COVID No Touch
EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
Vitals: [BP, HR, RR, Temp, O2]
Constitutional: The patient is alert and [in no acute distress]
Head: Normocephalic
Eyes: [No conjunctival injection]
Ears, Nose Throat: [moist] oral mucosa
Respiratory: [breathing comfortably on room air, no tachypnea]
Musculoskeletal: [spontaneously moves all viewable extremities]
Skin: [no diaphoresis]
Neurologic: [The patient is alert and conversational]
psychiatric: [normal speech content and affect]
MEDICAL DECISION MAKING AND COURSE IN THE ED: [I did begin a screening discussion with the patient utilizing a phone to speak with the patient]
patient presents with [], they have [not] had travel to any high risk areas for COVID-19. They have [not] had contact with any known person with COVID-19.
At this time the patient does [not] meet criteria for further investigation into coronavirus.
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Reassessment/Revaluation: [patient continues to be well-appearing, breathing comfortably on room air]
The patient is stable for discharge at this time, I did explain why we were unable to test the patient. Even though we are unable to test the patient I did explain the importance of hand hygiene and social distancing. I told the patient that they should quarantine themselves and gave them instructions regarding this. They were given anticipatory guidance about the possibility for coronavirus or other viral syndromes. They were told to return to the emergency department if their symptoms continue to worsen or if they began to have difficulty in breathing. They were told to return to their PCP after sufficient quarantine period was over unless they developed further concerning symptoms. They are amenable to this plan
DISPOSITION: The patient was discharged home in good condition. The patient will follow up with [their PCP within 2 weeks] []
FINAL IMPRESSION(S)/DIAGNOSES:
–[]
COVID Possible
EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
Vitals: [BP, HR, RR, Temp, O2]
Constitutional: The patient is alert and [in no acute] distress
Eyes: [No conjunctival injection, EOMI]
Ears, Nose Throat: [moist] oral mucosa, [no visible vesiculation, ulcerations, erythema or swelling in oropharynx/posterior pharynx]
Neck: [Supple, no LAD]
Cardiovascular: [Regular] rate, [no murmurs]
Respiratory: [breathing comfortable on room air, symmetric chest rise], [lungs clear to auscultation bilaterally]
Gastrointestinal: Abdomen is [soft and non distended]
Musculoskeletal: [No deformities], [spontaneously moves upper and lower extremities]
Skin: [Warm and dry], [no edema]
Neurologic: [The patient is alert and conversational]
MEDICAL DECISION MAKING AND COURSE IN THE ED:
[I did begin a screening discussion with the patient in a private closed room while I was outside of their room utilizing a phone to speak with the patient ] [I did begin a screening discussion with the patient in a private room while I donned appropriate PPE and maintained at least 6 feet of distance from patient]
patient presents with [], they have [not] had travel to any high risk areas for COVID-19. They have [not] had contact with any known person with COVID-19.
Based on their clinical history and symptoms the patient does [not] meet criteria for further investigation into coronavirus. []
Further patient contact and physical examination was performed while donning appropriate PPE
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Reassessment/Revaluation: []
[]
DISPOSITION:[]
FINAL IMPRESSION(S)/DIAGNOSES:
–[acute cough with suspected COVID-19, but does not meet criteria for emergent testing]
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COVID Admit
EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
Vitals: [BP, HR, RR, Temp, O2]
Constitutional: The patient is alert and [in no acute distress]
Eyes: [No conjunctival injection, EOMI]
Ears, Nose Throat: [moist] oral mucosa, [ no visible vesiculation, ulcerations, erythema or swelling in oropharynx/posterior pharynx]
Neck: [Supple, no LAD]
Cardiovascular: [Regular] rate and rhythm, [no murmurs]
Respiratory: [breathing comfortable on room air, symmetric chest rise], [lungs clear to auscultation bilaterally]
Gastrointestinal: Abdomen is [soft and non distended]
Musculoskeletal: [No deformities], [spontaneously moves upper and lower extremities]
Skin: [Warm and dry], [no edema]
Neurologic: [The patient is alert and conversational]
MEDICAL DECISION MAKING AND COURSE IN THE ED: [I did begin a screening discussion with the patient in a private room while I donned appropriate PPE, including gown, gloves, surgical mask and/or N95 mask with proper eye protection, proper doffing technique was subsequently applied after conclusion of my exam]
patient presents with [], they have [not] had travel to any high risk areas for COVID-19. They have [not] had contact with any known person with COVID-19.
Based on their clinical history and symptoms the patient does [] meet criteria for further investigation into possible coronavirus.
[]
Radiology Imaging Interpretation: A [one] view chest X-ray was done that showed [no cardiomegaly, focal opacities, focal infiltrates or any acute cardiopulmonary process.]
Lab Results and Interpretations: [Electrolyte studies reveal no acute abnormalities.] [Renal function assessed to be normal.] [No acute leukocytosis, anemia, or platelet abnormalities.] flu A/B was [negative], RSV [negative] []
Reassessment/Revaluation: []
[]
DISPOSITION: The patient was [admitted] to the [general medicine service] in [fair] condition.
FINAL IMPRESSION(S)/DIAGNOSES:
–[acute suspected COVID-19]
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