Assessment аnd Plаn: HPI: Agаtha Dubоis is a 65-year-оld female patient whо presents with a complaint of noticing blood in the toilet after she urinated a few days ago. Pt reports this episode occurred once 3 days ago and has not returned since. She reports the toilet water was tinged red when she got up. She reports that she had two prior similar episodes 6-7 months ago and sought care online via a telehealth platform through her job. She reports she was diagnosed with a “UTI” and was treated with an antibiotic (cannot recall which one), and states no testing was actually done to assess her. She reports no recurrence of the blood since that time, until 3 days ago, so she hadn’t worried about it until now. Pt admits to increased nocturia, with a sense of urinary urgency at times during the day. She reports no dysuria, flank pain, decreased urine output, incontinence, or abdominal pain associated with this and is unsure when the blood shows up (i.e., cannot distinguish if it is the entire stream, versus start or end). She reports no fever, night sweats, or chills. When specifically asked, the pt could not be entirely sure that the blood was in her urine versus vaginal bleeding that ended up in the toilet. She feels generally confident that it came from urination, however. Pt reports no symptoms prior to this occurring 6-7 months ago. Pt denies other associated symptoms and denies preceding trauma, exercise prior onset, injury, or recent fall. No recent or remote international travel. She denies easy bruising or bleeding otherwise. No constipation, straining at stool, melena, or blood in stool reported. She denies eating beets, red food coloring, or other red-colored food items. Medications: Metoprolol Succinate (ER) 50mg PO daily HCTZ 25mg PO daily Atorvastatin 40mg PO QHS No over-the-counter medications taken at this time Allergies: Sulfa Drugs (causes lip swelling and rash) Past Medical History: Chronic conditions: Primary Hypertension (diagnosed 20 years ago) Hyperlipidemia (diagnosed 20 years ago) No known bleeding disorder or hx of abnormal bleeding Surgeries: Benign thyroid nodule removal (age 55) R wrist fracture ORIF repair (age 42) due to a fall Health Maintenance/Immunizations: Up-to-date on most recommended, age-appropriate vaccines including COVID, influenza, Tdap. Pt reports she has not had a shingles or a pneumonia vaccine when asked. Pt’s last colonoscopy was 15 years ago at age 50 (no concerning findings reported). Pt has not yet completed any osteoporosis screening OB-GYN: G2P2002. Both spontaneous vaginal births with minimal complications of note. Pt completed routine pap smears/exams until age 60, at which time pt discontinued seeking women’s health care. She reports having an abnormal pap smear at age 50, but negative HPV testing throughout the years. She states the abnormality required “watching only”. Family History: Father: alive, 89 years old. Known hx of hypertension, hyperlipidemia, dementia. Mother: alive, 88 years old. Known hx of obesity, melanoma skin cancer (s/p Mohs surgery for removal), HTN, and diabetes type 2. Sister 1: alive, age 62, history of Type 2 DM, obesity, high cholesterol Sister 2: alive, age 64, history of thyroid cancer s/p thyroidectomy, chronic back pain Children: two, both alive and well Child 1 (female): Age 30, healthy Child 2 (male): Age 32, healthy Social History: Tobacco/Vape: Hx of tobacco use (age 20-50, has quit since age 50, reports smoking half pack to full pack per day during those years; with an estimated 22.5 pack/year hx) Alcohol: An occasional glass of wine on weekends Illicit drugs: Denies drug use Marital/Sexual: Pt is widowed (husband died 6 years ago from colon cancer), recently started dating again and has a new male partner as of 3 months ago. She is sexually active with that person and reports no use of contraceptive or birth control. Living situation: Lives in a condo in Santee Job: Retired nurse Hobbies: Golf, learning to sew/crochet, and loves photography Diet: Normal, no current restrictions or dietary allergies Religion: Atheist Sleep: Averages 6-7 hours of sleep per night ROS: Constitutional: See HPI. No changes in appetite. No reported unexplained weight loss or gain recently. Skin: Denies hair changes, nail changes, rash, lesions, bruising, or skin discoloration. HEENT: Denies rhinitis, sore throat, congestion, ear pain or discharge, eye pain or change in vision, or headache. Denies hearing loss, tinnitus, or nasal discharge. No lymph node or gland swelling reported. CV/PV: No chest pain, palpitations, swelling, cyanosis, or edema of extremities. No syncope reported. Pulmonary: No cough, SOB, dyspnea, orthopnea, or PND. GI: See HPI. Denies constipation, diarrhea, fecal incontinence, abdominal distention, or heartburn. No blood in stool reported or dark/tarry stools. GU: See HPI. Denies urinary incontinence, dysuria, or flank pain. MSK: Denies muscle aches/pain, joint swelling, or joint discoloration. No changes in gait. No back pain, neck pain, or joint pain. Neuro: Denies headaches, dizziness or lightheadedness, speech changes, slurred speech, numbness or weakness anywhere. Denies seizures, tremors, or confusion. Psych: Denies depression, mania, suicidal ideation, homicidal ideation or hallucinations. Endocrine: Denies heat or cold intolerance, polydipsia, or polyphagia. Heme/Lymph: Denies easy bruising or gum bleeding.
Nitrоgen fixаtiоn, the cоnversion of N2 to NH3, is аn ecologicаl service provided primarily by:
Apprоximаtely hоw mаny billiоns of yeаrs ago did Earth form?