Age: 60.0
Sex: M
Vaccine: COVID19
Symptoms: Platelet count normal, Pleuritic pain, Productive cough, Protein total normal, Red blood cell count normal
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: NP on July 19, 2022 15:54   Verified By: NP on July 19, 2022 15:54    Encounter Info: Hospital, Emergency, 07/19/22 - 07/19/22    * Final Report *        Basic Information  Time Seen: NP / 07/19/2022 12:59  Chief Complaint  COVID Pos SOB  History of Present Illness     Patient presents via  private vehicle due to  loss of voice, cough DOE, pleuritic chest pain. Covid +, day 6  since dx  per home test. Denies fever. VS are normal. Patient is vaccinated and has not received paxolovid or monoclonal therapy.. Patient denies n/v/d, abd pain .   Add'l medical hx includes:  Factor V leiden on eliquis, cardiomyopathy, HTN, DVT Social hx:  non smoker  Review of Systems     Constitutional: Fatigue,  body aches  Eye: Negative.   Ear/Nose/throat: ST  RR: cough productive, SOB, pleuritic chest pain  Cardiovascular: Negative.   Gastrointestinal: negative  Hematology/Lymphatics: Negative.   Endocrine: Negative.   Immunologic: Negative.   Musculoskeletal: myalgias   Integumentary: Negative.   Neurologic: Negative.   Psychiatric: No anxiety, No depression.   All other systems are negative   Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.4 DegC  Heart Rate:       83 bpm  Resp Rate:       23 br/min  BP #1:       157 / 91 mmHg  SpO2 (%):       96 %     Height CM: 185.4 cm  Weight KG: 95 kg  BSAM2 Weight in kg: 2.21 m2  BMI Weight in kg: 27.6 kg/m2  Ideal Body Weight: 79.88 kg     General: Alert and oriented, non toxic in appearance  Eye: Pupils are equal, round and reactive to light, Normal conjunctiva.   HENT: Normocephalic, Tympanic membranes are clear. Pharynx red, no exudate, mucous membranes moist  Neck: Non-tender No lymphadenopathy,   Cardiovascular: Regular rate, Normal rhythm, S1, S2. No edema  Respiratory: Lungs are coarse, scattered rhonchi, Respirations are non-labored. No crackles, no wheezes. No RR distress  Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds,   Integumentary: Warm, Dry, Intact. No rash  Neurologic: Alert, Oriented, Normal sensory, Normal motor function, No focal defects,   Psychiatric: Cooperative, Appropriate mood & affect.  Medical Decision Making     EKG   Time completed: 1326  Rhythm: NSR  Interp: NSR, normal intervals, no STEMI; interpreted by Dr.   rate: 77  QT/QTC: 372/420    Symptoms consistent with Covid 19 infection  No SIRS criteria  Patient does not meet criteria for admission at this time.   Chest XR possible infiltrate- azithromycin and albuterol MDI prescribed.  Prednisone burst prescribed for pharyngitis  No RR distress, maintaining room air sats > 93% without increased work of breathing  Patient is outside the window for Paxlovid or monoclonal therapy  Patient verbalizes understanding of quarantine instructions            Condition     stable  Assessment/Plan       1. COVID-19        2. Pneumonia due to COVID-19 virus        Orders:   albuterol, 2 Puff, Inhalation, 4 Times Daily, PRN for wheezing, Maintenance, Dispense: 1 Each, Refills: 0, Total Refills: 0, 07/19/22 15:45:00, Pharmacy: pharmacy, 2 Puff Inhalation 4 Times Daily,PRN:for wheezing, 185.4, cm, 07/19/22 13:30:00...  azithromycin, See Instructions, Orally, for 5 Days, Acute, Dispense: 6 Tablet, Refills: 0, Total Refills: 1, 2 Tablets Orally on Day 1 then 1 Tablet Orally Daily on Days 2-5., 07/19/22 15:45:00, 07/24/22 15:45:00, Pharmacy: pharmacy, 2 Tablets Ora...  predniSONE, 50 mg, = 1 Tablet, Orally, Daily, for 5 Days, Acute, Dispense: 5 Tablet, Refills: 0, Total Refills: 1, 07/19/22 15:45:00, 07/24/22 15:45:00, Pharmacy: pharmacy, 1 Tablet Orally Daily,x5 Days, Supply, 185.4, cm, 07/19/22 13:30:00,...  **Coronavirus SARS-CoV2 Rapid  Auto Diff  BNP Pl QN  CBC w/Differential  Comp Metabolic Panel  COVID 19 PCR  D-Dimer Pl QN  Discharge Patient  Electrocardiogram  Lactate Pl Venous QN  Peripheral IV Insertion  Troponin-I High Sensitivity  XR Chest PA or AP   Patient Education   Coronavirus Disease 2019: Caring for Yourself and Others  Follow Up        With  When  Contact Information         Additional Instructions: Please return to the ER if you develop worsening chest pain or shortness of air. You may contact virtual Covid 19 tele health for questions or concerns. Results of testing are expected in 24-72 hours. Quarantine required until resulted. Currently the CDC recommends quarantine for all who test positive for Covid 19 for 5 days and  IF ASSYMPTOMATIC at that time, they may leave quarantine if they adhere to strict mask wearing around others for an additional 5 days. If you are still symptomatic please remain in quarantine.      Current CDC recommendations for quarantine for those EXPOSED to COVID 19 but WITHOUT any symptoms:      If vaccinated within 6 months or vaccinated and boosted : wear a mask around others for 10 days, test on day 5.  If you develop symptoms quarantine and test.   If unvaccinated, vaccinated > 6 months ago and not yet boosted: quarantine for 5 days, test on day 5, then wear a mask around others for 5 days.      Previous Covid infection is not considered a vaccination.         Chronic Problem List    Benign neoplasm of ascending colon  Benign neoplasm of sigmoid colon  Cardiomyopathy  Essential hypertension  Factor V Leiden mutation  Insomnia  Male erectile disorder  Personal history of colonic polyps  Right leg DVT  Procedure/Surgical History  ?Eye Exam (09/08/2020) ?Cardiac catheterisation (12/04/2017) ?Lesion removal colonoscopy (03/10/2017) ?Colonoscopy (03/02/2017) ?Anal fistula operation ?Fatty tumor removed ?Hemorrhoidectomy    Medications  Home Medications (7) Active azithromycin 250 mg oral tablet See Instructions, Orally, 2 Tablets Orally on Day 1 then 1 Tablet Orally Daily on Days 2-5. Bystolic 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily Levitra 10 mg oral tablet 10 mg = 1 Tablet, PRN, Orally, As Directed, doses should be taken at least 24 hours apart predniSONE 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily traZODONE 50 mg oral tablet 1-2 Tablet, Orally, At Bedtime Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, 4 Times Daily Xarelto 20 mg oral tablet 20 mg = 1 Tablet, Orally, Every PM  Medication Administration   Given  dexamethasone, 6 mg, IV Push  Allergies   penicillin (Hives)  sulfa drugs (Hives)  Social History    Alcohol   Denies, 6 drinks/episode average. 10.00 drinks/episode maximum. Ready to change: Yes.   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description: Financial advisor.   Hobbies/Interests   Bicycling Sports/Fitness.   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   High blood pressure..: Mother and Father.  Macular disease: Mother.  Lab Results       Hemogram-Platelets-WBC Differential  LATEST RESULTS  HISTORICAL RESULTS          WBC  07/19/22 13:39  5.7  03/16/21  8.2          RBC  07/19/22 13:39  5.57  High  03/16/21  5.17          Hgb  07/19/22 13:39  16.2  03/16/21  15.7          Hct  07/19/22 13:39  48.8  03/16/21  47.2          MCV  07/19/22 13:39  88  03/16/21  91          MCH  07/19/22 13:39  29.0  03/16/21  30.3          MCHC  07/19/22 13:39  33.1  03/16/21  33.2          RDW  07/19/22 13:39  13.3  03/16/21  13.0          Platelet  07/19/22 13:39  235  03/16/21  308          MPV  07/19/22 13:39  7.6  03/16/21  8.2          Neutrophils %  07/19/22 13:39  49  03/16/21  51          Lymphocytes %  07/19/22 13:39  42  03/16/21  38          Monocytes %  07/19/22 13:39  7  03/16/21  9          Eosinophils %  07/19/22 13:39  1  03/16/21  1          Basophils %  07/19/22 13:39  0  03/16/21  0          Absolute Neutrophil  07/19/22 13:39  2.8  03/16/21  4.2          Absolute Lymphocyte  07/19/22 13:39  2.4  03/16/21  3.2          Absolute Monocyte  07/19/22 13:39  0.4  03/16/21  0.8          Absolute Eosinophil  07/19/22 13:39  0.1  03/16/21  0.1          Absolute Basophil  07/19/22 13:39  0.0  03/16/21  0.0          Routine Coagulation Studies  LATEST RESULTS        D-Dimer Pl QN  07/19/22 13:39  <200           Routine Serum/Plasma Chemistry Tests LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  07/19/22 13:39  137  03/16/21  139          Potassium SerPl QN  07/19/22 13:39  3.9  03/16/21  4.1          Chloride SerPl QN  07/19/22 13:39  102  03/16/21  104          Carbon Dioxide SerPl QN  07/19/22 13:39  25  03/16/21  27          Anion Gap  07/19/22 13:39  10  03/16/21  8          BUN SerPl QN  07/19/22 13:39  18  03/16/21  16          Creatinine SerPl QN  07/19/22 13:39  0.93  03/16/21  0.98          Estimated GFR (CKD-EPI)  07/19/22 13:39  88  03/16/21  84          Estimated GFR (CKD-EPI, no race)  07/19/22 13:39  >90              Estimated CRCL (CG)  07/19/22 13:39  101  03/16/21  102          Glucose SerPl QN  07/19/22 13:39  120  High  03/16/21  109  High          Calcium Total SerPl QN  07/19/22 13:39  9.1  03/16/21  9.1          Alkaline Phos SerPl QN  07/19/22 13:39  54  03/16/21  56          ALT SerPl QN  07/19/22 13:39  31  03/16/21  25          AST SerPl QN  07/19/22 13:39  22  03/16/21  17          Bilirubin Total SerPl QN  07/19/22 13:39  0.6  03/16/21  0.8          Total Protein SerPl QN  07/19/22 13:39  7.2  03/16/21  7.2          Albumin SerPl QN  07/19/22 13:39  3.8  03/16/21  4.1          Troponin-I High Sensitivity  07/19/22 13:39  4              BNP Pl QN  07/19/22 13:39  16              Lactate Venous Pl QN  07/19/22 13:39  1.3              Molecular Diagnostic Tests  LATEST RESULTS        COVID 19 Specimen Source  07/19/22 13:39  Nasal        Coronavirus SARS-CoV2 Rapid  07/19/22 13:39  Detected Abnormal      Diagnostic Results  XR Chest PA or AP    07/19/22 13:54:57  IMPRESSION:  1. Nonspecific mildly increased interstitial opacities within the  lung bases.   Thank you for consulting our team of subspecialty radiologists at Physicians Radiology. Healthcare providers wishing to discuss  this case further can contact the Reading Room.  For after-hours or emergency department cases, please call.   Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 07/19/22 15:54 ________________________________________________________ NP