Document Type: History and Physical   Document Subject: History & Physical Note     Encounter Info: 11/20/22 - 11/21/22    * Final Report *        Chief Complaint   Fall  History of Present Illness/Subjective     Patient is a 56 year old woman w/ h/o T2DM who presents after a fall on Friday. Patient states that she falls often due to her balance issues from her prior stroke. She denied any LOC. She also endorses a cough and sinus congestion over the last week. Her son recently tested positive for flu. Given her fall she sought care in the ER today. Upon arrival she was tachycardic at 102. BP was 115/76 and temp was 99.3. Labs were notable for a Cr of 1.25. Flu A was positive. CxR was clear. XR hip and knee were unremarkable. Patient was admitted to the medicine service for further management.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.4 (37.4-37.4)  Temp (FAHR) 99.3 (99.3-99.3), BP 115/76 (105-121)/(59-76), HR 101 (100-107), RR 20 (18-20), O2Sat 96 (88-96) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    101.4 kg    11/20/22    Patient Height  Current Height:    173 cm    11/20/22        Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Breathing comfortably on room air Cardiovascular:  Tachycardic Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan     Patient is a 56 year old woman admitted w/ flu A.      1. Influenza A   -Tamiflu (1/7)      2. Acute kidney injury    -LR at 100cc/hr  -Likely pre-renal in nature  -Renally dose meds  -Avoid nephrotoxins  -PVR urine  -Hold aldactone      3. CAD (coronary artery disease)  -Continue ASA and statin      4. HTN (hypertension)   -Continue home antihypertensive regimen      5. Type 2 diabetes mellitus    -Sliding scale   -Continue home insulin regimen at reduced dose  -Carb controlled diet  -Hypoglycemia protocol  -Hold oral DM meds      6. Morbid obesity   -Encourage weight loss      7. OSA on CPAP    -Continue home CPAP at night      8. History of pulmonary embolism   -Continue apixaban      9. History of stroke    -Continue statin and ASA      10. Fall   -Trauma w/u negative  -Due to balance issues after CVA  -PT OT  -Will obtain head CT given that she hit her face and is on blood thinners       Code Status  Full Code   Chronic Problem List    Asthma  Atrophic vaginitis  B12 deficiency  BPV (benign positional vertigo)  CAD (coronary artery disease)  Chronic pain  Chronic rhinitis  Chronic, continuous use of opioids  Degenerative disc disease, lumbar  Deviated nasal septum  Elevated liver transaminase level  Fatigue  Folate deficiency  History of pulmonary embolism  History of stroke  History of total right knee replacement  History of total right knee replacement  HTN (hypertension)  Ingrown toenail  Iron deficiency  Left ankle instability  Magnesium deficiency  Major depression, recurrent  Morbid obesity  Nasal turbinate hypertrophy  OSA on CPAP  Osteoarthritis of knees, bilateral  PAF (paroxysmal atrial fibrillation)  Patellar tendinitis  Primary osteoarthritis of left knee  Primary osteoarthritis of right knee  Type 2 diabetes mellitus  Urinary retention  UTI symptoms  Vitamin D deficiency  Xerostomia  Yeast vaginitis  Procedure/Surgical History  ?Diabetic retinal eye exam (09/07/2021) ?R TKA w/ nav DJL 06/25/19 (06/25/2019) ?Pacemaker Insertion (2012) ?Cardiac Cath (2006) ?Left Ankle Fx (2006) ?Colonoscopy (12/15/2005) ?Bladder Repair (2005) ?Hysterectomy (2005) ?Tubal Ligation (1996) ?Dilation and Curettage (1995)   Surgical History Internal  06/07/2021    Cholecystectomy Laparoscopic     06/25/2019    Knee Arthroplasty  (Right)    04/29/2019    Colonscpy Ablt Tmr Polyp Lsn     03/19/2018    Colonscpy Bx     09/13/2016    Colonscpy Control Bleeding  Medications   Home Medications (29) Active  albuterol HFA MDI 90mCg/puff inhalation aerosol 2 Puff, PRN, Inhalation, Q6H  apixaban 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, Daily, stop clopidegrel  Basaglar (insulin glargine) KwikPen 100 units/mL subcutaneous solution 15 Units, Subcutaneous, QPM  carvedilol 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  Crestor 40 mg oral tablet 40 mg = 1 Tablet, Orally, QHS  fenofibrate 54 mg oral tablet 54 mg = 1 Tablet, Orally, Daily, with food  ferrous sulfate 325 mg (65 mg elemental iron) oral delayed release tablet 325 mg = 1 Tablet, Orally, QAM  FLUoxetine 40 mg oral capsule 40 mg = 1 Capsule, Orally, QPM  folic acid 0.4 mg oral tablet 0.4 mg = 1 Tablet, Orally, Daily Test Strips Check daily, Other, Unscheduled  gabapentin 300 mg oral capsule 600 mg = 2 Capsule, Orally, QHS  HumaLOG (insulin lispro) 100 units/mL injection 5 Units, Subcutaneous, TID  hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, Orally, Q6H  hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, Orally, Q6H  hydroCODONE-acetaminophen 10 mg-325 mg oral tablet 1 Tablet, Orally, Q6H  Lancets Not Applicable, Other, TID  Lunesta 2 mg oral tablet 2 mg = 1 Tablet, PRN, Orally, At Bedtime  meclizine 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, TID  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  Ozempic 4 mg/3 mL (1 mg dose) subcutaneous solution 1 mg, Subcutaneous, Every Week  Pen Needles - Insulin (4mm x 32G) Use 4 times daily, Other, Unscheduled, Dispense QS 90 days  Probiotic Formula (Bacillus Coagulans) oral capsule 1 Capsule, Orally, QAM  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  spironolactone 25 mg oral tablet 12.5 mg = 0.5 Tablet, Orally, QHS  Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, QAM  Vitamin C 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, Daily  Vitamin D3 1,000 intl units (25 mCg) oral capsule 1,000 Units = 1 Capsule, Orally, QAM  Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q8H  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 11/19/22 00:00:00 TO 11/20/22 13:59:54  albuterol (albuterol 2.5 mg/0.5mL (0.5%) inhalation solution), Inhalation SOLN, 5 mg, Neb Inhal, ONCE, (1 DOSE 11/20/22 13:10:00)  HYDROmorphone (HYDROmorphone Inj ED (1 mg/mL)), Injection, 1 mg, IV Push, ONCE, (1 DOSE 11/20/22 13:35:00)  morphine (morphine inj ED), Injection, 4 mg, IV Push, ONCE, (1 DOSE 11/20/22 12:51:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 11/20/22 12:51:00)  PRN Medications (0600 - 0559) from 11/19 - 11/20  None Reported  Allergies   codeine (Vomiting, Nausea)  metFORMIN (Abdominal Pain, Nausea)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Work/School description: disabled, formerly a cashier.   Exercise   Home/Environment   Lives with her huband and son    Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Coronary artery disease..: Father.  Diabetes mellitus type 2: Father.  Hypertension..: Father.  Hypothyroidism: Child.  Lupus: Mother.  Stroke: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 5.1 k/cumm (11/20/22 12:12:00)  RBC: 4.56 million/cumm (11/20/22 12:12:00)  Hgb: 12.2 GM/dL (11/20/22 12:12:00)  Hct: 37.6 % (11/20/22 12:12:00)  MCV: 82 fL (11/20/22 12:12:00)  MCH: 26.7 pg Low (11/20/22 12:12:00)  MCHC: 32.4 GM/dL (11/20/22 12:12:00)  RDW: 16.7 % High (11/20/22 12:12:00)  Platelet: 220 k/cumm (11/20/22 12:12:00)  MPV: 6.8 fL Low (11/20/22 12:12:00)  Neutrophils %: 72 % (11/20/22 12:12:00)  Lymphocytes %: 17 % (11/20/22 12:12:00)  Monocytes %: 11 % (11/20/22 12:12:00)  Eosinophils %: 0 % (11/20/22 12:12:00)  Basophils %: 1 % (11/20/22 12:12:00)  Absolute Neutrophil: 3.6 k/cumm (11/20/22 12:12:00)  Absolute Lymphocyte: 0.9 k/cumm Low (11/20/22 12:12:00)  Absolute Monocyte: 0.5 k/cumm (11/20/22 12:12:00)  Absolute Eosinophil: 0 k/cumm (11/20/22 12:12:00)  Absolute Basophil: 0 k/cumm (11/20/22 12:12:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (11/20/22 12:12:00)  Potassium SerPl QN: 3.6 mmol/L (11/20/22 12:12:00)  Chloride SerPl QN: 100 mmol/L (11/20/22 12:12:00)  Carbon Dioxide SerPl QN: 27 mmol/L (11/20/22 12:12:00)  Anion Gap: 9 mmol/L (11/20/22 12:12:00)  BUN SerPl QN: 14 mg/dL (11/20/22 12:12:00)  Creatinine SerPl QN: 1.25 mg/dL High (11/20/22 12:12:00)  Estimated GFR (CKD-EPI, no race): 51 mL/min/1.73m2 Low (11/20/22 12:12:00)  Estimated CRCL (CG): 63 mL/min (11/20/22 12:12:00)  Glucose SerPl QN: 116 mg/dL High (11/20/22 12:12:00)  Calcium Total SerPl QN: 9.4 mg/dL (11/20/22 12:12:00)  Alkaline Phos SerPl QN: 35 Units/L (11/20/22 12:12:00)  ALT SerPl QN: 11 Units/L (11/20/22 12:12:00)  AST SerPl QN: 21 Units/L (11/20/22 12:12:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (11/20/22 12:12:00)  Total Protein SerPl QN: 6.8 GM/dL (11/20/22 12:12:00)  Albumin SerPl QN: 4 GM/dL (11/20/22 12:12:00)  Lactate Venous Pl QN: 0.8 mmol/L (11/20/22 12:12:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/20/22 12:06:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/20/22 12:06:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (11/20/22 12:06:00)  Rapid Influenza A PCR: Detected Abnormal (11/20/22 12:06:00)  Rapid Influenza B PCR: Not Detected (11/20/22 12:06:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/20/2022 12:53 - XR Pelvis and Hip Right  IMPRESSION:1.  No acute bony findings.Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Reading Room.    11/20/2022 12:55 - XR Knee 4+ View Right  IMPRESSION:1.  There is expected alignment of the right knee prosthesis.Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Reading Room.    11/20/2022 12:59 - XR Elbow 3 View Right  IMPRESSION:1.  No acute bony findings.Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discussthis case further can contact the Reading Room. 11/20/2022 13:01 - 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. Healthcare providers wishing to discussthis case further can contact the Reading Room Based on my review,I agree with the findings.