Age: 47.0
Sex: M
Vaccine: COVID19
Symptoms: Glucose urine absent, Haematocrit normal, Haemoglobin normal, Hypertension, Hypoxia
Clinical narrative: Date of Admission: 2/21/2022 Chief Complaint: SOB, Right Shoulder Pain. Source of Information: Patient. History of Present Illness: This is a 47y.o. male with PMH significant for sarcoidosis, cervical radiculopathy and obesity presents to ED with complaints of SOB and right shoulder pain. Pt states his SOB began yesterday and is persistent. He is not on home oxygen and denies history of HF, COPD, or asthma. SOB is worse on exertion. Pt denies fever, chills, chest pain, palpitations, sputum production, abdominal pain, N/V/D constipation or dysuria. Pt also states that he has severe right shoulder pain which he visited the ED for 2 weeks prior. He states he is unable to sleep flat at night due to this pain and that OTC pain medications have not worked. He is scheduled for an orthopedic appointment next month.      In the ED, Vitals on arrival of T 97°F, BP 154/84, HR 133, RR 20, SpO2 93% on RA Labs remarkable for CBC BMP unremarkable other than glucose 295. Patient received 1L saline bolus, solumedrol 125mg, ibuprofen, tylenol, and pt was initiated on antibiotic coverage with doxycycline.   Past Medical History: Diagnosis Date ? Sarcoidosis     History reviewed. No pertinent surgical history. History reviewed. No pertinent family history. Social History   Socioeconomic History ? Marital status: Single Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used       Family History No family history on file.  Medications:  Home Medications  Med Sig Last Dose Dt/Time  budesonide-formoterol (SYMBICORT) 160-4.5 MCG/ACT INHAL inhaler inhale 2 Puffs into the lungs once daily. 2/20/2022 Unknown time  CALCIUM PO take 1 Tablet by mouth once daily. 2/20/2022 Unknown time         Mon Feb 21, 2022  2:31 AM) Unknown dose  Glucosamine-Chondroitin (OSTEO BI-FLEX REGULAR STRENGTH PO) take 1 Tablet by mouth once daily. 2/20/2022 Unknown time  Omega-3 Fatty Acids (FISH OIL PO) take 1 Tablet by mouth once daily. 2/20/2022 Unknown time  VITAMIN D PO take 1 Tablet by mouth once daily. 2/20/2022 Unknown time         Mon Feb 21, 2022  2:31 AM) Unknown dose           Hospital Medications:  Current Medications Current Facility-Administered Medications Medication Dose Route Frequency Provider Last Rate Last Admin ? acetaminophen (TYLENOL) tablet 650 mg  650 mg Oral Q 6 H PRN      ? albuterol (PROVENTIL, VENTOLIN) (2.5 MG/3ML) 0.083% nebulizer solution 2.5 mg  2.5 mg Inhalation RT-QID ? albuterol (PROVENTIL, VENTOLIN) (2.5 MG/3ML) 0.083% nebulizer solution 2.5 mg  2.5 mg Inhalation Q 2 H PRN   ? benzonatate (TESSALON) capsule 200 mg  200 mg Oral Q 8 H PRN     ? doxycycline (MONODOX) capsule 100 mg  100 mg Oral Q 12   100 mg at 02/21/22 0220 ? enoxaparin (LOVENOX) injection 40 mg  40 mg Subcutaneous Q 24 H  40 mg at 02/21/22 0818 ? fluticasone-vilanterol (BREO ELLIPTA) 100-25 MCG/INH inhaler 1 Puff  1 Puff Inhalation DAILY ? guaiFENesin (MUCINEX) 12-hour tablet 600 mg  600 mg Oral Q 12 H ? ondansetron (ZOFRAN) injection 4 mg  4 mg Intravenous Q 6 H PRN     ? predniSONE (DELTASONE) tablet 40 mg  40 mg Oral DAILY  ? senna (SENOKOT) tablet 8.6 mg  1 Tablet Oral BID PRN ? sodium chloride 0.9 % flush injection 3 mL  3 mL Intravenous PRN       Current Outpatient Medications Medication Sig Dispense Refill ? budesonide-formoterol (SYMBICORT) 160-4.5 MCG/ACT INHAL inhaler inhale 2 Puffs into the lungs once daily.     ? CALCIUM PO take 1 Tablet by mouth once daily.     ? Glucosamine-Chondroitin (OSTEO BI-FLEX REGULAR STRENGTH PO) take 1 Tablet by mouth once daily.     ? Omega-3 Fatty Acids (FISH OIL PO) take 1 Tablet by mouth once daily.     ? VITAMIN D PO take 1 Tablet by mouth once daily.          Allergies:    Allergen Reactions ? Penicillins Hives     ROS: Gen: No fevers, chills, nightsweats, fatigue, weight loss HEENT: No headaches, visual changes, hearing changes, vertigo, congestion, rhinorrhea, sore throat CV: No chest pain, palpitations, diaphoresis, orthopnea, edema RESP: + SOB, +pulomary congestion. Crackles present bilateral bases.  Denies wheezing, or cough GI: No nausea, vomiting, constipation, diarrhea, abdominal pain, hematochezia, melena ENDO: No temperature intolerance, sweating, or polyphagia, polyuria, polydipsia GU: No dysuria, hematuria, increased frequency, urgency MSK: + R shoulder pain. 4/5 strength in R shoulder NEURO: No weakness, dizziness, seizures, tremors, lightheadedness  HEME: No easy bruising or bleeding PSYCH: No depression, anxiety or memory issues                             Last Filed Vitals: BP 140/89  | Pulse 95  | Temp 97.6 °F (36.4 °C) (Oral)  | Resp 22  | Ht 182.9 cm (6')  | Wt 129 kg (285 lb)  | SpO2 96%  | BMI 38.65 kg/m²  Body mass index is 38.65 kg/m².   Physical Examination:  GEN: A/O x 3. NAD. Well nourished-well developed who appears stated age HENT: Normocephalic. Atraumatic. EOMI. PERRL. No scleral icterus or JVD NECK: Supple. Trachea midline. No JVD, thyromegaly/goiter, carotid bruit.  CV: RRR. S1 S2 without S3 or S4. No murmurs, clicks or gallops RESP: Clear to auscultation bilaterally. No wheeze, rhonci, or rales. No accessory  muscle use GI: BS x 4. Non-tender, non-distended. Soft. No hepatosplenomegaly EXT: No cyanosis, clubbing or edema NEURO: CN II-XI grossly intact bilaterally. Muscle strength 5/5, sensation intact. No dysdiadokinesis. No focal deficits. No cerebellar signs SKIN: No gross rash, lesion, or breakdown       Labs: Recent Results Recent Results (from the past 24 hour(s)) Protime and aPTT   Collection Time: 02/21/22 12:56 AM Result Value Ref Range   Protime 11.6 9.2 - 13.5 Seconds   INR 1.0     APTT 29.3 25.0 - 38.0 Seconds Comprehensive Metabolic Panel (CMP)   Collection Time: 02/21/22 12:56 AM Result Value Ref Range   Sodium 139 135 - 145 mmol/L   Potassium 4.6 3.5 - 5.2 mmol/L   Chloride 102 98 - 111 mmol/L   Carbon Dioxide (CO2) 24 20 - 29 mmol/L   Anion Gap 13 5 - 17   Glucose 151 (H) 60 - 99 mg/dL   Blood Urea Nitrogen (BUN) 12 7 - 25 mg/dL   Creatinine 1.03 0.60 - 1.30 mg/dL   GFR African American 100 >=60 mL/min/1.73m2             Calcium 10.5 8.5 - 10.5 mg/dL   Protein Total 8.2 6.4 - 8.3 g/dL   Albumin 4.1 3.5 - 5.1 g/dL   Globulin 4.1 (H) 2.2 - 4.0 g/dL   Albumin/Globulin Ratio 1.0     Alkaline Phosphatase 111 33 - 120 U/L   Aspartate Aminotransferase (AST) 37 (H) <35 U/L   Alanine Aminotransferase (ALT) 98 (H) 9 - 47 U/L   Bilirubin Total 0.7 0.3 - 1.2 mg/dL Troponin I   Collection Time: 02/21/22 12:56 AM Result Value Ref Range   Troponin I 0.02 <=0.03 ng/mL D-Dimer   Collection Time: 02/21/22 12:56 AM Result Value Ref Range   D-Dimer 432 0 - 499 ng/mL FEU Covid-19, Flu, RSV by NAA   Collection Time: 02/21/22 12:56 AM   Specimen: Nasopharyngeal; Swab Result Value Ref Range   Influenza A Not Detected Not Detected   Influenza B Not Detected Not Detected   RSV Not Detected Not Detected   SARS-CoV-2 (COVID-19) by NAA, Micro  Detected (A) Not Detected Complete Blood Count (CBC) W/Auto Diff   Collection Time: 02/21/22 12:56 AM Result Value Ref Range   WBC 10.7 (H) 3.5 - 10.1 bil/L   RBC 5.10 4.31 - 5.48 tril/L   Hemoglobin 14.5 13.5 - 17.0 g/dL   Hematocrit 43.8 40.1 - 50.1 %   MCV 86 80 - 100 fL   MCH 28 28 - 33 pg   MCHC 33 32 - 36 g/dL   RDW-CV 15 12 - 15 %   Platelets 215 150 - 400 bil/L   Neutrophils 9.7 (H) 1.6 - 7.2 bil/L   Lymphocytes 0.7 (L) 1.1 - 4.0 bil/L   Monocytes 0.3 0.0 - 0.9 bil/L   Eosinophils 0.0 0.0 - 0.4 bil/L   Basophils 0.0 0.0 - 0.1 bil/L   Immature Granulocytes 0.11 (H) 0.00 - 0.04 bil/L   Immature Granulocyte % 1.0 % Thyroid Stimulating Hormon (TSH) With Reflex to Free Thyroxine (FT4)   Collection Time: 02/21/22  1:34 AM Result Value Ref Range   Thyroid Stimulating Hormone 0.44 0.40 - 4.50 uIU/mL Blood Gases, Venous (VBG)   Collection Time: 02/21/22  1:34 AM Result Value Ref Range   Sample Type Blood, venous     pH 7.39 7.32 - 7.42   PCO2 51 41 - 51 mmHg   Bicarbonate 30 (H) 19 - 27 mmol/L   Total CO2 32 (H) 20 - 29 mmol/L   Base Excess 4 -5 - 5 mmol/L   Oxyhemoglobin 64 55 - 85 %   Carboxyhemoglobin 0.8 <1.5 %   Methemoglobin 0.7 0.0 - 2.0 %   Hemoglobin 14.6 13.5 - 17.0 g/dL Troponin I   Collection Time: 02/21/22  2:30 AM Result Value Ref Range   Troponin I 0.02 <=0.03 ng/mL Troponin I   Collection Time: 02/21/22  4:20 AM Result Value Ref Range   Troponin I 0.02 <=0.03 ng/mL Basic Metabolic Panel (BMP)   Collection Time: 02/21/22  4:20 AM Result Value Ref Range   Sodium 138 135 - 145 mmol/L   Potassium 4.2 3.5 - 5.2 mmol/L   Chloride 104 98 - 111 mmol/L   Carbon Dioxide (CO2) 23 20 - 29 mmol/L   Anion Gap 11 5 - 17   Glucose 295 (H) 60 - 99 mg/dL   Blood Urea Nitrogen (BUN) 13 7 - 25 mg/dL   Creatinine 1.07 0.60 - 1.30 mg/dL   GFR African American 95 >=60 mL/min/1.73m2             Calcium 9.6 8.5 - 10.5 mg/dL Complete Blood Count (CBC)   Collection Time: 02/21/22  4:20 AM Result Value Ref Range   WBC 8.9 3.5 - 10.1 bil/L   RBC 4.91 4.31 - 5.48 tril/L   Hemoglobin 13.7 13.5 - 17.0 g/dL   Hematocrit 42.2 40.1 - 50.1 %   MCV 86 80 - 100 fL   MCH 28 28 - 33 pg   MCHC 33 32 - 36 g/dL   RDW-CV 15 12 - 15 %   Platelets 208 150 - 400 bil/L Magnesium Level   Collection Time: 02/21/22  4:20 AM Result Value Ref Range   Magnesium 1.9 1.7 - 2.5 mg/dL Urinalysis, Complete   Collection Time: 02/21/22  1:00 PM Result Value Ref Range   Color Yellow     Clarity Clear Clear   Glucose 150  (A) Negative mg/dL   Bilirubin Negative Negative   Ketones Negative Negative mg/dL   Specific Gravity, Urine 1.008 1.005 - 1.030   Blood Negative Negative   pH 6.0 5.0 - 8.0   Protein Negative Negative mg/dL   Urobilinogen <2.0 <2.0 mg/dL   Nitrites Negative Negative   Leukocyte Esterase Negative Negative   RBC 0-2 (Negative) 0-2 (Negative) /hpf   WBC 0-5 (Negative) 0-5 (Negative) /hpf   Epithelial, Squamous Negative Negative /lpf   Casts, Hyaline 0-2 (Negative) 0-2 (Negative) /lpf   Bacteria Negative Negative /hpf      Diagnostic Studies:  CHEST 2 VIEWS FRONTAL/LATERAL   Result Date: 2/21/2022 TWO VIEW CHEST X-RAY INDICATION: Shortness of breath. COMPARISON: Chest radiograph on 2/17/2011. TECHNIQUE:  Frontal and lateral views of the chest were obtained. FINDINGS/IMPRESSION: Multifocal patchy airspace disease. No pneumothorax identified. No large effusion. Cardiomediastinal is what is stable.    ECG   Result Date: 2/21/2022  2:23 AM ECG Date/Time: 2/21/2022 12:22 AM Contemporaneously ECG reviewed by ED Physician in the absence of a cardiologist: yes  Interpretation:   Interpretation: abnormal  Rate:   ECG rate:  127   ECG rate assessment: tachycardic  Rhythm:   Rhythm: sinus tachycardia       Assessment and Plan:     Active Hospital Problems   Diagnosis ? Principal Problem: Atypical pneumonia ? SOB (shortness of breath) ? Tachycardia  ? History of sarcoidosis  ? Hypoxemia requiring supplemental oxygen ? Pneumonia due to COVID-19 virus   Resolved Hospital Problems No resolved problems to display.     PLAN    Pneumonia - likely 2/2 COVID infection - CXR multifocal patchy airspace disease - Positive COVID 19 - On 2L NC, spO2 96%  - Antigen legionella, streptococcus pending - Blood cultures pending - doxycycline 100mg q12 - albuterol 2.5mg q2 prn - fluticasone-vilanterol 100-25 mcg 1 puff daily - decadron 6mg daily - mucinex 600mg q12    R Shoulder Parasthesia/Pain - ER 2 weeks ago for neck pain  - CT cervical spine 01/22/2022: multilevel disc degeneration and central canal stenosis. C4-C5 small left central disc herniation - R shoulder radiograph? - acetaminophen 650 prn - Orthopedic consult scheduled next month, pt states he will likely receive steroid shot there    HTN  - 142/74, HR 108. 154/84 HR 133 on admission - BMI 38.65 - likely 2/2 to pain?   -trend, continue acetaminophen     Hx Sarcoidosis - whats his home regimen, no steroid/immunosuppresants?      Not requiring O2 at present Was wheezing previously, but breathing better after inhaler and steroids. Based on his lack of hypoxia he does not need steroids for Covid, but does for reactive airway ID input- possible candidate for 3 day course of Remedsivir Right shoulder exam consistent with tendonitis- ortho follow up Add norco for breakthrough pain Patient personally seen and examined.  The above documentation reflects my own history gathering, physical exam and medical decision making.