Age: 60.0
Sex: M
Vaccine: COVID19
Symptoms: Chlamydia test negative, Coronavirus test negative, Cough, Decreased appetite, Dyspnoea
Clinical narrative: 10/05/2021 OFFICE VISIT -  Dx Cough  ? Shortness of Breath   Date of Service: 10/7/2021 Patient is a 60 y.o. with Cough ( States that he has been coughing for the past 8 days after having a positive exposure from his son.  ) and Shortness of Breath (States that he started feeling SOB today.  States that he feels SOB all the time.  Worse when we he up moving around.   Does have a decreased appetite as well.). He is accompanied by an adult male and female.     HPI  The patient states that he has chest pain on the right side and he began experiencing shortness of breath today. He describes the chest pain as a heaviness. He was involved in a car accident in the past and had a tracheostomy performed. He was also noted to be involved in a severe accident approximately 2 years ago and suffered a collapsed lung.   The male attendant reports that he tested positive for COVID-19, but states he is clear now. He relates that he has tried to stay away from the patient as best he could.     REVIEW OF SYSTEMS Constitutional: Negative for chills, fatigue and fever.  Respiratory: Positive for shortness of breath. Negative for cough,  and wheezing.   Cardiovascular: Positive for chest pain described as heaviness. Negative for palpitations and leg swelling.  Neurological: Negative for dizziness, tremors, weakness and headaches.  Psychiatric/Behavioral: Negative for confusion. The patient is not nervous/anxious.    ED to Hosp-Admission  Discharged 10/5/2021 - 10/9/2021 (4 days)  WellSpan Waynesboro Hospital Pneumonia due to COVID-19 virus  Principal problem  Presenting Problem/History of Present Illness/Reason for Admission Hypoxia [R09.02] Pneumonia due to COVID-19 virus [U07.1, J12.82]     Hospital Course  Pleasant 60-year-old male with a history of diabetes requiring insulin, hypertension, hypercholesterolemia and other problems as per problem list.  He presented to the ER with complaints of fever, chills, cough, generalized aches and myalgias, fatigue and worsening shortness of breath for about 5 days duration.  In the ER he was tachypneic and oxygen saturation was 87%.  Patient had been exposed to family members who had Covid.  Chest x-ray showed findings consistent with Covid pneumonia.  He was referred for admission. He was admitted to the medical floor where he received standard treatment with remdesivir, IV Decadron and supplemental oxygen.  The patient's oxygen requirement improved steadily, on the fifth day of admission, the patient weaned off oxygen and need for symptomatically improved.  He requested to be discharged home as he was no longer requiring oxygen.  On clinical examination, patient was stable and felt ready for discharge.  He was noted to have elevated blood glucose readings likely due to steroids and was advised to increase his insulin dosing if he continues to have elevations at home.  Patient is to follow-up with his PCP and observe routine CBC current time guidelines.  He was advised to be in isolation for a total of 10 days since onset of symptoms and if he has been afebrile for more than 24 hours.  He has pain.