Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Nausea, SARS-CoV-2 test negative, Vomiting
Clinical narrative: Patient reported:  Difficulty breathing; severe headaches, vomiting/nauseous for 3 weeks and counting, plus chills.  Went to Urgent Care 4.1.21.  Back to Urgent Care 4.9.21 - this time with symptoms above plus cough, SOB, N/V.  CXR (-) COVID (-).  Patient received dose J&J vaccine 3.23.21.  HISTORY OF PRESENT ILLNESS: Patient is a 59 y.o. female who presents to the Urgent Care with COVID-19 (sick after receiving COVID vaccine x1week ago. Vomiting, headaches, nausea, chills)  HPI:  Patient presents today with complaints of nausea, vomiting, headache and chills intermittently over the past 1 week after receiving her 1st COVID 19 vaccination.  She states that she got the Johnson Johnson COVID-19 vaccine.  She states of then she has had an episode of vomiting daily some nausea.  She has also had a headache every single day as well as some constipation.  She denies any numbness or tingling, abdominal pain, diarrhea.  She states that she has been taking ibuprofen, Pepto-Bismol, and Tylenol for her symptoms with minimal relief.  She is drinking a lot of water as well.  Medical Decision Making:  No concerns for acute abdomen or neurological deficits are noted on exam today. Patient is reporting some symptomatic relief after receiving the Toradol injection today in urgent care. Educated the patient on the following: Zofran for nausea and vomiting. MiraLax and senna for any constipation symptoms.  Motrin and Tylenol for pain or fever. Drink plenty of fluids.  Follow up with PCP as needed. If symptoms worsen go to the emergency room such as you are not able to keep fluids down while taking the Zofran, if you develop any bloody stools, bloody vomit, or increasing abdominal pain.  HISTORY OF PRESENT ILLNESS Patient is a 59 y.o. female who presents to the Urgent Care with COUGH (cough, SOB, congestion, vomiting everyday until about 1PM. headache off and on. x 2 weeks (since covid vaccine))     HPI: Patient is a 59 y.o. female who presents to the urgent care with cough, shortness of breath, congestion, nausea and vomiting and intermittent headaches over the past 2 weeks.  Patient states that the symptoms started the day of her COVID vaccine.  She states that she receive the Johnson&Johnson 1 time dose.  She states later that day after receiving the vaccination she had a significant headache that developed.  She states that since then she has had a dry nonproductive cough with intermittent shortness of breath and morning nausea and vomiting that last till about 1:00 p.m..  She states that the headaches have resolved at this time but the cough, intermittent shortness of breath and nausea and vomiting have persisted.  She denies any abdominal pain, chest pain, chest pressure or chest tightness.  She states that she has not been experiencing any dizziness, vision changes or lightheadedness.  She was seen in the urgent care about a week ago and was prescribed Zofran to assist with the nausea.  She states that she was taking it twice in the morning and has now been able to only take it once, does feel that the nausea is improving but was out of the medication today, states that she was not able to take anything today and did have an episode of nonbloody nonbilious vomiting.  She states that she was having some constipation she feels that this was related to the over-the-counter pain medications that she was taking for the headaches.  She states that she was advised to take MiraLax at her last urgent care visit which she has been taking, had a normal bowel movement yesterday.  She states that she has had pneumonia in the past, no history of asthma or chronic obstructive pulmonary disease.  With the continued symptoms came to the urgent care for evaluation.  She states that there have been to other coworkers who have had exposure or have now tested positive for COVID-19.  Medical Decision Making:  59-year-old well-appearing female who presents to the urgent care with cough and nausea and vomiting over the past 2 weeks.  Reviewed patient's previous urgent care notes as well as immunization record.  Her vital signs are stable in the urgent care today and exam is largely benign.  Given her history and current complaints did obtain a chest x-ray which appears negative, formal interpretation was pending at time of discharge.  She was provided Zofran in the urgent care today which she did state helps with the nausea.  Discussed with patient that I do feel that COVID-19 testing should be collected as at the time of her symptoms and given her continued symptoms she has not had full immunity from the vaccination and this could still be a COVID-19 infection.  She is in agreeance and COVID testing is pending.  Prescribed refill of her Zofran as well as Tessalon for cough relief and advised continued symptomatic measures and close follow-up with PCP for any persistent symptoms.  She was provided a work note given her symptoms and COVID-19 testing she was provided the standard COVID-19 work letter.  Patient educated on warning signs and symptoms that would prompt immediate reevaluation. They conveyed understanding and were agreeable to this plan of care. All questions addressed at this time. Pt was non toxic appearing and not in any acute distress upon discharge.