History is unknown  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 11.8 k/cumm High (01/26/23 20:17:00)  RBC: 5.43 million/cumm (01/26/23 20:17:00)  Hgb: 15.2 GM/dL (01/26/23 20:17:00)  Hct: 46.3 % (01/26/23 20:17:00)  MCV: 85 fL (01/26/23 20:17:00)  MCH: 28.1 pg (01/26/23 20:17:00)  MCHC: 32.9 GM/dL (01/26/23 20:17:00)  RDW: 14.8 % High (01/26/23 20:17:00)  Platelet: 321 k/cumm (01/26/23 20:17:00)  MPV: 7.9 fL (01/26/23 20:17:00)  Neutrophils %: 64 % (01/26/23 20:17:00)  Lymphocytes %: 23 % (01/26/23 20:17:00)  Monocytes %: 8 % (01/26/23 20:17:00)  Eosinophils %: 3 % (01/26/23 20:17:00)  Basophils %: 1 % (01/26/23 20:17:00)  Absolute Neutrophil: 7.5 k/cumm (01/26/23 20:17:00)  Absolute Lymphocyte: 2.8 k/cumm (01/26/23 20:17:00)  Absolute Monocyte: 1 k/cumm (01/26/23 20:17:00)  Absolute Eosinophil: 0.4 k/cumm High (01/26/23 20:17:00)  Absolute Basophil: 0.2 k/cumm (01/26/23 20:17:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (01/26/23 20:17:00)  Potassium SerPl QN: 4.3 mmol/L (01/26/23 20:17:00)  Chloride SerPl QN: 99 mmol/L (01/26/23 20:17:00)  Carbon Dioxide SerPl QN: 28 mmol/L (01/26/23 20:17:00)  Anion Gap: 9 mmol/L (01/26/23 20:17:00)  BUN SerPl QN: 20 mg/dL (01/26/23 20:17:00)  Creatinine SerPl QN: 1.16 mg/dL (01/26/23 20:17:00)  Estimated GFR (CKD-EPI, no race): 67 mL/min/1.73m2 (01/26/23 20:17:00)  Estimated CRCL (CG): 83 mL/min (01/26/23 20:17:00)  Glucose SerPl QN: 122 mg/dL High (01/26/23 20:17:00)  Calcium Total SerPl QN: 10 mg/dL (01/26/23 20:17:00)  Alkaline Phos SerPl QN: 87 Units/L (01/26/23 20:17:00)  ALT SerPl QN: 11 Units/L (01/26/23 20:17:00)  AST SerPl QN: 17 Units/L (01/26/23 20:17:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (01/26/23 20:17:00)  Total Protein SerPl QN: 7.4 GM/dL (01/26/23 20:17:00)  Albumin SerPl QN: 4.2 GM/dL (01/26/23 20:17:00)  Troponin-I High Sensitivity: 4 ng/L (01/26/23 21:27:00)  Coagulation:  PT: 26.7 seconds High (01/26/23 20:17:00)  INR: 2.26 High (01/26/23 20:17:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (01/26/23 20:12:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (01/26/23 20:12:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 01/26/2023 20:49 - XR Chest PA or AP Portable  IMPRESSION:1.  Small left pleural effusion.2.  Cardiomegaly and pulmonary vascular congestion without overtpulmonary edema.