Age: 46.0
Sex: M
Vaccine: COVID19
Symptoms: Upper-airway cough syndrome
Clinical narrative: Document Type: Urgent Care Provider Note   Document Subject:  Progress Note   Performed By: NP on August 23, 2022 09:06   Verified By: NP on August 23, 2022 09:06   Encounter Info: Outpatient, 08/23/22 - 08/23/22    * Final Report *        Chief Complaint   cough, headache, fever x 2 days  Subjective     cough, headache, fever x 2 days  Patient presents with complaints of cough and headache.  States symptoms started 2 days ago with non-productive cough, headache, mild fever.  Denies sore throat, ear pain, sinus congestion although does state at night he feels like stuff is running down back of his throat and causing him to cough.  Rapid COVID positive Fully vaccinated  yes Boosted yes, x 2 Previously had COVID  no          Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       37.0 DegC  Heart Rate:       95 bpm  BP #1:       128 / 74 mmHg  SpO2 (%):       96 %     No qualifying data available.      Constitutional:  No acute distress,  well-nourished Eyes:  PEERL,  EOMI,  normal conjunctiva,   ENMT: Normal and atraumatic, TM's within normal limits bilaterally, EACs clear , no hearing loss, moist oral mucosa , - pharyngeal erythema - tonsil enlargement- tonsil exudate, - nasal congestion- sinus tenderness Respiratory:  Lungs CTAB,normal respiratory effort  Cardiovascular:  Regular rate and rhythm         Assessment/Plan       1. COVID-19    Discussed COVID - advised symptoms can last 10-14 days  Advised antibiotics not indicated at this time.  Increase clear fluid intake. Rest advised. Saline nasal spray as directed.   May use OTC cough & cold meds cautiously as directed. Advised to monitor blood pressure to ensure not elevated.    OTC Mucinex as directed.  Tylenol or Motrin as directed for fever and pain.   Call office if not better, increase in fever or worsening of symptoms.  Return or call for any questions or concerns  Patient advised to present to the nearest ER or call 911 if they develop symptoms of Shortness of Breath or signs of Respiratory Distress. Patient aware and verbalized understanding. Advised of Precautionary Measures and Quarantine guidelines below.  Precautionary Measures/Quarantine Guidelines 5 days from symptom onset AND 24 hours afebrile without fever reducing medicine WITH improved symptoms (MUST continue until afebrile X3 days)   1. Avoid crowds and large gatherings such as events, places of worship, or museums. Practice social distancing by staying at least 6 feet away from other people.  a. Stay away from people at great risk of becoming severely ill. That includes people >60 years of age with multiple medical problems and people with weakened immune systems.   2. Cover coughs and sneezes. To prevent spreading germs to others, when coughing or sneezing cover your mouth and nose with a tissue or your sleeve. Throw used tissues in a lined trash can, and immediately wash hands with soap and water for at least 20 seconds, or use alcohol-based hand sanitizer if soap and water are not available. You should use soap and water if your hands are visibly dirty.  3. Wash your hands often with soap and water for at least 20 seconds or use an alcohol-based hand sanitizer that contains 60% to 95% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. You should use soap and water if your hands are visibly dirty.  Paxlovid as directed   Ordered:   nirmatrelvir-ritonavir, 3 Tablet, Orally, BID, for 5 Days, Acute, Dispense: 30 Tablet, Refills: 0, Total Refills: 0, 08/23/22 8:59:00 , 08/28/22 8:59:00 , Pharmacy: Pharmacy, 3 Tablet Orally BID,x5 Days      Suspected COVID-19 virus infection       Ordered:   AMB COVID SARS Ag FIA POC      Orders:   Coronavirus SARS Ag FIA, POC    Chronic Problem List    No qualifying data       Medications  Home Medications (1) Active  Paxlovid 150 mg-100 mg (300 mg-100 mg Dose) oral tablet 3 Tablet, Orally, BID  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Tobacco   Tobacco Use: Never (less than 100 in lifetime).    Lab Results    Coronavirus SARS Ag FIA, POC: Coronavirus SARS Ag FIA, POC  Coronavirus SARS Ag FIA, POC: Positive  A                 Signature Line Electronically Signed on 08/23/22 09:06  ________________________________________________________ NP  Electronically Signed on 08/24/22 06:45  ________________________________________________________ MD