WK 8-CLINICAL CASE 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 2 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 2/24/2024 3 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 2/24/2024 4 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 2/24/2024 5 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 6 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.,