Received Feb 20, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) | SANOFI PASTEUR | N/A | u8465ca | SYR |
Document Type: History and Physical Document Subject: History & Physical Note Performed By: MD on February 20, 2025 03:55 EST Verified By: MD on February 20, 2025 03:55 EST Encounter Info: Hospital, Observation, 02/19/25 - * Final Report * Chief Complaint chest pain History of Present Illness/Subjective This is a 54-year-old man with past medical history of hypertension, CAD, CKD stage II, heart failure with reduced ejection fraction of 39%, anxiety, diabetes mellitus, hyperlipidemia, obesity, OSA, and GERD. Also has a recent medical history of hospitalization first at Hospital, and subsequently a University Hospital in January 2025. Had received PCI with stenting x 2 with hospital, then presented to University Hospital where he was found to have a proximal LAD lesion requiring PCI and stenting. The aforementioned clinical course was complicated by development of pericardial effusion and Dressler syndrome. The patient was initiated on GDMT as well as colchicine, repeat echocardiogram showed decrease in size of pericardial effusion. He now presents to University Hospital on 2/20/2025. Primary complaints on presentation are surrounding accelerated blood pressure at home, noted to be systolically in the 160s. Patient had mid back pain radiating to the left shoulder with associated chest pain. Patient describes slight shortness of breath at the time of the event. Given his recent history of coronary event, he was concerned and presented to the emergency department for further evaluation. Pain now resolved at the time of evaluation. On initial evaluation, hemogram values relatively within normal limits. Electrolyte analysis within normal limits. Renal function analysis shows slight reduction in GFR from relative baseline. Troponin elevated at 148 x 2. Repeat pending. Vital signs show the patient to be afebrile, without sustained tachypnea or tachycardia, saturating suitably well, and slightly hypertensive throughout. Imaging was obtained showing small left-sided pleural effusion. At this time the patient will be placed in observation for ongoing evaluation and treatment. 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: + Shortness of breath, no cough, no wheeze Cardiovascular: + Chest pain, no palpitations, 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: + Arthralgia, + myalgia Skin: No rash, no pruritus Neurological: No headache, no focal weakness, no numbness Psychiatric: + Anxiety, no depression Physical Exam/Objective Vitals & Measurements most recent past 24 hours T: 36.7 °C (Oral) BP: 156/91 HR: 86 (Monitored) RR: 17 SpO2: 96% Oxygen Therapy: Room air Hemodynamics Neurologic Glasgow Coma Score: 15 Patient Weight Patient Height Current Height: 182.9 cm 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: No acute respiratory distress, nonlabored respiratory pattern, no overt wheezing or stridor Cardiovascular: Regular rate and rhythm 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. Chest pain R07.9 Resolved at the time of evaluation, likely multifactorial in the setting of recent MI and Dressler syndrome as well as accelerated hypertension and increased afterload with increased myocardial demand. Continue antiplatelet therapy, colchicine, and will obtain limited echocardiogram to evaluate stability of pre-existing pericardial effusion and rule out any complications of known Dressler syndrome 2. Accelerated hypertension I10 Down trended since arrival, continue at home antihypertensive regimen, continue to trend, will provide IV PRNs as required. 3. Elevated troponin R79.89 148 x 2 on presentation, likely due to increased mismatch demand with underlying physiological stress in the setting of accelerated hypertension. Likely non-myocardial injury related elevation in troponin. Will continue to trend serial enzymes. 4. CAD (coronary artery disease) I25.10 Chest pain resolved at this time, continue GDMT with titration as appropriate 5. CKD (chronic kidney disease) stage 2, GFR 60-89 ml/min N18.2 Stable with slight reduction from relative baseline, avoid nephrotoxins as possible and continue to trend 6. HFrEF (heart failure with reduced ejection fraction) I50.20 relatively euvolemic continue GDMT with titration as appropriate, baseline ejection fraction 39% on most recent echocardiogram, small left pleural effusion noted, likely secondary to increased afterload. 7. Dressler syndrome I24.1 Continue colchicine, limited echocardiogram pending. 8. Anxiety F41.9 Continue appropriate anxiolytics 9. DM2 (diabetes mellitus, type 2) E11.9 Continue subcutaneous insulin via CDA protocol and carb controlled diet for tight glycemic control. Initiate baseline basal/bolus regimen as indicated by clinical course with appropriate titration, resume home oral agents/analogs as appropriate when nearing discharge. 10. HLD (hyperlipidemia) E78.5 stable on current statin regimen 11. Obesity E66.9 Would benefit from dietary and exercise modification following resolution of acute illness 12. OSA (obstructive sleep apnea) G47.33 continue CPAP as required/tolerated??????? 13. GERD (gastroesophageal reflux disease) K21.9 continue PPI??????? Code Status Full Code Chronic Problem List Acute coronary syndrome with high troponin Anxiety BMI 31.0-31.9,adult Chronic kidney disease (CKD), stage III (moderate) Chronic pain syndrome Cigarette nicotine dependence in remission CKD (chronic kidney disease) Coronary artery disease involving coronary bypass graft of native heart with unstable angina pectoris Cough Degenerative tear of medial meniscus of right knee Diabetes DM (diabetes mellitus), type 2, uncontrolled Encounter for long-term (current) use of medications Erectile dysfunction of organic origin Essential hypertension Fracture of nasal bones, initial encounter for open fracture Hx of opioid abuse Hypercholesterolemia Hypertension Hypogonadism male Knee effusion Knee osteoarthritis Low back pain Mass of tongue Mixed hyperlipidemia Nasal septal deviation Obesity Peripheral edema Preop examination Primary osteoarthritis of right knee (Mod MC, Mild PF) Renal calculus Right knee pain Shortness of breath Sleep apnea Tobacco use Tonsillar hypertrophy, unilateral Tonsillar mass Uvular hypertrophy Procedure/Surgical History ?History of back surgery ?throat Medications Home Medications (18) Active ALprazoLAM 1 mg oral tablet 1 mg = 1 Tablet, PRN, Orally, BID Aspirin Low Dose 81 mg oral delayed release tablet 81 mg = 1 Tablet, Orally, Daily atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, At Bedtime BD Ultra-Fine Nano (4mm x 32G) Pen Needle Use 4 per day, Other, 4 Times Daily, Dispense QS for 30 days colchicine 0.6 mg oral tablet 0.6 mg = 1 Tablet, Orally, BID Dexcom G7 Receiver Use As Directed, Other, ONCE Dexcom G7 Sensor Use As Directed, Other, Unscheduled, Replace every 10 days fluticasone 50 mCg/inh nasal spray 100 mCg = 2 Spray, Nostrils, Both, Daily insulin lispro 100 units/mL injection 17 Units, Subcutaneous, TID, Admelog Vial isosorbide mononitrate 30 mg oral tablet, extended release 30 mg = 1 Tablet, Orally, QAM, do not crush or chew nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min, If chest pain not relieved in 5 minutes after first dose, seek immediate medical attention pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily prasugrel 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily sodium bicarbonate 650 mg oral tablet 1,300 mg = 2 Tablet, Orally, Daily Toprol-XL 50 mg oral tablet, extended release 50 mg = 1 Tablet, Orally, Daily, continue home medication torsemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily Tresiba (insulin degludec) FlexTouch (CONCENTRATED) 200 units/mL subcutaneous solution See Instructions, 40 Units QAM 20 Units QHS valsartan 40 mg oral tablet 20 mg = 0.5 Tablet, Orally, Daily Active Scheduled Inpatient Medications None Reported One-Time Medications Given 02/19/25 00:00:00 TO 02/20/25 03:54:32 aspirin, Tab, Chewable, 324 mg, Orally, ONCE, (1 DOSE 02/20/25 01:24:00) PRN Medications (0600 - 0559) from 02/19 - 02/20 None Reported Allergies No Known Medication Allergies Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Former use, quit more than 90 days ago. Employment/School DISABILITY Substance Abuse Past Tobacco Tobacco Use: Former smoker, quit more than 30 days ago. Family History Anxiety: Mother. Apnea, sleep..: Father. COPD: Father. Cancer..: Mother. Depression: Mother. Diabetes mellitus type 2: Mother. Diabetes..: Father. Heart disease: Father. Hypertension..: Father. Kidney disease: Father. SOB (shortness of breath)..: Father. Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 8 k/cumm (02/19/25 23:43:00) RBC: 4.77 million/cumm (02/19/25 23:43:00) Hgb: 13.9 GM/dL (02/19/25 23:43:00) Hct: 40.5 % (02/19/25 23:43:00) MCV: 85 fL (02/19/25 23:43:00) MCH: 29.2 pg (02/19/25 23:43:00) MCHC: 34.4 GM/dL (02/19/25 23:43:00) RDW: 15.3 % High (02/19/25 23:43:00) Platelet: 179 k/cumm (02/19/25 23:43:00) MPV: 9.7 fL (02/19/25 23:43:00) Neutrophils %: 52 % (02/19/25 23:43:00) Lymphocytes %: 35 % (02/19/25 23:43:00) Monocytes %: 10 % (02/19/25 23:43:00) Eosinophils %: 2 % (02/19/25 23:43:00) Basophils %: 0 % (02/19/25 23:43:00) Absolute Neutrophil: 4.1 k/cumm (02/19/25 23:43:00) Absolute Lymphocyte: 2.8 k/cumm (02/19/25 23:43:00) Absolute Monocyte: 0.8 k/cumm (02/19/25 23:43:00) Absolute Eosinophil: 0.2 k/cumm (02/19/25 23:43:00) Absolute Basophil: 0 k/cumm (02/19/25 23:43:00) Chemistry: Sodium SerPl QN: 139 mmol/L (02/19/25 23:43:00) Potassium SerPl QN: 3.5 mmol/L (02/19/25 23:43:00) Chloride SerPl QN: 103 mmol/L (02/19/25 23:43:00) Carbon Dioxide SerPl QN: 27 mmol/L (02/19/25 23:43:00) Anion Gap: 9 mmol/L (02/19/25 23:43:00) BUN SerPl QN: 27 mg/dL High (02/19/25 23:43:00) Creatinine SerPl QN: 1.41 mg/dL High (02/19/25 23:43:00) Estimated GFR (CKD-EPI, no race): 59 mL/min/1.73m2 Low (02/19/25 23:43:00) Estimated CRCL (CG): 78 mL/min (02/19/25 23:43:00) Glucose SerPl QN: 137 mg/dL High (02/19/25 23:43:00) Calcium Total SerPl QN: 9.9 mg/dL (02/19/25 23:43:00) Troponin-I High Sensitivity: 148 ng/L High (02/20/25 01:25:00) Diagnostics Radiology Results - Last 24 hours Across Visits 02/19/2025 23:57 - XR Chest PA or AP Portable IMPRESSION: Cardiomegaly. Small left pleural effusion. Thank you for consulting our team of subspecialty radiologists at Medical Group Radiology. Please contact us with any questions. Signature Line Electronically Signed on 02/20/25 03:55 EST ________________________________________________________ MD