Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Chills, Cough, Diarrhoea, Dyspnoea, Electrocardiogram
Clinical narrative: Cough  Fatigue  Headache  Sore throat Office Visit 5/20/2021   PA-C Family Medicine Other form of dyspnea +1 more Dx Cough  Reason for Visit Progress Notes PA-C (Physician Assistant) ? ? Family Medicine ? ? Encounter Date: 5/20/2021 ? ? Signed Cosigned by: MD at 5/31/2021  7:50 PM Expand AllCollapse All    MDM  1. Other form of dyspnea  2. Chest pressure    History and physical exam consistent with chest pressure with dyspnea.  EKG shows nonspecific T wave changes.  Although I see no acute ischemic changes, she does have risk factors for heart disease and is complaining about worsening dyspnea on exertion and I therefore encouraged her to go to the emergency department for blood work to verify that this is not cardiogenic.  Symptoms could likely be due to her respiratory illness but given her history of hypertension and family history of heart disease, feel a set of troponins is indicated.  Patient is agreeable and states she will go to emergency department.  She does have her sister with her who is driving. Patient does not appear to be toxic or dehydrated and vital signs are stable. See HPI and physical exam to review pertinent information regarding visit. Images available were reviewed by me and reviewed with pt/family. Prescription medication recommendations were reviewed in light of the patient's age, past medical history and comorbidities. Plan of care reviewed; patient/family member agrees with plan. See patient discharge instructions for more details. Follow up with PCP if symptoms do not improve or go to ER if symptoms worsen. Discussed antibiotic stewardship as appropriate  Careline information discussed and included in AVS.    Patient was seen today for cough.   Diagnoses and all orders for this visit:   Other form of dyspnea -     X-ray chest 2 views; Future -     ECG 12-lead: URGENT CARE (Here and Now)   Chest pressure       History  Chief Complaint Patient presents with ? Cough     productive cough with white sputum, diarrhea x 7 days,  today is day 10 since COVID positive dx and not getting better     ED Discharged  5/20/2021 (1 hours) Hospital ER  MD Last attending ? Treatment team Pneumonia due to COVID-19 virus Clinical impression Shortness of Breath Chief complaint ED Provider Notes MD (Physician) ? ? Emergency Medicine Expand AllCollapse All      HPI      Chief Complaint Patient presents with ? Shortness of Breath     HPI  64 y.o. F p/t ED for cough SOB diarrhea and CP.  Has history of hypertension.  No smoke history.  No lung disease history.  She has had 10 days of symptoms.  Tested positive for COVID-19.  She was vaccinated.  She works as a respiratory therapist as an outpatient performing PFTs daily.  Symptoms have not gotten any better and she started feeling short of breath over the last 2 days.  She had mild cough, productive.  No leg pain or swelling.  No history of DVT or PE.  Seen at urgent care and found to have EKG with nonspecific T wave changes so sent to the ED for further evaluation the light of her chest pressure.  Chest pressure and shortness of breath are worse with ambulation and activity.  No fevers.  Has had some chills.  Loss of taste and smell.  Chest x-ray obtained an outpatient was demonstrated to some patchy infiltrate in the right lower lobe.