Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 21, 2023 21:58   Verified By: MD on February 21, 2023 21:58   Encounter Info: Hospital, Observation, 02/21/23 -     * Final Report *        Chief Complaint   Fatigue  History of Present Illness/Subjective     77-year-old female with past medical history hypertension, hypothyroidism, here with atrial fibrillation with rapid ventricular response.  The patient reports feeling malaise for the past 2 to 3 days, anorexia, generalized weakness, no fevers, no chest pain, no palpitations, no shortness of breath nausea vomiting.  Patient presenting initially to Hospital emergency department, subsequently discussed with ED provider and arrangements made for transfer to hospital for further treatment and evaluation.  The patient was given metoprolol and digoxin in the emergency department at hospital with good efficacy, heart rate dropping below 100.   The patient denies any chest pain, shortness of air, stomach pain, hemoptysis, fevers, chills.  She has no diagnosis of sleep apnea.  Tells me that she had an NSTEMI in the past, diagnosed at hospital, however, no stents, CABG, etc.  Normally active without angina.   COVID-19 negative.  Influenza negative.  Thyroid function within normal limits.  Urine equivocal.  Slightly elevated protein and total bilirubin.  D-dimer within normal limits.  Chest x-ray showed no acute cardiopulmonary abnormality, personally reviewed.   I reviewed the patient's echocardiogram from March 2022, normal LV systolic function, normal left atrium dimensions, no evidence of elevated pulmonary arterial or right heart pressures.  Troponin normal.  BNP minimally elevated.  Creatinine and BUN minimally elevated.   No history of intracranial hemorrhage, GI bleed.  Review of Systems     Remaining 10 point review of systems negative except as noted above.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.3 (37.3-37.3)  Temp (FAHR) 99.1 (99.1-99.1), BP 138/83 (138-138)/(83-83), HR 116 (116-116), RR 20 (20-20), O2Sat 100 (100-100)     Patient Weight  Current Daily Weight:    65.1 kg    02/21/23  Previous Daily Weight:    65.5 kg    02/21/23  Difference from Previous:    -0.400000 kg  BMI:    22    02/21/23    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    172.7 cm    02/21/23        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 Respiratory:  Lungs CTAB, normal work of breathing Cardiovascular: Irregular rhythm, normal rate 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. Atrial fibrillation with RVR     Somewhat equivocal as to whether the patient has a history of atrial fibrillation based on chart review, however, A-fib with RVR on this presentation.  Aside from fatigue, possibly exacerbated by ongoing atrial fibrillation, no significant symptoms, i.e., no chest pain, shortness of air, near syncope, palpitations, etc.  Thyroid function normal.  D-dimer within normal limits.  No history of sleep apnea or primary lung disease.  Will gently hydrate, monitor electrolytes, repeat EKG now that rate is controlled, continue AV nodal blockers in the form of oral beta-blocker at this time.  Consider repeat echocardiogram, it has been nearly 12 months.  Will defer cardiology consult to day team.   CHA2DS2-VASc score is between 4 and 5.  I am going to start the patient on Eliquis 5 mg twice daily at this time.   2. Acute lower UTI    Could be an inciting factor.  Cultures.  Rocephin.    3. Hypertension    Continue beta-blocker but will increase to 25 mg twice daily.  Hold hydrochlorothiazide for now.   4. Hypothyroidism    Continue levothyroxine.   5. Generalized weakness   Hydrate.  Treat UTI.  Rate controlled.  Reassess tomorrow.   Orders:   apixaban, 5 mg, Orally, Tablet, BID, NOW, 02/21/23 21:49:00  aspirin, 81 mg, Orally, Tab, Delayed Rel, Daily, 02/22/23 9:00:00   atorvastatin, 20 mg, Orally, Tablet, Daily, 02/22/23 9:00:00   ceftRIAXone, 1 GM, IVPB, Injection, Q24H, Indication: UTI, 02/21/23 22:00:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  cyanocobalamin, 1,000 mCg, Sublingually, Tablet, Daily, 02/22/23 9:00:00   Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 02/21/23 21:50:00, 125 mL/hr, Clinical Weight  levothyroxine, 37.5 mCg, Orally, Tablet, Daily, 02/22/23 6:00:00   lisinopril, 20 mg, Orally, Tablet, Daily, 02/22/23 9:00:00   memantine, 10 mg, Orally, Tablet, Daily, 02/22/23 9:00:00   metoPROLOL, 25 mg, Orally, Tablet, BID, 02/22/23 9:00:00   multivitamin, 1 Tablet, Orally, Tablet, Daily, 02/22/23 9:00:00   Apixaban Education: Pharmacy  Basic Metabolic Panel  Care Management Consult  CBC  Creatinine SerPl QN  Diagnosis  Hgb  PTINR  Full code.  Code Status   None Recorded   Chronic Problem List    Colon polyp  Elevated troponin  History of recent hospitalization  Hypertension  Hypothyroidism  Mild pulmonary hypertension  Positive colorectal cancer screening using Cologuard test  Sensorineural hearing loss of both ears  Procedure/Surgical History  ?Colonoscopy (10/05/2020) ?Hip replacement   Surgical History Internal  10/05/2020    Colonscpy Bx     Medications   Home Medications (12) Active  Aspirin Low Dose 81 mg oral tablet   atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  benazepril 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  Calcium 500+D   cyanocobalamin 1000 mCg sublingual tablet 1,000 mCg = 1 Tablet, Sublingually, Daily  donepezil 10 mg oral tablet , TAKE 2 TABLETS EVERY DAY  hydrochlorothiazide 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  levothyroxine 0.025 mg (25 mCg) oral tablet See Instructions, 1 & 1/2 Tablet Orally Daily  memantine 5 mg oral tablet 10 mg = 2 Tablet, Orally, Daily, START WITH 1 TABLET DAILY X7 DAYS, THEN INCREASE TO 2 TABLETS DAILY  metoPROLOL tartrate 25 mg oral tablet 12.5 mg = 0.5 Tablet, Orally, Q12  multivitamin 1 Tablet, Orally, Daily  Tessalon Perles 100 mg oral capsule 100 mg = 1 Capsule, Orally, Q12H  Active Scheduled Inpatient Medications  apixaban, Tablet, 5 mg, Orally, BID, Start: 02/21/23 21:49:00  aspirin (Aspirin Enteric Coated), Tab, Delayed Rel, 81 mg, Orally, Daily, Start: 02/22/23 09:00:00  atorvastatin, Tablet, 20 mg, Orally, Daily, Start: 02/22/23 09:00:00  ceftRIAXone, Injection, 1 GM, IVPB, Q24H, Indication: UTI, Start: 02/21/23 22:00:00  cyanocobalamin, Tablet, 1,000 mCg, Sublingually, Daily, Start: 02/22/23 09:00:00  levothyroxine, Tablet, 37.5 mCg, Orally, Daily, Start: 02/22/23 06:00:00  lisinopril, Tablet, 20 mg, Orally, Daily, Start: 02/22/23 09:00:00  memantine, Tablet, 10 mg, Orally, Daily, Start: 02/22/23 09:00:00  metoPROLOL (metoPROLOL tartrate), Tablet, 25 mg, Orally, BID, Start: 02/22/23 09:00:00  multivitamin, Tablet, 1 Tablet, Orally, Daily, Start: 02/22/23 09:00:00  Sodium Chloride 0.9%  1,000 mL IV  70 mL/hr     Lactated Ringers  1,000 mL IV  125 mL/hr       One-Time Medications Given 02/20/23 00:00:00 TO 02/21/23 21:58:30  None Reported  PRN Medications (0600 - 0559) from 02/20 - 02/21  None Reported  Allergies   NKA  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Hypertension: Mother.  Father: History is negative  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 11.2 k/cumm High (02/21/23 15:00:00)  RBC: 5.09 million/cumm (02/21/23 15:00:00)  Hgb: 15 GM/dL (02/21/23 15:00:00)  Hct: 44 % (02/21/23 15:00:00)  MCV: 87 fL (02/21/23 15:00:00)  MCH: 29.5 pg (02/21/23 15:00:00)  MCHC: 34.1 GM/dL (02/21/23 15:00:00)  RDW: 13.5 % (02/21/23 15:00:00)  Platelet: 366 k/cumm (02/21/23 15:00:00)  MPV: 8.2 fL (02/21/23 15:00:00)  Neutrophils %: 71 % (02/21/23 15:00:00)  Lymphocytes %: 15 % (02/21/23 15:00:00)  Monocytes %: 12 % (02/21/23 15:00:00)  Eosinophils %: 2 % (02/21/23 15:00:00)  Basophils %: 1 % (02/21/23 15:00:00)  Absolute Neutrophil: 8 k/cumm High (02/21/23 15:00:00)  Absolute Lymphocyte: 1.7 k/cumm (02/21/23 15:00:00)  Absolute Monocyte: 1.3 k/cumm (02/21/23 15:00:00)  Absolute Eosinophil: 0.2 k/cumm (02/21/23 15:00:00)  Absolute Basophil: 0.1 k/cumm (02/21/23 15:00:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (02/21/23 15:00:00)  Potassium SerPl QN: 4 mmol/L (02/21/23 15:00:00)  Chloride SerPl QN: 101 mmol/L (02/21/23 15:00:00)  Carbon Dioxide SerPl QN: 29 mmol/L (02/21/23 15:00:00)  Anion Gap: 8 mmol/L (02/21/23 15:00:00)  BUN SerPl QN: 32 mg/dL High (02/21/23 15:00:00)  Creatinine SerPl QN: 1.24 mg/dL High (02/21/23 15:00:00)  Estimated GFR (CKD-EPI, no race): 45 mL/min/1.73m2 Low (02/21/23 15:00:00)  Estimated CRCL (CG): 40 mL/min Low (02/21/23 15:00:00)  Glucose SerPl QN: 103 mg/dL High (02/21/23 15:00:00)  Calcium Total SerPl QN: 10 mg/dL (02/21/23 15:00:00)  Alkaline Phos SerPl QN: 87 Units/L (02/21/23 15:00:00)  ALT SerPl QN: 9 Units/L (02/21/23 15:00:00)  AST SerPl QN: 17 Units/L (02/21/23 15:00:00)  Bilirubin Total SerPl QN: 1.4 mg/dL High (02/21/23 15:00:00)  Total Protein SerPl QN: 8.2 GM/dL High (02/21/23 15:00:00)  Albumin SerPl QN: 4.2 GM/dL (02/21/23 15:00:00)  Troponin-I High Sensitivity: 5 ng/L (02/21/23 15:00:00)  BNP Pl QN: 154 pg/mL High (02/21/23 15:00:00)  Lactate Venous Pl QN: 1.3 mmol/L (02/21/23 15:00:00)  Coagulation:  D-Dimer Pl QN: 236 ng/mL DDU (02/21/23 15:00:00)  Urine Studies:  Color: Yellow (02/21/23 16:31:00)  Clarity: Clear (02/21/23 16:31:00)  Specific Gravity: 1.020 (02/21/23 16:31:00)  pH: 6.0 (02/21/23 16:31:00)  Protein: TRACE. Abnormal (02/21/23 16:31:00)  Glucose: NEGATIVE (02/21/23 16:31:00)  Ketones: TRACE. Abnormal (02/21/23 16:31:00)  Bilirubin: SC Small Abnormal (02/21/23 16:31:00)  Hgb Ur: MODERATE. Abnormal (02/21/23 16:31:00)  Nitrite: NEGATIVE (02/21/23 16:31:00)  Urobilinogen: >=8.0 Abnormal (02/21/23 16:31:00)  Leukocyte Esterase Ur: NEGATIVE (02/21/23 16:31:00)  WBC: 0-5 (02/21/23 16:31:00)  RBC: 6-10 Abnormal (02/21/23 16:31:00)  Bacteria: Moderate Abnormal (02/21/23 16:31:00)  Squamous Epithelial: Few (02/21/23 16:31:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/21/23 15:48:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/21/23 15:48:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/21/23 15:48:00)  Rapid Influenza A PCR: Not Detected (02/21/23 15:48:00)  Rapid Influenza B PCR: Not Detected (02/21/23 15:48:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/21/2023 15:44 - XR Chest PA or AP Portable  IMPRESSION:No radiographic evidence of acute cardiopulmonary process.                Signature Line Electronically Signed on 02/21/23 21:58  ________________________________________________________ MD