Progress NotesWillie B Magdamo, MD at 5/12/2023 2:15 PM
Subjective
Patient ID: Michael Golen is a 55y.o. male.
HPI
Reports symptoms started about a couple of days ago in Canada and states the night before their flight started feeling achy back aches, shoulders, legs but states they were doing a lot of walking during their trip, caring backpacks and thought he thought that was just that but then developed diarrhea states every hour, loose watery stools, nonbloody but also "heartburn" 2 days ago and he reports feels like the need to burp more often and states it hurts to breathe and states he gets winded. States family history of CAD.
Denies abdominal pain or further heartburn, diarrhea, no fever. No recent URI symptoms.
Review of Systems
Constitutional: Positive for fatigue. Negative for appetite change, diaphoresis and fever.
Respiratory: Positive for shortness of breath. Negative for cough.
Cardiovascular: Positive for chest pain. Negative for palpitations and leg swelling.
Gastrointestinal: Positive for diarrhea. Negative for abdominal pain, nausea and vomiting.
Endocrine: Negative for polydipsia and polyuria.
Genitourinary: Negative for dysuria.
Musculoskeletal: Positive for myalgias. Negative for back pain and neck pain.
Skin: Negative for color change and rash.
Neurological: Negative for dizziness, weakness, light-headedness and headaches.
Psychiatric/Behavioral: The patient is not nervous/anxious.
Objective
BP 128/80 | Pulse 90 | Temp 98.9 °F (37.2 °C) (Oral) | Wt 209 lb 12.8 oz (95.2 kg) | SpO2 97% | BMI 26.94 kg/m²
Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: He is not in acute distress.
Appearance: He is not toxic-appearing.
HENT:
Right Ear: Tympanic membrane normal. No middle ear effusion. Tympanic membrane is not erythematous or bulging.
Left Ear: Tympanic membrane normal. No middle ear effusion. Tympanic membrane is not erythematous or bulging.
Nose: No congestion or rhinorrhea.
Right Sinus: No maxillary sinus tenderness.
Left Sinus: No maxillary sinus tenderness.
Mouth/Throat:
Mouth: Mucous membranes are dry.
Pharynx: No oropharyngeal exudate or posterior oropharyngeal erythema.
Eyes:
General: No scleral icterus.
Conjunctiva/sclera: Conjunctivae normal.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds. No murmur heard.
Pulmonary:
Effort: No accessory muscle usage or respiratory distress.
Breath sounds: Normal breath sounds.
Chest:
Chest wall: No tenderness.
Abdominal:
Palpations: Abdomen is soft.
Tenderness: There is no abdominal tenderness. There is no guarding.
Lymphadenopathy:
Cervical: No cervical adenopathy.
Skin:
Findings: No rash.
Neurological:
Mental Status: He is oriented to person, place, and time.
Assessment & Plan
Diagnoses and all orders for this visit:
Pleuritic chest pain (Primary)
– EKG W/ INTERPRETATION
Fatigue, unspecified type
– SARS COV-2/FLU A&B, NAA (STAT-LIMITED SUPPLY) (VTM/UTM SWAB); Future
Diarrhea, unspecified type
– SARS COV-2/FLU A&B, NAA (STAT-LIMITED SUPPLY) (VTM/UTM SWAB); Future
Body aches
– SARS COV-2/FLU A&B, NAA (STAT-LIMITED SUPPLY) (VTM/UTM SWAB); Future
Abnormal EKG
Discussed with patient EKG findings, he is with his wife, recommend further eval in the ED and to proceed to ER of choice directly from here. They will proceed to St. Davids 620 RR via private vehicle.and he is stable for the short drive via private vehicle and instructions given. Patient reports okay to drive, declined EMS as he had the symptoms for 2 days. Patient agrees with plan and verbalizes understanding..MA Casey spoke with ER.
Return for Next scheduled follow up.
Patient Instructions
Willie B Magdamo, MD at 5/12/2023 2:15 PM