Age: 59.0
Sex: M
Vaccine: COVID19
Symptoms: Normocytic anaemia, Oropharyngeal pain, Pharyngeal erythema, Platelet count increased, Pneumonia
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on December 11, 2022 15:09   Verified By: MD on December 12, 2022 20:04   Encounter Info: Hospital, Inpatient, 12/11/22 -     * Final Report *        Basic Information  Time Seen: MD / 12/11/2022 14:50  Chief Complaint  Cough/ Sore Troat  History of Present Illness     Patient is a 61-year-old male with a history of atrial fibrillation, not on any medications, who presents to the ED today for evaluation of cough, malaise, difficulty sleeping, dyspnea, and diarrhea.  Patient reports that his symptoms been ongoing for 1.5 weeks.  They have been worsening recently and he notes the cough is kept him from sleeping.  He does endorse subjective fevers, mild headache, and myalgias starting a few days after the cough began.  He also describes some soreness in the flank which is present with coughing.  Notes that his sister has been ill, and she does live with him.  He denies chest pain, nausea, vomiting, hematochezia or melena.  He denies taking any medications at this time.  Notes that he was formerly on Eliquis but is not taking it anymore.  Denies any over-the-counter medication use.  Review of Systems     A 10+ point, complete review of systems was obtained and was negative unless otherwise noted in the HPI  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       37.1 DegC  Heart Rate:       74 bpm  Resp Rate:       20 br/min  BP:       136 / 81 mmHg  SpO2 (%):       94 %  O2 Device:       Room air     Weight KG: 96.8 kg     General: Patient is awake, alert, oriented to person, place, and time. Frequent coughing spells HEENT: NCAT. EOMI. Conjunctiva without injection or exudate. Oropharynx with slight postnasal drip and slight erythema although no tonsillar hypertrophy or exudates noted. Mucous membranes are tacky. Nose without discharge. Respiratory: Frequent coughing with scattered crackles most on the left. Intermittent wheezing with cough only. Breathing is non-labored. Cardiovascular: Heart is irregularly irregular and tachycardic. Chest wall slightly tender across right ribs. Abdomen: Abdomen is soft and nontender, nondistended, without guarding or rebound. No peritoneal signs. Normal, active bowel sounds. Musculoskeletal: Extremities without deformity or tenderness. Normal joint range of motion. Integument: No rashes or lesions. Neurologic: Cranial nerves II-XII are grossly intact, no focal deficits. Strength (5/5) and equal in BUE and BLE. Sensation to light touch intact and equal in bilateral upper and lower extremities.  Medical Decision Making     Patient was evaluated in the ED.  History obtained and exam performed.  Vital signs as documented.  Differential diagnosis is broad and includes pneumonia versus viral process.  Patient does describe some right-sided chest discomfort which began after his cough and I suspect is likely musculoskeletal in etiology.  He has also had some loose stools but does not have any vomiting and abdomen is completely soft and nontender on examination so my concern for an acute intraabdominal process is low.  Do believe PE to be less likely given pulmonary exam, frequent coughing.  Similarly given lack of significant chest discomfort, do believe ACS to be less likely, however will obtain a troponin and EKG to further evaluate. Will provide him with some Tylenol as well as some IV fluids.  Labs obtained as indicated.   15:25 EKG: Rate of 135: Irregularly irregular, appears to be aFib vs variable flutter. Narrow QRS with borderline QT. Significant baseline artifact but no obvious evidence of STEMI.   CBC with leukocytosis of 16.1.  Mild normocytic anemia.  Patient does have a slight thrombocytosis.  Elevated PT/INR.  Patient is hypokalemic with mildly elevated BNP.  Normal troponin and magnesium.  Normal lactate.  Normal TSH.  COVID and flu negative.   Chest x-ray shows some patchy bibasilar opacities slightly more prominent on the left but could be bilateral infectious process.   Did order small dose of metoprolol which did control his rate after fluid administration. Did order potassium repletion. Did order rocephin and doxy for antibiotic coverage.  12/11/22 15:35:33 Re-assessment: Patient is continuing to cough and is hypoxic requiring a couple liters of oxygen. I discussed XR findings of possible pneumonia. Denies history of CHF. Discussed plan to have pt admitted. The pt is agreeable with the plan for admission. All questions addressed. Messaged hospitalist regarding admission.  12/11/22 18:53:15: Pt has been accepted for admission by Dr., Hospitalist, to inpatient med surg.     Assessment/Plan     Pneumonia  Afib with RVR  Hypokalemia  Elevated PT/INR  Elevated BNP  Leukocytosis  Thrombocytosis   Attestations  I, acting as scribe for Dr.      Signed by Scribe, at 12/11/22 15:07:12  I, acting as a scribe for Dr. on 12/11/22 18:53:32. Signed, 12/11/22 18:53:32.  I, attest that the scribe?s documentation has been prepared under my direction and personally reviewed by me in its entirety. I confirm that the note above accurately reflects all work, treatment, procedures, and medical decision-making performed by me.   Chronic Problem List    Actinic keratosis  Biceps muscle tear  Bilateral hearing loss due to cerumen impaction  BPH (benign prostatic hyperplasia)  Cerumen impaction  Colon cancer screening  Encounter for preventative adult health care examination  Osteoarthritis  Paroxysmal atrial fibrillation  Procedure/Surgical History  ?Colonoscopy  Medications  Denies  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   Never   Substance Abuse   Denies   Tobacco   Tobacco Use: Never Smoker.  Lab Results      Hemogram-Platelets-WBC Differential FS  LATEST RESULTS        WBC  12/11/22 15:34  16.1  High        RBC  12/11/22 15:34  4.40        Hgb  12/11/22 15:34  13.0  Low        Hct  12/11/22 15:34  38.4  Low        MCV  12/11/22 15:34  87        MCH  12/11/22 15:34  29.4        MCHC  12/11/22 15:34  33.8        RDW  12/11/22 15:34  14.2        Platelet  12/11/22 15:34  473  High        MPV  12/11/22 15:34  7.4        Neutrophils %  12/11/22 15:34  81        Lymphocytes %  12/11/22 15:34  8        Monocytes %  12/11/22 15:34  10        Eosinophils %  12/11/22 15:34  0        Basophils %  12/11/22 15:34  0        Absolute Neutrophil  12/11/22 15:34  13.1  High        Absolute Lymphocyte  12/11/22 15:34  1.3        Absolute Monocyte  12/11/22 15:34  1.7  High        Absolute Eosinophil  12/11/22 15:34  0.0        Absolute Basophil  12/11/22 15:34  0.0          Routine Coagulation Studies FS  LATEST RESULTS        PT  12/11/22 15:34  20.9  High        INR  12/11/22 15:34  1.79  High        aPTT  12/11/22 15:34  29.7          Routine Chemistry Tests FS  LATEST RESULTS        Sodium SerPl QN  12/11/22 15:34  135        Potassium SerPl QN  12/11/22 15:34  3.0  Low        Chloride SerPl QN  12/11/22 15:34  97  Low        Carbon Dioxide SerPl QN  12/11/22 15:34  29        Anion Gap  12/11/22 15:34  9        BUN SerPl QN  12/11/22 15:34  10        Creatinine SerPl QN  12/11/22 15:34  1.13        Estimated GFR (CKD-EPI, no race)  12/11/22 15:34  74        Estimated CRCL (CG)  12/11/22 15:34  80        Glucose SerPl QN  12/11/22 15:34  120  High        Calcium Total SerPl QN  12/11/22 15:34  9.1        Magnesium SerPl QN  12/11/22 15:34  2.4        Troponin-I High Sensitivity  12/11/22 15:34  9        BNP Pl QN  12/11/22 15:34  293  High        Lactate Venous Pl QN  12/11/22 15:44  1.3          Endo Serum/Plasma Tests FS  LATEST RESULTS        TSH 3rd Gen SerPl QN  12/11/22 15:34  0.850          Molecular Diagnostic Tests  LATEST RESULTS        COVID 19 Specimen Source  12/11/22 14:58  Nasal        Coronavirus SARS-CoV2 Rapid  12/11/22 14:58  Not Detected          Viral FS  LATEST RESULTS        Rapid Influenza Method  12/11/22 14:58  PCR - Liat        Rapid Influenza A PCR  12/11/22 14:58  Not Detected        Rapid Influenza B PCR  12/11/22 14:58  Not Detected      Diagnostic Results  XR Chest PA and Lateral    12/11/22 15:27:22  impression.   IMPRESSION:   New nonspecific patchy bibasilar opacities, slightly more prominent  on the left side. Appearance may be slightly exaggerated secondary to  lower lung volumes, however differential diagnosis includes bibasilar  infectious process.. Mediastinal contour and heart size are stable  and within normal limits. No significant pleural effusion, pulmonary  edema, or pneumothorax.     Thank you for consulting with Radiology. Healthcare providers  wishing to discuss this case further can contact the Emergency  Radiology reading room.   Electronically Signed by:     Signed By: MD      Signature Line Electronically Signed on 12/12/22 22:28  ________________________________________________________   Electronically Signed on 12/11/22 18:56 ________________________________________________________   Electronically Signed on 12/12/22 20:04 ________________________________________________________ MD  Reviewed by MD