Patient Information:
JF, a 32-year-old female, presents with complaints of fever, cough, and shortness of breath.
S.
CC (chief complaint): Fever, cough, and shortness of breath.
HPI: JF reports feeling unwell for the past week, with symptoms that started as a mild cough and progressed to fever and shortness of breath. She describes her cough as dry and non-productive, and her shortness of breath is worse with exertion. She denies chest pain or pressure, nausea, vomiting, or diarrhea. She has not traveled recently, but she reports being in close contact with someone who tested positive for COVID-19. She is vaccinated against COVID-19.
Current Medications: None
Allergies: No known drug allergies or reactions to environmental factors such as food, pollen, or dust.
PMHx: JF has a history of seasonal allergies and asthma, which is well-controlled with an inhaler. She has never been hospitalized for any medical condition.
Soc & Substance Hx: She works as a teacher and is married with two children. She has never smoked or used illicit drugs and drinks alcohol occasionally.
Fam Hx: Her mother has a history of high blood pressure and her father has diabetes.
Surgical Hx: None
Mental Hx: None
Violence Hx: None
Reproductive Hx: G1P1, uncomplicated vaginal delivery.
ROS:
GENERAL: Feels tired and weak.
HEENT: Eyes: No visual disturbances. Ears, Nose, Throat: Nasal congestion.
SKIN: No rash, itching, or skin discoloration.
CARDIOVASCULAR: No chest pain, palpitations, or edema.
RESPIRATORY: Shortness of breath, non-productive cough.
GASTROINTESTINAL: No vomiting, diarrhea, or abdominal pain.
GENITOURINARY: No dysuria or hematuria.
NEUROLOGICAL: No headache, dizziness, or confusion.
MUSCULOSKELETAL: No joint pain or stiffness.
HEMATOLOGIC: No bleeding, anemia, or bruising.
LYMPHATICS: No enlarged lymph nodes.
PSYCHIATRIC: None
ENDOCRINOLOGIC: No heat or cold intolerance, polydipsia, polyuria.
REPRODUCTIVE: Normal menstrual periods.
O.
Vital Signs: Blood pressure 130/80 mmHg, heart rate 90 bpm, respiratory rate 22 breaths per minute, oxygen saturation 93% on room air, temperature 101°F (38.3°C).
Physical Examination: Lungs: bilateral crackles and wheezing heard on auscultation.
Diagnostic tests: Chest X-ray shows bilateral infiltrates. COVID-19 test ordered.
A.
JF presents with symptoms suggestive of COVID-19 infection, with bilateral lung infiltrates and hypoxia. She also has a history of asthma, which puts her at an increased risk of complications from COVID-19 infection.
P.
The patient was advised to self-quarantine and instructed to monitor her symptoms, especially her oxygen saturation levels, and to seek immediate medical attention if her condition worsens. She was prescribed an inhaler to manage her asthma symptoms and given a prescription for a short course of antibiotics to treat a possible bacterial superinfection. She was advised to continue taking over-the-counter medications such as acetaminophen to manage her fever and to stay hydrated. Follow-up with her primary care physician was recommended for ongoing monitoring of her symptoms and to ensure proper management of her asthma.
References:
CDC. (2021). Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID
