Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Diarrhoea, Fatigue, Full blood count, Gait disturbance, Hyperreflexia
Clinical narrative: June 14th: Treated for fatigue In ER by MD.  Labs completed:C-Reactive Protein CBC CK Comprehensive Metabolic Panel Troponin I Urinalysis (Macro w/Microscopic if Indicated) Urine Microscopic. Labs in process:COVID-19 Symptomatic Priority 2: Result will change management in the next 1-2 days Gray Tube Serum Separator Tube Urine Container June 15th: Visit with primary provider NP at 6/15/2021 10:45 AM Chief Complaint: ED Follow-up and Fatigue (overall feeling unwell since Friday) 1. Distal muscle weakness He has diffuse distal muscle weakness of bilateral upper and lower extremities on exam. Upper muscle strength is equal and strong. Mild bilateral patellar hyperreflexia. Unclear etiology at this point. Concern is for motor/neuron cause. Labs were normal. CK is normal. Guillain Barre? He has good DTR. He does not have any neck pain or nuchal rigidity. Inflammatory markers are normal to think infectious process. We'll get an MG panel, repeat inflammatory markers, CK, aldolase levels today. Check chest x-ray. Consider MRI of the spine looking for cord compression? Consider lumbar puncture.   Addendum 6/16/21: Dr. talked to Dr.. Per neurology's recommendation, stat MRI of the cervical, thoracic and lumbar spine to evaluate for cord compression or MS plaques. Stat Lumbar Puncture looking for protein. Concern for Guillain Barre, despite normal reflexes.  No orders of the defined types were placed in this encounter.  History ofPresent Illness:  Patient is a 58 y.o.  male who presents today with a chief complaint of ED Follow-up and Fatigue (overall feeling unwell since Friday)  He has not felt well for 2 weeks.  He initially started with body aches and fatigue. He was having some chills. The next day, he went to work, and his boss sent him home because he did not look good. He spent the next few days resting. He had diarrhea during this time and fever of 102. He improved. He went back to work for 2 days then started feeling some cramps in his left leg. The next day he wanted to play basketball. His muscles gave out. He just did not have the strength to keep playing. His legs were giving out. He felt like he couldn't run. He didn't push himself too much. The next day he had a hard time getting out of bed to mow the yard, but couldn't. He woke up Saturday (3 days ago) and had no strength. He can't put socks on because he is too weak. His muscles aren't working well. He denies any shortness of breath, chest pain, or cough. He has not had any recurrent abdominal pain, nausea, vomiting, or fevers. His ONLY symptom now is muscle weakness and fatigue. Nobody else is sick.  June 16th: NP at 6/16/2021  9:30 AM Ambulatory Visit  In an effort to avoid potential COVID-19 exposure in this patient, this visit occurred by telehealth. Verbal informed consent was obtained from patient, parent or guardian to proceed with telehealth service.   Patient identification completed: Yes Mode of Communication: Telephone Application Used: Phone Patient Location: Home Residence Provider Location: Clinic  Subjective:  HPI: Patient is a 58 y.o. male patient with chief complaint of Extremity Weakness  One day follow up on distal muscle weakness. Labs were reviewed. The patient is feeling worse. His legs are weaker. His ability to walk is affected. Denies respiratory symptoms. Discussed with neuro. Concern for Guillan-Barre. Given his worsening weakness, an in-patient admission is recommended.   June 16th-21st- Hospitalized: 6/21/2021 12:06 PM Discharge Summary 6/21/2021  8:45 AM Progress Notes 6/21/2021  8:19 AM Progress Notes 6/20/2021  5:12 PM Progress Notes 6/19/2021  2:51 PM Progress Notes 6/19/2021 12:15 PM Progress Notes 6/18/2021  1:52 PM Progress Notes 6/18/2021  3:56 PM Progress Notes 6/18/2021  3:33 PM Progress Notes 6/17/2021  5:56 PM Progress Notes addendum by Speech and Language Pathologist 6/17/2021  4:11 PM Progress Notes 6/17/2021  3:51 PM Progress Notes 6/17/2021  2:39 PM Progress Notes 6/17/2021 12:27 PM Progress Notes 6/17/2021 11:49 AM Progress Notes 6/16/2021  6:53 PM H&P 6/16/2021  4:40 PM Progress Notes signed by Speech and Language Pathologist