Prior Authorizations

	cephalexin (KEFLEX) 500 MG capsule	Take 1 capsule (500 mg total) by mouth 3 (three) times daily. Taking for 10 days
	cyanocobalamin, vitamin B-12, (VITAMIN B-12) 1,000 mcg Subl	Take 1 tablet 3x a week
	dilTIAZem (CARDIZEM LA) 120 mg 24 hr tablet	Take 1 tablet (120 mg total) by mouth daily.
	ferrous sulfate 324 mg (65 mg iron) TbEC	Take 1 tablet (324 mg total) by mouth daily with breakfast.
	ferrous sulfate 325 mg (65 mg iron) tablet (Expired)	Take 1 tablet (325 mg total) by mouth every other day.
	multivitamin (DAILY-VITE) tablet	Take 1 tablet by mouth daily.
	nitrofurantoin, macrocrystal-monohydrate, (MACROBID) 100 MG capsule	Take 1 capsule (100 mg total) by mouth 2 (two) times a day.
	potassium citrate (UROCIT-K) 10 mEq (1,080 mg) SR tablet	Take 1 tablet (10 mEq total) by mouth 2 (two) times a day.
	UNABLE TO FIND	Take 1 tablet by mouth daily. joint health supplement

I identified the patient by two identifiers at the time of entry into the room and at anytime I re-entered the room after exiting. Additionally, I reviewed the nursing assessment at the time of the appointment.

SUBJECTIVE:

HPI: _Judith E Coots_ is a _68 y.o._ _female_ who presents to the office today for a follow up of their chronic conditions as detailed below.

_ 1.	Hyperlipidemia, unspecified hyperlipidemia type
2.	Primary hypertension
3.	Chronic anemia
4.	Hypomagnesemia

Labs reviewed in detail. Hgb remains below her baseline. She feels good, no signs of bleeding, no shortness of breath or fatigue. Continues on a daily iron supplement

Continues to get her allergy shots.

Chronic UTI-following with Dr, Horner

Preventive care is UTD

The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history and problem list.

_Review of Systems

Respiratory: Negative for shortness of breath.

Cardiovascular: Negative for palpitations and leg swelling.

Gastrointestinal: Negative for constipation and diarrhea.

Skin: Negative for rash.

All other systems reviewed and are negative.

OBJECTIVE:


_ Wt Readings from Last 3 Encounters:
11/16/23	229 lb (103.9 kg)
08/31/23	228 lb 6.4 oz (103.6 kg)
08/26/23	231 lb (104.8 kg)

_ Physical Exam Vitals and nursing note reviewed.

Constitutional:

Appearance: Normal appearance. She is obese.

Neck:

Musculoskeletal: Normal range of motion and neck supple.

Thyroid: No thyromegaly.

Cardiovascular:

Rate and Rhythm: Normal rate and regular rhythm.

Pulses: Normal pulses.

Heart sounds: Normal heart sounds.

Pulmonary:

Effort: Pulmonary effort is normal.

Breath sounds: Normal breath sounds.

Musculoskeletal:

Cervical back: Normal range of motion and neck supple.

Lymphadenopathy:

Cervical: No cervical adenopathy.

Neurological:

General: No focal deficit present.

Mental Status: She is alert and oriented to person, place, and time.

Skin:

General: Skin is warm and dry.

Psychiatric:

Mood and Affect: Mood normal.

Behavior: Behavior normal.

Thought Content: Thought content normal.

Judgment: Judgment normal.

_Physical exam as documented by the NP student.

Labs:


_ Lab Results
Component	Value	Date
	WBC	4.6 (L)	11/15/2023
	HGB	8.5 (L)	11/15/2023
	HCT	26.6 (L)	11/15/2023
	PLT	215	11/15/2023
	CHOL	198	11/15/2023
	TRIG	142	11/15/2023
	HDL	55	11/15/2023
	LDLCAL	114.6	11/15/2023
	ALT	13	11/15/2023
	AST	19	11/15/2023
	NA	139	11/15/2023
	K	4.7	11/15/2023
	CL	109 (H)	11/15/2023
	CREATININE	1.37 (H)	11/15/2023
	BUN	33 (H)	11/15/2023
	CO2	21.5	11/15/2023
	TSH	1.497	11/15/2023
	INR	1.4 (H)	03/26/2023

ASSESSMENT / PLAN:

_Judith was seen today for hypertension, urinary tract infection and results.

Diagnoses and all orders for this visit:

Hyperlipidemia, unspecified hyperlipidemia type

- CBC and Differential; Future

- Comprehensive Metabolic Panel; Future

- LIPID PANEL; Future

- Magnesium; Future

Primary hypertension

- CBC and Differential; Future

- Comprehensive Metabolic Panel; Future

- LIPID PANEL; Future

- Magnesium; Future

Chronic anemia

- CBC and Differential; Future

- Comprehensive Metabolic Panel; Future

- LIPID PANEL; Future

- Magnesium; Future

- Iron; Future

- Ferritin; Future

- Transferrin; Future

Hypomagnesemia

- Magnesium; Future

Routine health maintenance:


_ Health Maintenance
Topic	Date Due
•	Covid-19 Vaccine (1)	Never done
•	Depression Screening	11/09/2023
•	Annual Medicare Wellness	05/09/2024
•	Fall Risk Assessment	08/26/2024
•	Mammogram	09/21/2024
•	Colorectal Cancer Screen	08/15/2026
•	Pre-Diabetes Screening	11/15/2026
•	Hepatitis C Screening	Completed
•	Influenza Vaccine	Completed
•	Pneumococcal Polysaccharide 65+ years	Completed
•	Osteoporosis Screening- Dexa Scan	Completed
•	Zoster/Shingrix	Completed

Follow Up: _No follow-ups on file._

_Robin R Jasinski, CRNP_

Dr. Erlikh was available as my collaborating physician.

Patient: _ Judith E Coots_ MRN: _1154358_ DOB: _6/12/1955_

Date: _8/31/2023_ Cardiology PA: _Sierra Rose Palochak, PA-C_ P CP: _Jasinski, Robin R, CRNP_

-------------------------------------------------------------------------------------------------------------------

Assessment :

1. Paroxysmal atrial fibrillation

1. Recently discovered during urological procedure in March 2023.

2. Underwent TEE guided DCCV and converted to sinus rhythm. Initiated on anticoagulation Xarelto.

3. Patient admitted to hospital for acute GI blood loss presenting with hematemesis and melanotic diarrhea but normal EGD and colonoscopy. Patient decided to discontinue anticoagulation in spite of risks for stroke; patient counseled on increased potential to convert back to atrial fibrillation due to underlying LA enlargement.

4. Thirty day event monitor without evidence of atrial fibrillation.

2. H/o of mildly reduced LV systolic function with recovery of normal LV function with an EF of 55% on most recent ECHO 3/21/23. 50% by echocardiogram in 2016, improved to 57% in October 2019. At this time, LV EF is grossly stable. Patient notes an upcoming procedure to remove additional ureteral stones and stenting for the right kidney. From the perspective of pre-operative clearance the patient is a low cardiac risk for a low risk procedure.

3. Hypertension

1. Blood pressure currently well controlled.

4. Hx of premature atrial complexes

1. compromising less than 1% of her beats on last Holter monitor from October 2019. Hx of greater than 10% burden PACs in 2016. Decline beta-blocker at that time. However, now on diltiazem 120 mg daily

5. Recent GI bleed in 3/2023

1. GI w/u EGD and colo unremarkable, no capsule study

6. Severe allergies requiring monthly allergy injections

7. History gastric bypass surgery

Plan

1. Paroxysmal atrial fibrillation

a. EKG is sinus rhythm. Thirty day event monitor without evidence of atrial fibrillation

b. Continue rate control with diltiazem.

c. With regards to anticoagulation she was admitted for acute GI bleed with hematemesis and melena. Had reportedly normal EGD and colonoscopy. Never underwent pill study. Patient made decision to discontinue anticoagulation despite risk for stroke.

d. Long discussion had today with regards to ongoing management for atrial fibrillation. Patient is very hesitant to pursue any type of anticoagulation therapy at this time. We did discuss the potential for Watchman procedure which he does not want at this time. She is aware of increased risk of thromboembolism/TIA/CVA with history of AFib off of anticoagulation

e. We discussed ways to monitor for recurrent atrial fibrillation at home. Cardia mobile device versus pulse rate checks. Patient notes that she will pick up a cardia mobile diet by signed contact office if any recurrent arrhythmias noted.

f. Patient is adamant if blood thinners are needed in the future she does not wish to take Eliquis as this is a Pfizer medication.

2. Hypertension

a. Well controlled by log. History of white coat hypertension.

b. Continue current antihypertensive agents.

c. Home monitoring discussed.

3. Recent GI bleed March 2023

a. GI w/u EGD and colo unremarkable, no capsule study

4. Severe allergies

a. Continue with injections

5. History of gastric bypass surgery.

-----------------------------------------------------------------------------------------------------------------

Chief Complaint: Follow-up atrial fibrillation prior

History of Present Illness:

Judith E Coots is a 68 y.o. female with a history of gastric bypass surgery and hypertension who presents today for follow-up

Was hospitalized March of 2023. Patinet presented to hospital in March for development of ureteral stone that required stone extraction and stenting. Was found to have AKA. During the urological procedure, the patient developed atrial fibrillation. She subsequently underwent TEE and DCCV which converted her back to sinus rhythm. She returned to the hospital on 3/26/23 with acute GI blood loss, Hgb 4.9, requiring 4 units of blood transfusion. She had a EGD and colonoscopy which were normal. At that time, patient had decided to discontinue the anti-coagulation due to the bleeding issue. She was counseled on her increased risk for stroke without continuing on anti-coagulation.

The patient presents today for follow-up.

The patient states that they are doing well from a cardiovascular standpoint. They voiced no symptomatic cardiac complaints today. Pt denies chest pain, shortness of breath, lightheadedness, dizziness, presyncope, syncope, PND, orthopnea, lower extremity edema, palpitations.

Medications

Previously stopped on Xarelto secondary to GI bleed with hemoglobin low. Does not wish to resume today. She is aware of increased risk for thromboembolism given history of atrial fibrillation off of anticoagulation.

Blood Pressure:

Health Port BP cuff:

Pressure log demonstrates well-controlled blood pressures. SBP 114-129 mmHg. DBP 60 - 84 mmHg

Pulse:

68 - 81 BPM

_ Current Medications

	Start	End
cephalexin (KEFLEX) 500 MG capsule	8/26/2023	9/5/2023
Sig - Route: Take 1 capsule (500 mg total) by mouth 3 (three) times daily for 10 days. - Oral
cyanocobalamin, vitamin B-12, (VITAMIN B-12) 1,000 mcg Subl	6/20/2023
Sig: Take 1 tablet 3x a week
Class: No Print
dilTIAZem (CARDIZEM LA) 120 mg 24 hr tablet	7/7/2023	7/6/2024
Sig - Route: Take 1 tablet (120 mg total) by mouth daily. - Oral
ferrous sulfate 324 mg (65 mg iron) TbEC
Class: Historical Med
ferrous sulfate 325 mg (65 mg iron) tablet	3/29/2023	5/28/2023
Sig - Route: Take 1 tablet (325 mg total) by mouth every other day. - Oral
multivitamin (DAILY-VITE) tablet
Class: Historical Med
potassium citrate (UROCIT-K) 10 mEq (1,080 mg) SR tablet	7/5/2023
Class: Historical Med
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 mg per tablet	8/23/2023
Class: Historical Med
UNABLE TO FIND
Class: Historical Med

_No Known Allergies_


_ Past Medical History:
Diagnosis	Date
•	Anemia
	hx of , on and off
•	Asthma
	ALLERGY INDUCED, / NO INHALER USE NOW/ MAY 2016
•	Environmental allergies
	ON ALLERGY SHOTS MONTHLY
•	PFO (patent foramen ovale)
•	Premature atrial beats
•	Primary osteoarthritis of right knee


_ Past Surgical History:
Procedure	Laterality	Date
•	CESAREAN SECTION
	1980
•	COLONOSCOPY
	X2
•	CYSTOSCOPY W/ LASER LITHOTRIPSY	Right	6/27/2023
	Procedure: RIGHT URETEROSCOPY, LASER LITHOTRIPSY, STENT PLACEMENT; Surgeon: Horner, Scott A, MD; Location: RH MAIN OR; Service: Urology; Laterality: Right;
•	GASTRIC BYPASS
	2008
•	KNEE ARTHROSCOPY	Right	y-19
•	LEFT TOTAL HIP REPLACEMENT	Left	10/05/2016
	longenecker
•	RIGHT TOTAL KNEE REPLACEMENT	Right	06/07/2016
	Longenecker


_ Immunization History
Administered	Date(s) Administered
•	Flu (Quad) MDV w/Preserv =/>3 years	10/23/2015, 10/30/2018
•	Flu (Quad) PF =/>6 mo	10/10/2017
•	Flu (quad) PF =/>3 yr	10/05/2016, 10/30/2018
•	Flublok Quad Egg Free =/>18 yrs (High Dose)	10/21/2020, 11/09/2022
•	Influenza, Unspecified Formulation	09/30/2021
•	Pneumococcal Conj (Prevnar13)	10/06/2016
•	Pneumococcal Poly(Pneumovax 23)	08/25/2020
•	Shingrix	08/16/2018, 10/31/2018


_ Family History
Problem	Relation	Age of Onset
•	Heart disease	Mother
•	Heart disease	Father
•	Asthma	Daughter
•	Cancer	Maternal Aunt
•	Diabetes	Maternal Aunt
•	Stroke	Maternal Aunt

_ Social History


Socioeconomic History
•	Marital status:	Married
		Spouse name:	Not on file
•	Number of children:	Not on file
•	Years of education:	Not on file
•	Highest education level:	Not on file
Occupational History
•	Not on file
Tobacco Use
•	Smoking status:	Never
		Passive exposure:	Never
•	Smokeless tobacco:	Never
Vaping Use
•	Vaping Use:	Never used
Substance and Sexual Activity
•	Alcohol use:	No
•	Drug use:	No
•	Sexual activity:	Yes
		Partners:	Male
		Comment: husband
Other Topics	Concern
•	Not on file
Social History Narrative
•	Not on file

Social Determinants of Health


Financial Resource Strain: Unknown
•	Difficulty of Paying Living Expenses: Patient refused
Food Insecurity: Not on file
Transportation Needs: Not on file
Physical Activity: Not on file
Stress: Not on file
Social Connections: Not on file
Intimate Partner Violence: Not on file
Housing Stability: Low Risk
•	Unable to Pay for Housing in the Last Year: No
•	Number of Places Lived in the Last Year: 1
•	Unstable Housing in the Last Year: No

Review of Systems: (Positives are bold, others negative.)

Constitutional: Fever - Appetite Change - Fatigue - Weight Change.

Eyes: Redness - Itching - Vision Loss.

ENT: Sore Throat - Ear Pain - Sinus Congestion.

Respiratory: Breathlessness - Cough - Wheezing - Hemoptysis - Pleuritic Pain.

Cardiovascular: Chest Pain - Lightheadedness - Syncope - Palpitations.

Gastrointestinal: Nausea - Vomiting - Constipation - Diarrhea - Melena.

Genitourinary: Dysuria - Hematuria - Urinary Frequency.

Musculoskeletal: Myalgias - Joint Swelling/Pain/Tenderness/Redness.

Skin: Rash - Bruising - Itching.

Neurological: Dizziness - Weakness - Numbness - Slurred Speach.

Hematological: Enlarged Lymph Nodes - Pallor - Night Sweats

Psychiatric/Behavioral: Behavioral Problems - Confusion - Memory Loss..

(Comprehensive Review of Systems findings reviewed personally)

Physical Examination:

Vital Signs:

_	6/27/2023 9:30 AM	6/27/2023 9:40 AM	7/12/2023 9:09 AM	7/19/2023 10:00 AM	7/26/2023 9:29 AM	8/18/2023 9:42 AM	8/26/2023 10:23 AM
Vitals - 1 value per visit
SYSTOLIC	148	154	122	124	132	138	150
DIASTOLIC	80	74	74	62	82	80	82
Heart Rate	69		73	63	71	67	68
Temp	36.6 °C (97.9 °F)	36.5 °C (97.7 °F)	36.7 °C (98 °F)	36.6 °C (97.8 °F)	36.6 °C (97.8 °F)	36.2 °C (97.2 °F)	36.8 °C (98.2 °F)
Resp	19	18	16	16	18	16	20
SpO2	100 %	99 %	98 %	100 %	99 %	98 %	100 %
Weight (lb)							231
Weight (kg)							104.781
BMI							38.44 kg/m2 38.44 kg/m2
BSA (m2)							2.19 m2 2.19 m2
Visit Report							Report

General appearance: Well appearing. No acute distress .

Eyes: Pupils equal, extraocular motion grossly intact .

Ears, nose, throat, neck: Oropharynx clear, neck supple.

Respiratory: Symmetric chest expansion . Clear breath sounds with no crackles or wheezes .

Cardiovascular: Neck veins not distended. Carotid upstrokes are palpable. S1 and S2 are regular. Sclerotic aortic valve, rubs or gallops.

Gastrointestinal: Abdomen is soft and nontender with normal bowel sounds .

Extremities : Distal pulses palpable. No edema.

Skin: No rash .

Musculoskeletal: Grossly intact .

Neuro: Alert and fully oriented. Face symmetric. Strength grossly intact .

Psychiatric: Affect and judgment appear appropriate .


_ Recent Labs
Lab	08/03/23 1150	07/05/23 1054	04/03/23 1100	03/29/23 0419	03/28/23 0342
NA	137	139	138	138	139
K	5.1	4.2	3.7	3.6	4.1
CL	106	107	103	104	105
CO2	23.6	22.6	26.0	25.5	26.0
BUN	35*	38*	12	11	18
CREATININE	1.60*	1.79*	1.30	1.42*	1.40*
GLUCOSE	89	90	85	92	88

_CrCl cannot be calculated (Patient's most recent lab result is older than the maximum 7 days allowed.)._


_ Recent Labs
Lab	08/03/23 1150	07/05/23 1054	05/03/23 0920	03/27/23 0322	03/26/23 0534	03/20/23 0229	03/19/23 1150
CALCIUM	9.3	< >	--	< >	8.2*	< >	--
MG	--	--	1.9	< >	--	< >	--
ALT	--	--	--	--	22	--	--
AST	--	--	--	--	23	--	--
TSH	--	--	--	--	--	--	0.978
< > = values in this interval not displayed.


_ Recent Labs
Lab	05/03/23 0920	11/08/22 0924
CHOL	174	207*
TRIG	157	157*
HDL	46	57
LDLCAL	96.6	123*


_ Recent Labs
Lab	06/13/23 1459	05/03/23 0920	04/03/23 1100
WBC	7.0	5.7	4.5*
HGB	10.2*	8.7*	9.4*
HCT	33.9*	28.1*	29.7*
PLT	232	282	210


_ Recent Labs
Lab	03/26/23 0534	03/21/23 0421	03/18/23 1410
INR	1.4*	1.3*	1.4*

_‌_

Cardiology Studies :

EKG: (EKG tracings reviewed personally) sinus rhythm heart rate 70 beats per minute. No ST changes.

Event monitor

Thirty day event monitor showing predominantly sinus rhythm at a heart rate of 73 beats per minute with a moderate frequency of premature ventricular complexes and premature atrial complexes.. It is of bigeminal PVCs with short, 4 beat run of nonsustained ventricular tachycardia at 119 beats per minute. There was no atrial fibrillation.

Instructions

Narrative & Impression

Ventricular Rate^70^BPM

Atrial Rate^70^BPM

P-R Interval^166^ms

QRS Duration^76^ms

Q-T Interval^386^ms

QTC Calculation(Bazett)^416^ms

P Axis^57^degrees

R Axis^7^degrees

T Axis^56^degrees

Normal sinus rhythm

Low voltage QRS

When compared with ECG of 14-JUN-2023 13:54,

No significant change