Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: White blood cell count normal
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on September 19, 2022 17:31 EDT   Verified By: DO on September 21, 2022 09:22 EDT   Encounter Info: Hospital, Emergency, 09/19/22 - 09/19/22    * Final Report *        Basic Information  Time Seen: DO / 09/19/2022 16:39  Chief Complaint  Dizziness (Complaint of), SOB (Complaint of)  History of Present Illness     A 67 year old male presents from public housing to the ED via private vehicle complaining of  worsening dyspnea onset one week. Patient said last night his shortness of breath continued to worsen with associated fever, chills, diaphoresis, headache, and "ringing" in bilateral ears. He endorses nausea and mild dehydration. Denies diarrhea or any known sick contacts.   Pt reports using an inhaler and Mucinex for symptom relief.   Denies PMHx of CHF or A-fib but reports having pneumonia once. Pt smokes. Denies other drug use.  Review of Systems     Constitutional: +fever +chills, +dehydration, +diaphoresis Respiratory:  +dyspnea Gastrointestinal:  no diarrhea, , +nausea Neurologic: +headache Additional ROS info:  Except as noted in the above Review of Systems and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.4 DegC  Heart Rate:       88 bpm  Resp Rate:       18 br/min  BP #1:       95 / 50 mmHg  SpO2 (%):       94 %  O2 Device:       Room air     Weight KG: 100.5 kg     General:  alert, no acute distress Skin: warm, dry Head:  normocephalic, atraumatic Eye: PERRL, EOMI ENT: TMs normal, Tongue midline, uvula midline, oral mucosa mildly dry Neck:  supple , no tenderness, trachea midline Cardiovascular:  regular rate and rhythm, no murmur, normal peripheral perfusion Respiratory:  lungs CTA, respirations non-labored, breath sounds equal Chest Wall: no tenderness, no deformity Back: Non tender, normal ROM, normal alignment Gastrointestinal:  soft, non tender, non distended, normal bowel sounds, no rebound, no guarding, two large ventral hernias-not reducible Extremities:  no deformity, no tenderness, no swelling, normal ROM, normal strength Neurological:  CN II-XII intact, normal speech, normal motor, normal sensory, no focal neuro deficits Psych: cooperative, appropriate mood & affect  Medical Decision Making     ED RN notes reviewed. Prior charts reviewed.   Labs: Reviewed Diagnostic imaging: Reviewed  09/19/22 18:07:40  Pt is pending another liter of fluids and repeat troponin. I have transitioned care of the patient to Dr., we have discussed the clinical presentation, work-up, and ED course thus far.            Condition     Stable  Attestations  I, scribing for Dr. on 09/19/22 17:14:33 Signed by, scribe 09/19/22 17:14:33 I, D.O, 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 reflected all work, treatment, procedures, and medical decision making by me.   Assessment/Plan       1. Dyspnea   R06.00    2. Bronchitis   J40    3. Dizziness   R42    4. Dehydration   E86.0       Follow Up  No qualifying data available   Chronic Problem List    Incisional hernia  Tobacco use  Procedure/Surgical History  ?Appendectomy (01/01/2015)    Medications  Home Medications (4) Active gabapentin , Orally Lipitor 40 mg, Orally, Daily metFORMIN , Orally Xarelto , Orally  Medication Administration   Given  NS - ED Bolus, 1000 mL, IVPB  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   Cardiovascular disease: Father.  Lab Results      Hemogram-Platelets-WBC Differential FS  LATEST RESULTS        WBC  09/19/22 16:47  9.3        RBC  09/19/22 16:47  4.23        Hgb  09/19/22 16:47  10.8  Low        Hct  09/19/22 16:47  32.6  Low        MCV  09/19/22 16:47  77  Low        MCH  09/19/22 16:47  25.5  Low        MCHC  09/19/22 16:47  33.1        RDW  09/19/22 16:47  16.8  High        Platelet  09/19/22 16:47  268        MPV  09/19/22 16:47  8.2        Neutrophils %  09/19/22 16:47  75        Lymphocytes %  09/19/22 16:47  9        Monocytes %  09/19/22 16:47  15        Eosinophils %  09/19/22 16:47  0        Basophils %  09/19/22 16:47  1        Absolute Neutrophil  09/19/22 16:47  7.0        Absolute Lymphocyte  09/19/22 16:47  0.9  Low        Absolute Monocyte  09/19/22 16:47  1.4  High        Absolute Eosinophil  09/19/22 16:47  0.0        Absolute Basophil  09/19/22 16:47  0.1          Routine Coagulation Studies FS  LATEST RESULTS        PT  09/19/22 16:47  16.9  High        INR  09/19/22 16:47  1.46  High        aPTT  09/19/22 16:47  40.6  High          Routine Chemistry Tests FS  LATEST RESULTS        Sodium SerPl QN  09/19/22 16:47  131  Low        Potassium SerPl QN  09/19/22 16:47  4.1        Chloride SerPl QN  09/19/22 16:47  96  Low        Carbon Dioxide SerPl QN  09/19/22 16:47  22        Anion Gap  09/19/22 16:47  13  High        BUN SerPl QN  09/19/22 16:47  14        Creatinine SerPl QN  09/19/22 16:47  0.91        Estimated GFR (CKD-EPI)  09/19/22 16:47  87        Estimated GFR (CKD-EPI, no race)  09/19/22 16:47  >90        Estimated CRCL (CG)  09/19/22 16:47  105        Glucose SerPl QN  09/19/22 16:47  154  High        Calcium Total SerPl QN  09/19/22 16:47  9.1        Alkaline Phos SerPl QN  09/19/22 16:47  253  High        ALT SerPl QN  09/19/22 16:47  8        AST SerPl QN  09/19/22 16:47  10  Low        Bilirubin Total SerPl QN  09/19/22 16:47  0.6        Total Protein SerPl QN  09/19/22 16:47  7.6        Albumin SerPl QN  09/19/22 16:47  3.6        Magnesium SerPl QN  09/19/22 16:47  1.8        Troponin-I High Sensitivity  09/19/22 16:47  7        BNP Pl QN  09/19/22 16:47  138  High        Lactate Venous Pl QN  09/19/22 16:47  3.1  High      Diagnostic Results  XR Chest PA or AP Portable    09/19/22 17:39:38  IMPRESSION:  Bibasilar interstitial and airspace opacities which may reflect  atelectasis/scarring or bibasilar infiltrates.   Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss  this case further can contact the Cardiothoracic Reading Room at. For after-hours or emergency department cases, please  call.   Electronically Signed by:     Signed By: MD  EKG  Time: 9/19/2022 16:06 Rate: 85 bpm Rhythm: normal sinus rhythm Axis: normal ST-T segments: no changes T waves: normal Ectopy: none P waves and PR interval: within normal limits QT/QTc interval: within normal limits QRS interval: within normal limits Previous EKG: none available EP Interpretation      Signature Line Electronically Signed on 09/19/22 18:08 EDT ________________________________________________________   Electronically Signed on 09/21/22 09:22 EDT ________________________________________________________ DO