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Posted: February 12th, 2023

S: CC: “I tested positive for COVID-19 last week and am here for a follow up exam.”

S: CC: “I tested positive for COVID-19 last week and am here for a follow up exam.”
HPI: 38-year-old male with a past medical history of asthma who tested positive for COVID-19 via PCR test 8 days ago. Reports initial symptoms included cough, fever of 102F, body aches, headache, and loss of taste and smell. Symptoms have been improving but still has intermittent cough.
General: Reports improved energy but still fatigued.
HEENT: Negative except for intermittent cough.
Respiratory: Occasional cough but lungs now clear without wheezes or crackles.
Cardiovascular: Negative, regular rate and rhythm.
GI: Negative, appetite returning.
Musculoskeletal: Residual muscle aches improving.
Neuro: Negative, headache resolved.
O: Vitals: T 98.6F, HR 90, RR 18, BP 120/80, SpO2 96% on room air. General appearance is recovering. Oral exam benign. Lungs clear to auscultation bilaterally. Heart regular rate and rhythm without murmurs. Abdomen soft non tender non distended.
A: COVID-19, improving.
P: Symptoms continuing to resolve as expected given timeline from initial infection. Recommend continuing isolation at home until afebrile for 24 hours without antipyretics and cough has significantly improved, which should be within the next few days. Advised to follow up sooner if symptoms worsen or any new concerns arise. Counseled on importance of vaccination to reduce risk of future infection.


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