WK 8-CLINICALCASE
PRESENTATION
Anilu Gomez
Nova Southeastern University, Ron and
Kathy Assaf College of Nursing
NSG 5590: FNP Capstone
Dr. Janice Linton
February 22, 2024
SUBJECTIVE
• CC- Cough, runny nose, low grade fever x 3 days
• HPI- 88 year old male with PMH of HTN and hyperlipidemia presents to clinic with wife who both
have complaints of cough, runny nose, and low grade fever. Pt does not use oxygen at home, denies
SOB, chest pain, or dizziness. States this has been going on for 3 days.
• ROS- Constitutional: No feeling tired, Fever
• ENT: No loss of hearing, Runny nose
• Eyes: No blurred vision
• Cardiovascular: No chest pain, no chest discomfort, no palpitations, no bilateral leg edema
• Respiratory: No difficulty breathing or wheezing, Dry cough
• Neurological: No dizziness or headaches
• NKDA
• Meds- simvastatin 10 mg once daily, amlodipine 5 mg once daily
2/24/2024
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OBJECTIVE
Wt: 142 lbs, BMI: 22.92, Temp: 99.6 F, BP: 134/68 mm Hg, Pain scale: 0 1-10, HR: 61 /min, RR: 18 /min,
Oxygen sat %: 96 %
PE
Constitutional: Vitals signs noted, and in no acute distress
In office testing:
Neuropsych: Alert and oriented x3
Eyes: Equal and round, conjunctiva were clear.
Flu + SARS Antigen
(Sofia)
ENT: Lips without lesions, rhinorrhea,
INFLUENZA A: Negative
Neck: Normal appearing
Heart: Regular rate and rhythm without murmurs, no pitting edema.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
INFLUENZA B: Negative
SARS: Positive
Musculoskeletal: Normal stance and gait
Skin: No rashes in visible areas
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ASSESSMENT
Diagnosis
U071: COVID-19
Differential Diagnosis:
J09X2: Influenza due to identified novel influenza A virus with other respiratory
manifestations
B974: Respiratory syncytial virus as the cause of diseases classified elsewhere
Office visit code: 99213 established patient
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PLAN
• Pt to start Paxlovid (150/100) Tablet Therapy Pack Orally, twice a day, 5 days, as directed to
shorten course of illness
• Pt was started on Paxlovid to shorten progression of illness and to avoid hospitalization. Pt was
experiencing mild to moderate symptoms of COVID-19 such as cough, fever, and runny nose; and
symptoms where in the 5 day window of treatment with Paxlovid (Shah et al., 2022).
• Pt to stop simvastatin 10 mg while taking Paxlovid.
• Given COVID-19 information
• Told to rest, hydrate, and isolate
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REFLECTION
• Advise pt and wife, once they recover to
• Continue social distancing, avoid very crowded spaces
• Handwashing, hand sanitizer, sanitize shopping carts
• Masking in crowded places
• Remind their family members that they are old, don’t come to visit if you are sick
2/24/2024
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REFERENCES
Shah, M. M., Joyce, B., Plumb, I. D., Sahakian, S., Feldstein, L. R., Barkley, E., Paccione, M.,
Deckert, J., Sandmann, D., Gerhart, J. L., & Hagen, M. (2022). Paxlovid associated with
decreased hospitalization rate among adults with covid-19 — united states, april–
september 2022. MMWR. Morbidity and Mortality Weekly Report, 71(48), 1531–1537.
https://doi.org/10.15585/mmwr.mm7148e2
2/24/2024
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