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Patient was in their usual state of health until _ days prior to presentation when they developed congestion. _ fever. _ ear pain. _ sore throat. Pt has a cough that is mild. No NVD. No abdominal pain. Symptoms are mild. Patient is nontoxic. Pt looks good clinically.
_ tachycardia
_ hypoxia
_ dyspnea
Covid symptoms that are present _
(fever, sore throat, nasal congestion, cough, dyspnea, body aches, loss of smell, diarrhea)
Patient is vaccinated for Covid-19.
Review of Systems
No chest pain, shortness of breath.
Physical Examination
GEN: Alert, pleasant, INAD
HEENT: Minimal conj. injection. Mild rhinorrhea. TM’s pearly with good landmarks. O/P slightly red with moist MM. No tonsillar hypertrophy or exudates and no palatal petechiae. Sinuses are nontender to percussion.
NECK: Supple, no LAD.
CV: RRR, no M/R/G
PUL: CTAB, no wheeze, no rhonchi, no rales
EXT: No edema. No rash
ASSESSMENT / PLAN
1. URI, LIKELY VIRAL — Discussed with patient that there are no indications for antibiotics at this time, and viral respiratory illness can be persistent in duration. Recommend Tylenol and Ibuprofen (if no allergy), rest, potential isolation if Covid positive. Patient instructed to return to clinic if worsening shortness of breath, chest pain, hypoxia, or other concerns. Clear anticipatory guidance is given. I don’t think this patient has pneumonia. Vital signs are reassuring.
Tessalon Perles Rx provided to patient
Covid test has been ordered. Results are Pending. Education provided.
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