Age: 28.0
Sex: M
Vaccine: COVID19
Symptoms: Rales, Red blood cell count decreased, Red cell distribution width normal, SARS-CoV-2 test, SARS-CoV-2 test negative
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: December 09, 2022 18:17 EST   Verified By: MD on December 09, 2022 21:42 EST   Encounter Info: Hospital, Emergency, 12/09/22 - 12/10/22    * Final Report *        Basic Information  Time Seen: 12/09/2022 18:08  Chief Complaint  SOB  History of Present Illness     Patient Seen: 12/09/22 18:16:59  69 year old male with hx of atrial fibrillation, DVT, on Warfarin presents to the ED for cough, dyspnea and confusion. Pt accompanied to ED by wife who notes they have been ill for w/ cough, dyspnea and malaise for past 2 weeks. Pt has also had diarrhea and intermittent confusion for the past day or so wife reporting  "not himself and off balance". He was evaluated by PCP in clinic today, exam noted rales in left chest and he was given Rocephin IM and prescribed cefdinir. Wife notes they monitored SpO2 at home which was 87-89% on RA prompting ED evaluation. He does not wear O2 at baseline.   Denies recent falls/head strikes.  Review of Systems     Constitutional:  no fever, no chills, no sweats,  Respiratory:  +dyspnea, +cough Cardiovascular:  no chest pain 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:       37.4 DegC  Heart Rate:       67 bpm  Resp Rate:       18 br/min  BP:       132 / 62 mmHg  SpO2 (%):       90 %  O2 Device:       Room air     Height CM: 183 cm  Weight KG: 124.6 kg  Ideal Body Weight: 77.71 kg     General- well appearing NAD Head- atraumatic Neck- supple, NT CV- normal perfusion, rate Lungs- coarse breath sounds bilaterally with scattered crackles and expiratory wheezes Abd- ND, NT MS- normal perfusion, no acute change.      Medical Decision Making     Documents Reviewed:  ED nurse, prior records  Diagnostic Results:  Labs: Reviewed Imaging: Reviewed  12/09/22 19:44:56 Influenza A positive. CXR earlier today negative. Oxygenation borderline to low and pt given breathing tx and steroids here for significant wheezing. If improved, plan to discharge home otherwise he will need admission.  12/09/22 20:52:26  SpO2 dropped to 85% w/ ambulation, no supplemental O2 at baseline. Pt will have to be admitted.  12/09/22 21:11:02  Pending admission. I have transitioned care of the patient to Dr., we have discussed the clinical presentation, work-up, and ED course thus far.                 Condition     Stable Disposition: 12/09/22 21:21:06  Care transitioned to Dr.   Attestations: I, serving scribe for Dr.  12/09/22 18:17:10        Signed by, Scribe, 12/09/22 18:17:10   I, 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 reflects all work, treatment , procedures , and medical decision-making performed by me.     Assessment/Plan      Influenza A   Orders:   albuterol, 2 Puff, Inhalation, Aerosol, MDI/DPI Inhaler Treatment, Q4H, PRN, Wheezing, 12/09/22 19:06:00 EST  **Coronavirus SARS-CoV2 Rapid  **Rapid Influenza PCR  Auto Diff  Basic Metabolic Panel  Blood CX  Blood CX  BNP Pl QN  CBC w/Differential  COVID 19 PCR  D-Dimer Pl QN  Lactate Pl Venous QN  Peripheral IV Insertion  Rapid Influenza A/B Ql  Resp Evaluation or Assessment  Troponin-I High Sensitivity     Follow Up  No qualifying data available   Chronic Problem List    AF (atrial fibrillation)  Encounter for long-term (current) use of medications  Encounter for monitoring coumadin therapy  Family history of prostate cancer  Hypertension  Long term current use of anticoagulant  Major depression  Obesity  Osteoarthritis  Thrombophlebitis  Procedure/Surgical History  ?colonoscopy (11/10/2017) ?Esophagogastroduodenoscopy (06/15/2012) ?Bariatric operative procedure  Surgical History Internal  11/10/2017    Colonscpy Diagnostic/Screen    MD  01/31/2012    Gastric Bypass Laparoscopic    MD  Medications  Home Medications (5) Active amiodarone 200 mg oral tablet 200 mg, Orally, Daily cefDINIR 300 mg oral capsule 300 mg = 1 Capsule, Orally, Q12H citalopram 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily lisinopril 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily warfarin 5 mg oral tablet See Instructions, as instructed each week by PCP5mg x 3 days & 2.5mg x 4 days(8/11)  Medication Administration   Given  albuterol HFA MDI 90mCg/puff inhalation aerosol, 2 Puff, Inhalation  methylPREDNISolone sodium succinate, 125 mg, IV Push  Allergies   codeine (Rash, Hives)  Social History    Alcohol - Denies Alcohol Use   Current, Beer, 1-2 times per month   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description: farmer/ bus driver.   Home/Environment   married, 3 children, Lives with Spouse.   Substance Abuse   Denies   Tobacco - Low Risk   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Heart disease..: Mother.Negative: Father.  Prostate cancer..: Father.  Lab Results      Hemogram-Platelets-WBC Differential FS  LATEST RESULTS        WBC  12/09/22 18:41  7.5        RBC  12/09/22 18:41  4.05  Low        Hgb  12/09/22 18:41  12.1  Low        Hct  12/09/22 18:41  36.5  Low        MCV  12/09/22 18:41  90        MCH  12/09/22 18:41  30.0        MCHC  12/09/22 18:41  33.2        RDW  12/09/22 18:41  13.3        Platelet  12/09/22 18:41  236        MPV  12/09/22 18:41  7.8        Neutrophils %  12/09/22 18:41  82        Lymphocytes %  12/09/22 18:41  10        Monocytes %  12/09/22 18:41  8        Eosinophils %  12/09/22 18:41  0        Basophils %  12/09/22 18:41  0        Absolute Neutrophil  12/09/22 18:41  6.1        Absolute Lymphocyte  12/09/22 18:41  0.8  Low        Absolute Monocyte  12/09/22 18:41  0.6        Absolute Eosinophil  12/09/22 18:41  0.0        Absolute Basophil  12/09/22 18:41  0.0          Routine Coagulation Studies FS  LATEST RESULTS        D-Dimer Pl QN  12/09/22 18:41  350  High          Routine Chemistry Tests FS  LATEST RESULTS        Sodium SerPl QN  12/09/22 18:41  136        Potassium SerPl QN  12/09/22 18:41  4.2        Chloride SerPl QN  12/09/22 18:41  99        Carbon Dioxide SerPl QN  12/09/22 18:41  25        Anion Gap  12/09/22 18:41  12  High        BUN SerPl QN  12/09/22 18:41  18        Creatinine SerPl QN  12/09/22 18:41  0.91        Estimated GFR (CKD-EPI, no race)  12/09/22 18:41  >90        Estimated CRCL (CG)  12/09/22 18:41  105        Glucose SerPl QN  12/09/22 18:41  120  High        Calcium Total SerPl QN  12/09/22 18:41  9.0        Troponin-I High Sensitivity  12/09/22 18:41  9        Lactate Venous Pl QN  12/09/22 18:41  1.1          Molecular Diagnostic Tests  LATEST RESULTS        COVID 19 Specimen Source  12/09/22 18:41  Nasal        Coronavirus SARS-CoV2 Rapid  12/09/22 18:41  Not Detected          Viral FS  LATEST RESULTS        Rapid Influenza Method  12/09/22 18:41  PCR - Liat        Rapid Influenza A PCR  12/09/22 18:41  Detected Abnormal        Rapid Influenza B PCR  12/09/22 18:41  Not Detected      Diagnostic Results  No qualifying data available.        Signature Line Electronically Signed on 12/09/22 21:22 EST ________________________________________________________   Electronically Signed on 12/09/22 21:42 EST ________________________________________________________ MD