Age: 32.0
Sex: M
Vaccine: COVID19
Symptoms: Neutrophil count, Neutrophil percentage, Platelet count normal, Pneumonia, Protein total
Clinical narrative: ****This form is being filled out by the patient, however I am copying and pasting the visit's ED Provider Notes from my health portal below the dashed line. I only changed some formatting issues***** ----------------------------------------------------------------------------------- ED Provider Notes Clinical Impression Final diagnoses: Chest pain, unspecified type Bronchopneumonia Pulmonary nodule    Assessment and Plan Laboratory studies are unremarkable.  In discussion with the radiologist patient has findings consistent with bronchopneumonia.  Patient was given doxycycline, and was tested for Covid, Covid was negative.  Patient is satting well on room air.  I do not feel he requires admission at this time.  His headache is completely resolved after descent, I do not feel he needs any advanced imaging.  Patient had chest pain started at midnight, given this I do not feel repeat troponin or EKG is necessary.  At this time I feel the patient is appropriate for discharge.  Counseled to follow-up with his primary care physician.  Discussed continuing to stay in town and not sending again.  Patient voiced understanding.  Counseled to return for any further chest pain, shortness of breath, fevers, or any other concerns.  Patient was understanding, discharged home.   Patient was not informed of his pulmonary nodule department, I attempted to contact the patient on several different occasions, left multiple voicemails.  Given this we will send a certified letter to the patient to let him know about his pulmonary nodule so that he can have this followed up by his primary care physician.   EKG: Sinus rhythm rate 82, QRS 84, QTc 439, no ST-T changes, interpreted by myself.   Procedures   ED Course   ED Course as of Jun 18 0412 Tue Jun 15, 2021 0945   Negative for PE        History   Chief Complaint Patient presents with ?   Vomiting ?   Shortness of Breath   MODE OF ARRIVAL: The patient arrived by private car CHIEF COMPLAINT: Vomiting and Shortness of Breath   HISTORY OF PRESENT ILLNESS: 32 y.o. male complains of Vomiting and Shortness of Breath This is a 32-year-old male no significant past medical history presents emergency department with a chief complaint of chest pain, shortness of breath.  Patient recently drove to the mountains.  States that while he was up there he did have a mild headache, has had some nausea and vomiting, nonbilious/nonbloody.  No associated fevers or chills.  No numbness tingling or weakness.  This persisted and also started develop some shortness of breath and had some episode of hemoptysis.  Also states that he was having some chest discomfort.  He is unable to further describe it.  Subsequently decided to descend.  Since arriving patient has complete resolution of headache.  States he still feels mildly short of breath.  He has no history of blood clots, no family history of blood clots.  He has not take anything for this.   PAST MEDICAL HISTORY: denies   PAST SURGICAL HISTORY:  denies   FAMILY HISTORY:  No h/o blood clots   MEDICATIONS: denies ALLERGIES: NKDA PCP: NONE GIVEN PCP    SOCIAL HISTORY: no tobacco, daily etoh, no illicits   (Please note that portions of this note may have been completed with a voice recognition program. Efforts were made to edit the dictations but occasionally words are mis-transcribed.)         No past medical history on file.   No past surgical history on file.   No family history on file.   Social History      Tobacco Use ?   Smoking status:   Not on file Substance Use Topics ?   Alcohol use:   Not on file ?   Drug use:   Not on file     Review of Systems  All other systems reviewed and are negative. ROS: A complete 10-point REVIEW OF SYSTEMS was performed and is negative with the exception of those items previously documented in the HPI and nursing notes. As is my standard practice, ALL pertinent positives from the ROS are documented.     Physical Exam      ED Triage Vitals [06/15/21 0755] Temp 37 °C (98.6 °F)  Pulse 93  Resp 20 BP 149/83 SpO2 97 %   Temp Source  Temporal Heart Rate Source  -- Patient Position (BP)  -- BP Location  Left arm FiO2 (%) --    Physical Exam Vitals reviewed.  Constitutional:      Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Comments: No meningismus Cardiovascular:     Rate and Rhythm: Normal rate.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.  No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     Mental Status: He is alert.     Comments: Cranial nerves II through XII intact, 5 out of 5 strength throughout, sensation intact to light touch, finger-to-nose intact, no pronator drift  Psychiatric:        Mood and Affect: Mood normal.          MDM Number of Diagnoses or Management Options Diagnosis management comments: Patient presenting with chest pain, shortness of breath, hemoptysis, concerning for high-altitude pulmonary edema, pulmonary embolism will check basic laboratory studies, rule out ACS with EKG, troponin.         06/18/21 0412