Age: 66.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Cough, Creatinine renal clearance decreased, Differential white blood cell count, Dyspnoea, Electrocardiogram normal
Clinical narrative: 67 year old male presents to the ED via private vehicle complaining of cough onset PTA. pt reports coughing up blood recently and is trying to cough now but cant. Pt was recently diagnosed with COVID-19 on 12/13/21. Pt c/o of dyspnea, chest pain, back pain ,nasal congestion and headache. Pt reports that the chest pain is a stabbing pain that is worse with deep inspiration. he reports feeling better from COVID-19 but is still having symptoms. He denies fever, dysuria or hematuria.    Review of Systems     Constitutional:  no fever Eyes: no eye pain ENMT:  no sore throat, +nasal congestion Cardiovascular: +chest pain Respiratory:  +shortness of breath, +cough Gastrointestinal:  no abdominal pain Genitourinary:  no dysuria Musculoskeletal:  +back pain Skin:  no rash Neurologic:  +headache  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.9 DegC  Heart Rate:       84 bpm  Resp Rate:       32 br/min  BP #1:       110 / 72 mmHg  SpO2 (%):       90 %  O2 Flow (l/min):          2 L/min  O2 Device:       Nasal Cannula     Height CM: 180 cm  Weight KG: 83.2 kg  Ideal Body Weight: 74.99 kg     I have reviewed the triage vital signs General:  mild distress,  Eye: no conjunctival injection Cardiovascular: rhythm regular, S1S2 within normal limits Respiratory:  lungs clear, tachypneic but speaking in full sentences Gastrointestinal:  soft, non-distended, nontender, no guarding  Msk:  NC/AT, extremities without deformity Skin:  warm, dry, no cyanosis Psych: appropriate mood and affect Neurological:  Alert, conversant, speech normal  Medical Decision Making     67 year old year old male presents with cough. Pt was in ED 12/21 for emesis and nausea. Diagnosed with COVID-19 on 12/13.  Pt arrived hypoxic to 89%. He was placed on 2L NC.  Found to have pulmonary embolism.  Nasal cannula was escalated to HHFNC due to tachypnea.   Labs: reviewed  Radiology: reviewed  EKG: 1319. Rate: 80. Rhythm: sinus. Axis: normal. Intervals: normal. ST segments: no ST  depression or elevation     Re-Assessment  12/27/21 13:04:05 Pt is 94% on 2L.   12/27/21 17:53:10 Requested high flow cannula, respiratory rate is in 30-40 range   Condition     Stable  Disposition: 12/27/21 18:05:06 Transferred care of pt to Dr., MD   Counseled patient regarding diagnosis, regarding diagnostic results, regarding treatment plan. Patient indicated understanding of instructions.    Assessment/Plan       1. Pulmonary emboli   I26.99     2. Hemoptysis   R04.2     3. Chest pain   R07.9     4. COVID-19   U07.1     5. Leukocytosis   D72.829             Chronic Problem List      Procedure/Surgical History  ?Diabetic retinal eye exam (05/07/2021) ?Septo/Turbs (11/17/2020) ?septoplasty, turbinate reduction with Dr. on 11/17/2020 (11/17/2020) ?Diabetic retinal eye exam (01/16/2020) ?Diabetic retinal eye exam (01/24/2019) ?Teeth Extraction (2013) ?egd (01/10/2006) ?laparotomy with small bowel resection for gunshot wound (1974) ?Splenectomy (removal of spleen) (1974) ?Fracture repair (1966) ?Ingrown toenail removal both feet.  Medications  Home Medications (28) Active Accu-Chek Guide Blood Glucose Meter Not Applicable, Other, Unscheduled Accu-Chek Guide Test Strips Check 2 times daily, Other, Unscheduled Accu-Chek Softclix Lancets Check 2 times daily, Other, Unscheduled, Dispense QS 90 days albuterol 0.63 mg/3 mL (0.021%) inhalation solution 0.63 mg = 3 mL, PRN, Neb Inhal, Q6H aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Every Other Day, Do not take aspirin for 10 days atorvastatin 80 mg oral tablet 80 mg = 1 Tablet, Orally, Daily Atrovent Nasal 42 mCg/spray 2 Spray, intraNASAL, TID docusate sodium 100 mg oral capsule 100 mg = 1 Capsule, Orally, Daily Dulera 100 mCg-5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID Glucophage XR 500 mg oral tablet, extended release 1,000 mg = 2 Tablet, Orally, BID Jardiance 10 mg oral tablet 10 mg = 1 Tablet, Orally, QAM Keppra 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, BID losartan 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily Nebulizer - Standard Small Volume (ONCE) Not Applicable, Other, Unscheduled Neurontin 300 mg oral capsule 600 mg = 2 Capsule, Orally, At Bedtime ondansetron 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q6H Pen Needles - Insulin (4mm x 32G) Use daily, Other, Unscheduled, Dispense QS 90 days;needs pen needles for Victoza pens Prilosec 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily ProAir HFA 90 mCg/inh inhalation aerosol 1 Puff, PRN, Inhalation, 4 Times Daily promethazine 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, Q4H propranolol 40 mg oral tablet See Instructions, take 2 tablets in AM and 1 tablet in PM rizatriptan 5 mg oral tablet, disintegrating 5 mg = 1 Tablet, Orally, Daily, may repeat dose once in 2 hours Singulair 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily tamsulosin 0.4 mg oral capsule 0.8 mg = 2 Capsule, Orally, QHS topiramate 50 mg oral tablet 50 mg = 1 Tablet, Orally, BID Victoza 18 mg/3 mL subcutaneous solution 1.8 mg, Subcutaneous, Daily, Please dispense 90 day supply Vitamin D3 2,000 intl units (50 mCg) oral capsule 50 mCg = 1 Capsule, Orally, Daily, OTC Voltaren Topical 1% topical gel 2 GM, Topical, 4 Times Daily, not to exceed 8 grams/day/single joint of upper extremitiesnot to exceed 32 grams/day    Tobacco Use: Former Smoker. Cigarettes, 0.25 packs per day. 50 year(s).  Family History   Brain cancer 02-JUL-2017 11:19:02<$>: Mother and Father.  Heart disease..: Mother, Father and Brother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  12/27/21 14:02  16.8  High  12/21/21  8.2          RBC  12/27/21 14:02  4.49  12/21/21  4.81          Hgb  12/27/21 14:02  13.4  12/21/21  14.7          Hct  12/27/21 14:02  41.8  12/21/21  44.4          MCV  12/27/21 14:02  93  12/21/21  92          MCH  12/27/21 14:02  29.8  12/21/21  30.6          MCHC  12/27/21 14:02  32.0  12/21/21  33.2          RDW  12/27/21 14:02  13.7  12/21/21  14.3          Platelet  12/27/21 14:02  221  12/21/21  276          MPV  12/27/21 14:02  7.5  12/21/21  7.2          Neutrophils %  12/27/21 14:02  78  12/21/21  72          Lymphocytes %  12/27/21 14:02  9  12/21/21  16          Monocytes %  12/27/21 14:02  12  12/21/21  11          Eosinophils %  12/27/21 14:02  0  12/21/21  0          Basophils %  12/27/21 14:02  0  12/21/21  0          Absolute Neutrophil  12/27/21 14:02  13.1  High  12/21/21  5.9          Absolute Lymphocyte  12/27/21 14:02  1.5  12/21/21  1.3          Absolute Monocyte  12/27/21 14:02  2.0  High  12/21/21  0.9          Absolute Eosinophil  12/27/21 14:02  0.0  12/21/21  0.0          Absolute Basophil  12/27/21 14:02  0.1  12/21/21  0.0           Routine Coagulation Studies FS  LATEST RESULTS  HISTORICAL RESULTS          PT  12/27/21 14:02  16.6  High              INR  12/27/21 14:02  1.43  High              D-Dimer Pl QN  12/27/21 14:02  6028  High  12/21/21  484  High           Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  12/27/21 14:02  137  12/21/21  136          Potassium SerPl QN  12/27/21 14:02  4.3  12/21/21  4.0          Chloride SerPl QN  12/27/21 14:02  101  12/21/21  104          Carbon Dioxide SerPl QN  12/27/21 14:02  22  12/21/21  22          Anion Gap  12/27/21 14:02  14  High  12/21/21  10          BUN SerPl QN  12/27/21 14:02  24  High  12/21/21  21  High          Creatinine SerPl QN  12/27/21 14:02  1.03  12/21/21  1.07          Estimated GFR (CKD-EPI)  12/27/21 14:02  75  12/21/21  71          Estimated CRCL (CG)  12/27/21 14:02  77  12/21/21  71          Glucose SerPl QN  12/27/21 14:02  111  High  12/21/21  96          Calcium Total SerPl QN  12/27/21 14:02  8.6  12/21/21  8.9          Alkaline Phos SerPl QN  12/27/21 14:02  99  12/21/21  77          ALT SerPl QN  12/27/21 14:02  21  12/21/21  33          AST SerPl QN  12/27/21 14:02  25  12/21/21  49  High          Bilirubin Total SerPl QN  12/27/21 14:02  1.0  12/21/21  1.0          Total Protein SerPl QN  12/27/21 14:02  7.2  12/21/21  7.5          Albumin SerPl QN  12/27/21 14:02  3.2  Low  12/21/21  3.8          Troponin-I High Sensitivity  12/27/21 14:02  4  12/21/21  7          BNP Pl QN  12/27/21 14:02  87              Blood Bank Testing  LATEST RESULTS        ABO Rh  12/27/21 14:02  A Pos        IAT Interp  12/27/21 14:02  Neg      Diagnostic Results  XR Chest PA or AP Portable    12/27/21 13:42:08  IMPRESSION:   Patchy bilateral pulmonary infiltrates are increased compared to  12/21/2021. The appearance is nonspecific but consistent with  COVID-19 infection.   Electronically Signed by:     Signed By: MD     ************************************************** CTA Chest Pulm Embolism W/IV Contrast    12/27/21 16:33:51  IMPRESSION:   Bilateral and predominantly posterior pulmonary infiltrates and/or  pulmonary hemorrhage have progressed slightly since 12/21/2021.   Interval development of a large pulmonary embolus to the right middle  and lower lobe pulmonary artery segments.