Age: 17.0
Sex: M
Vaccine: COVID19
Symptoms: Pharyngeal erythema, Pneumonia, Rales, Respiratory disorder, Rhinorrhoea
Clinical narrative: 17yo otherwise healthy male presents to clinic for worsening cough, runny nose congestion, and sweats starting 4 days ago. He received the COVID vaccine 5 days ago in the afternoon and initially had what he expected to be normal side effects from the vaccine that evening. Symptoms included body aches, runny nose and general malaise. However, over the last few days he has felt worse and developed more congestion, cough, and sweating. He did improve a little bit 2 days ago but then started to feel worse yesterday and had a worsening cough that is resulting in some chest tightness. Cough is productive sounding. Mom describes it as barking. No appreciable wheezing but he sounds hoarse. He has some SOB after coughing repeatedly. He states it simply feels like it is hard to breathe for 10-20minutes after a coughing attack but then it resolves. He developed sweating yesterday as well. He states he will just start sweating for no reason. No measured fever. No chills. Today he has dried skin and cracked lips from blowing/wiping his nose all the time. No fevers. No vomiting. No diarrhea. No numbness/tingling. No redness/swelling at injection site. No rashes. No HA.            EXPOSURE: No one at home is sick, No known exposures prior to vaccine            CHRONIC: None, no hx of asthma or allergies, hx of eczema.            PCP: None            UTD on imms.   Vitals:        Wt 163.4, HR 60, RR 18, Temp 97.8, O2 sat % 98            Past Results:    Examination:                   GENERAL APPEARANCE: alert, no acute distress, non-toxic, mildly diaphoretic, talking and cooperating throughout exam, sitting comfortably on exam bed, able to talk in complete sentences.          HEAD: no visible lesions or abnormalities.          EYES:  no eye, eyelid, or orbital abnormalities identified.          EARS:  BILATERAL TMs pearly gray without erythema, effusion, or purulence; EAC with normal amount of cerumen bilaterally, no mastoid erythema or tenderness.          NOSE:  patent nares, congested, clear rhinorrhea.          MOUTH/THROAT:  moist mucous membranes, uvula midline, mild pharyngeal erythema without tonsillar exudate, no soft palate lesions, no trismus, no soft palate swelling or erythema, no difficulty swallowing or drooling.          NECK:  supple, non-tender, FROM.          CHEST:  normal shape, good expansion, no visible lesions/abnormalities, no tenderness, no retractions, no grunting, no stridor.          HEART: no murmur, RRR.          LUNGS: clear to auscultation, prior to administration of inhaler, diffuse wheezing and rhonchi throughout, post inhaler, improved air movement with focal rales in RIGHT poseterior middle lung field around T5.          ABDOMEN:  soft, no tenderness, no masses palpated, normoactive bowel sounds, non-distended.          NEURO: alert, non-focal exam.          SKIN: warm, dry without rash, petechiae, or purpura.    Pneumonia of right middle lobe due to infectious organism          Start Albuterol (Eqv-Proventil HFA) aerosol, 90 mcg/inh, 2 puff(s), inhaled, every 6 hours, 30 day(s), 1          Start amoxicillin tablet, 500 mg, 2 tab(s), orally, 3 times a day, 10 day(s), 60          Imaging:XR CHEST 2 VIEWS PA AND LAT          Notes: History and exam are consistent with Community Acquired Pneumonia. CXR final read indicates RIGHT middle lobe bronchopneumonia. Suspect that pneumonia is unrelated to COVID vaccine. Pneumonia is an inflammation of the lungs caused by infection. Antibiotics are used to treat bacterial pneumonia. Other medications may help improve breathing and relieve symptoms in bacterial and viral pneumonia. Start and complete entire course of antibiotics. Increase fluids and restas much as possible. Patient informed to return if not improved or go to ER if worsening sympmtoms, SOB, or increased chest pain. Should be rechecked in 2-3 days by PCP. Discussed side effects and risks of medications with the patient. Patient expressed understanding and a willingness to participate in the plan. Patient left the UC in a stable condition with all questions answered at this time.      Cough          Imaging:XR CHEST 2 VIEWS PA AND LAT          Notes: Discussed cough in clinic. Will plan to treat with albuterol PRN cough/wheezing every 4-6hrs and Stiolto Respimat 2 inhalations QD after discussion with Dr. First dose of Stiolto given in clinic with improvement in symptoms and improved aeration. Focal findings now appreciable. Discussed close follow-up and when to return to clinic. Will report symptoms to VAERS. All questions and concerns answered and addressed.