Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Cough, Decreased appetite, Diarrhoea, Dyspnoea exertional, Electrocardiogram normal
Clinical narrative: Basic Information  Time Seen:   Chief Complaint   pt reports worsening cough since thursday. pt reports diarrhea is slowly improving since Friday night. pt reports subjective fevers and chill. no nausea. pt reports exertional shortness of breath but no chest pain  History of Present Illness      58-year-old male with a history of type 2 diabetes (not on any medications), vaccinated for COVID-19, presenting to the ED for evaluation of diarrhea and fatigue. Initial onset of 10/29/2021 where patient describes having 4-5 loose diarrheal stools that are nonbloody.  Associate with loss of appetite but no nausea, vomiting or abdominal pain.  Patient does endorse a nonproductive cough and associated with exertional shortness of breath/fatigue.  Associated with chills and subjective fevers at home.  Denies chest pain.  Denies any recent antibiotic use in the past 2 months.  Denies recent hospitalizations.  Unknown if he has been exposed to COVID-19 or influenza.  Review of Systems      Constitutional: Endorses fever. Endorses chills. Skin: No rashes. No lesions. Eye: No visual problems ENT: No sore throat. No nasal congestion. Resp: Endorses cough. Endorses SOB. No wheezing. CV: No chest pain. GI: No abdominal pain. No nausea. No vomiting. Endorses diarrhea. GU: No dysuria. No hematuria. MSK: No back pain. Neuro: No headache. No numbness. No tingling. Noweakness. Psych: No anxiety.  _ All other systems reviewed and are otherwise negative. ROS reviewed as documented in chart.  Physical Exam  Vitals & Measurements  T: 36.9 °C  HR: 93  RR: 18  BP: 139/76  SpO2: 95%  WT: 100.4 kg      General: A&Ox3, NAD Skin/Wound: warm, dry, intact HEENT: Pupils are equal, round and reactive to light.  Tongue appears dry Cardiac: RRR, Normal S1/S2, distal radial pulses symmetric Pulmonary: CTAB, no wheezes GI: soft, non-tender, no rebound or guarding Extremity: normal ROM, no cyanosis, no edema Back: No CVA tenderness, no tenderness to palpation along spine Neuro: CN II-XII grossly intact, strength and sensation intact throughout Psych: cooperative, appropriate mood and affect  Medical Decision Making     58-year-old male with a history of type 2 diabetes (not on any medications), vaccinated for COVID-19, presenting to the ED for evaluation of diarrhea and fatigue since 10/29/2021.  -Initial vitals reviewed within normal limits.  Of note, point-of-care glucose in triage was 209.  -On exam patient is nontoxic-appearing.  Appears tired but comfortable.  Dry oral mucosal membranes.  Clear lung sounds bilaterally with no wheeze.  Benign abdominal exam.  -Chart review performed and shows that patient is not in our system as far back as 2010.  -Labs including CBC, CMP, troponin, Rapid COVID-19 were reviewed and most notable for testing positive COVID-19, elevated creatinine 1.3 however we do not know patient's baseline, decreased bicarb down to 18 with anion gap.  Otherwise no leukocytosis, no anemia.  -Given the anion gap, poor p.o. intake, case was discussed with ED observation team who agreed to admit the patient for his AKI, continue fluid for hydration, and monitor p.o. intake.  Patient is amendable.  Not on any supplemental oxygen.  Reexamination/Reevaluation     Hemodynamically stable on reevaluation's  Assessment/Plan      1. AKI (acute kidney injury)     2. COVID-19 virus detected     3. Fatigue     4. Hyperglycemia     Orders:   Influenza A and B Antigen Rapid  XR Chest Portable