Age: 41.0
Sex: F
Vaccine: COVID19
Symptoms: Oropharyngeal pain, Pain, Paranasal sinus discomfort, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: 10/18/2021 Urgent Care - CRNP Exposure to SARS-associated coronavirus + Cough  ? Sore Throat ? Fever  ? Fatigue ? Shortness of Breath Patient was seen today for cough, sore throat, fever, fatigue and shortness of breath.    Diagnoses and all orders for this visit:  Exposure to SARS-associated coronavirus  -     POCT COVID-19 PCR  Patient presented to the urgent care with cough, sore throat, fever fatigue and shortness of breath for 1 to 2 days.  Patient was vaccinated for COVID-19.  Covid point-of-care test was run during this visit.  Most likely viral upper respiratory infection/bronchitis.  Placed the patient on 5-day course of prednisone and albuterol inhaler.  Also prescribed Tessalon Perles.  Informed patient presents to improve in the next 2 to 3 days to follow-up with her PCP.   I notified the patient that she is positive for COVID-19 and that she needs to stay quarantine for 10 days.  Informed the patient that her symptoms become life-threatening such as increased shortness of breath or difficulty breathing that she needs to go to the ER for further evaluation. Patient Education    There are no Patient Instructions on file for this visit.     History Chief Complaint Patient presents with ? Cough     sx's started yesterday  ? Sore Throat ? Fever     pt reports temp of 101.2 yesterday  ? Fatigue ? Shortness of Breath     Patient is a 41 y.o. female    HPI   Pt presents with concerns of possible Covid 19. Pt reports the following symptoms that started 2 days ago. Sinus pain and pressure No Fever/ chills Yes Headache Yes Body aches Yes Cough Yes Sob Yes Sore throat Yes Nausea/ vomiting/ diarrhea. No Loss of taste or smell No Medications used:No Tolerating fluids:Yes Tolerating. solids:Yes Smoke exposure:No Exposed to someone who tested positive for COVID 19: No History of asthma, bronchitis, pneumonia. Yes Pt works at school district  ED   Discharged 10/18/2021 (2 hours)  Hospital ED, MD    COVID-19  &  fatigue   Patient is a 41 y.o. female with hx of Addison's disease, migraines, fibromyalgia, anxiety, asthma, POTS presenting to the ED with fatigue, body aches, nausea, cough.   Patient is a symptoms started just yesterday.  Woke up and had some body aches and chills with some increasing fatigue and a sore throat.  Sore throat has since subsided, but has since developed cough.  Went to urgent care earlier today where she did have a COVID-19 test that did return positive. Patient was immunized x2 doses of Pfizer in April and May.  States that she does have a bit of shortness of breath, but cough continues.  Given her history of pots and Addison's disease is, is concerned for the reaction her body may face and states that she gets dehydrated very easily.  States that her p.o. intake has been significantly decreased over the past 24 hours, but denies any vomiting or diarrhea. Work-up largely reassuring.  Patient does feel bit better after IV fluids.  Otherwise cleared for discharge and advised to follow primary care provider.  Offered monoclonal about infusion given possible immunosuppression given history of Addison's disease on chronic steroids, but she does not wish to have this done at this time.  She has been vaccinated otherwise has reassuring vital signs including pulse oximetry.  Again advised to follow primary care provider given strict precautions.  She voices understanding agreed with plan.