Urgent Care Focused H&P                                   

Date: 03/08/21
Patient Name:  ML
CC: chest pain, headache, cough x 2 days

HPI: 41 y/o female with PMH of ankylosing spondylitis presenting with 2 days of chest pain, dry cough, and headache. Pt stated that symptoms came on gradually beginning with headache and cough, with chest pain starting later on. Chest pain described as right-sided 6/10 intermittent burning pain occasionally radiating to left side, worse with deep breathing and cough. Pt was sitting down when chest pain started, Tylenol provides mild relief. Headache described as generalized bilateral pain with gradual onset. Of note, patients husband tested positive for COVID-19 5 days prior and pt tested negative 4 days prior. Pt denies fever, SOB, dizziness, palpitations, syncope, nausea, diarrhea, vomiting, numbness/tingling, blurry vision, recent injuries, muscle/joint pain, recent travel, OCP use.

With chest pain presentations include ROS such as: family hx of cardiac disease or sudden cardiac death, family or personal history of DVT/PEs

PMH
Current illnesses: ankylosing spondylitis
Past Illness: denies
Surgeries: denies
Allergies: denies
Medications: Cosentyx
Hospitalizations: denies
Trauma/Injuries: denies

Social History
Education: college
Work/finances: unemployed
Family & relationships: married, living with spouse and child
Habits/risk factors: denies
Reproductive History: G1 T1 P0 A0 L1

Review of Systems

General: Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight loss/gain.

Head: admits headache. Denies dizziness, head trauma, unconsciousness, coma, fractures.

Mouth/throat: Denies sore throat, bleeding gums, sore tongue, mouth ulcers, voice changes.

Neck: denies localized swelling/bumps, stiffness, decreased range of motion.

Pulmonary System: admits dry cough. Denies dyspnea, SOB, wheezing, hemoptysis, cyanosis, orthopnea, PND.

Cardiovascular System: admits chest pain. Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.

Gastrointestinal System: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, change in appetite, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructation, jaundice, change in bowel habits, hemorrhoids, rectal bleeding, blood in stool, flank pain.

Musculoskeletal System: denies muscle/joint pain, deformity, swelling, redness, arthritis.

 

Physical Exam

VS: BP: 113/67  HR: 56  RR: 16  O2 sat: 98%  Temp:  98.8 F

General: A&O to person, place, time. Well groomed, appropriately dressed, in no apparent distress.

Skin: skin is warm, moist, good turgor.

Head: normocephalic, atraumatic, non-tender to palpation.

Pharynx: well-hydrated. No injection, exudates, masses, lesions, foreign bodies. Tonsils present with no injection, exudates. Uvula pink, no edema or lesions.

Thorax and lungs: chest symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxic respirations, no use of accessory muscles. Lungs clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiovascular: RRR. S1 and S2 distinct, no S3 or S4, no murmurs, no friction rub noted.

Abdomen: flat and symmetric with no scars, striae, pulsations noted. Bowel sounds normoactive in all quadrants, no aortic/renal/iliac/femoral bruits heard. Non-tender to palpation throughout. No guarding or rebound noted. No CVA tenderness noted.

 

 

Assessment:

41 y/o female with PMH of ankylosing spondylitis presenting with 2 days of pleuritic chest pain, dry cough and headache.

Ddx:
– MI (unlikely due to pleuritic nature of pain, no risk factors)
– pericarditis (unlikely due to lack of fever and friction rub)
– PE (unlikely due to 98% O2 sat, no risk factors, no SOB)
– pneumothorax (unlikely due to lack of trauma, risk factors, SOB, and gradual onset of symptoms)
– COVID-19
– URI

Plan:

• EKG
• Chest x-ray
• COVID rapid and PCR test
• Rapid strep test

Pertinent Results:

• EKG showed no evidence of acute MI, no arrhythmia, axis deviation, abnormalities.
• Chest x-ray showed no evidence of consolidation, infiltrates, cardiomegaly, pneumothorax, effusion
• Rapid COVID test positive
• Rapid strep test negative

 

Disposition:

Pt discharged home with diagnosis of COVID-19. Instructed to treat symptoms with Tylenol, cough syrup. Pt instructed to watch out for SOB, worsening symptoms and seek appropriate care if necessary, including going to emergency room. Isolate for 10 days.

Good plan, given that patient is COVID positive with chest pain, she has an increased chance of having PE, using a PERC score may help justify not working up for PE, as she meets PERC criteria