Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen, Discomfort, Dyspnoea, Enterovirus test negative, Fatigue
Clinical narrative: ED Discharged   8/15/2021 - 8/16/2021 (5 hours) Hospital ED  MD  Last attending ? Treatment team COVID-19 virus infection +1 more  Clinical impression Fever ? Flank Pain ? Cough  Chief complaint   ED Provider Notes DO (Resident) ? ? Emergency Medicine Cosigned by: MD at 8/16/2021  2:14 PM Expand AllCollapse All        ED RESIDENT NOTE        Patient:  MRN:   Attending: Dr.         Chief Complaint      Chief Complaint Patient presents with ? Fever ? Flank Pain ? Cough        History of Present Illness     Patient is a 67 y.o.  male with a history of COPD, hepatitis C, hypertension, presenting to the ED with multiple complaints.  Patient reports productive cough, congestion, some shortness of breath, body aches, fatigue, headache. He reports right flank pain.  He reports that his symptoms have been going on for about a week and a half.  He states the pain in his right flank is worse with movement.  Patient recently had an outpatient ultrasound of his liver after having elevated LFTs on labs.  Patient has had both his Covid vaccines.  Denies recent sick contacts.  Denies known Covid exposure.  Denies dysuria, urinary symptoms, hematuria.  Denies abdominal pain, nausea, vomiting, diarrhea.        Medical Decision Making     Patient is a 67-year-old male presenting the emergency department with multiple complaints, see HPI.  Patient's vital signs are stable upon arrival, nearly febrile.  He appears in no acute distress, however does appear uncomfortable secondary to his symptoms.  Heart is regular rate and rhythm.  Lungs are clear to auscultation bilaterally, no wheezes or rales.  Nonpitting peripheral edema.  Tenderness to palpation over right lower back.  No CVA tenderness or midline lumbar spine tenderness.  Differential includes Covid, pneumonia, musculoskeletal back pain, kidney stone, lower suspicion for aortic pathology.  Will obtain labs, EKG, chest x-ray, CT abdomen pelvis.  Will give Toradol and lidocaine for his symptoms. ED Course as of Aug 16 0801 Mon Aug 16, 2021 0159 Laboratory evaluation shows no leukocytosis, H/H stable, electrolytes within normal limits, normal kidney function, AST 128, ALT 142, which are improved from previous lab work.  Urinalysis does not show signs of infection or stone.    0240 COVID-19 SARS-CoV-2 Overall Result(!!): Detected  0320 No acute findings.  No focal infiltrates or consolidations.  X-ray chest 1 view - Portable  0320 Patient maintained oxygen saturations of 94 to 95% on room air while ambulating.    0344 CT scan of the abdomen and pelvis with contrast shows no specific cause of the patient's right flank pain.   There is minimal calcification in the dependent portion of the bladder. The gallbladder is normal in size and contour. No acute obstruction.   There are small lymph nodes in the retroperitoneum and central abdomen. This is nonspecific and correlation should be made with patient's history.   Calcifications are present.   Normal bony structures.  CT abdomen pelvis without contrast  0455 Patient reports some improvement in his symptoms with given medications.  Patient able to ambulate without difficulty and maintaining his oxygen saturations.  Patient stable for discharge.  He will be discharged home with a pulse oximeter.  He was given return precautions regarding his Covid status.  He was also given Covid isolation precautions.  Prompt follow-up with his PCP.  Discussed appropriate outpatient medications.  Given strict ED return precautions.  He voiced understanding was agreeable to plan.      ED Course User Index