| Days after vaccination:||68
|Vaccination / Manufacturer
||Lot / Dose
||Site / Route|
|COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA
||045A21A / 2
||- / -
Administered by: Private Purchased by: ?
Exposure to SARS-CoV-2,
SARS-CoV-2 test positive
SMQs:, Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Permanent Disability? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Other Medications: ?nateglinide 120 mg tablet 1 tab(s) orally 3 times a day (before meals) ?Januvia 100 mg tablet 1 tab(s) orally once a day ?One Touch Ultra glucose monitor as directed ?One touch Ultra test strips as directed test bid ?One Touch
Current Illness: 6-1-2021: Pt here for possible COVID-19 exposure through his wife, she was diagnosed yesturday, pt has been fully immunized for COVID; pt reports occasional stuffy nose and mild diarrhea otherwise no other symptoms. 5-13-2021: 58 y/o M c/o white discoloration on interior cheek both sides. R$g$g$gL. Sx present for 3-4 months. When he opens his mouth it stretches or feels like that. Occasional stinging. But no real pain. Dentist did not comment on it last week. Pt is a non smoker. Non tobocco user. Dx: Candidal stomatitis Tx Plan: Start nystatin suspension, 100000 units/mL, 5 ml, orally, 4 times a day, 7 days, 140 ml, Refills 0 Notes: we can try to see if the nystatin clears this up, but if no response, He will f/u with ENT for eval.
Preexisting Conditions: Hyperlipidemia. Diabetes mellitus. Colon polyp (2019). Male erectile dysfunction, unspecified.
Allergies: Lipitor: muscle pain
Diagnostic Lab Data: PCR tested on 6-1-2021, Result came back positive on 6-2-2021
CDC Split Type:
Write-up: 6-1-2021: Pt here for possible COVID-19 exposure through his wife, she was diagnosed yesterday, pt has been fully immunized for COVID; pt reports occasional stuffy nose and mild diarrhea otherwise no other symptoms. Doctor F 6/2/2021 9:17:26 PM $g + PCR lab for COVID-19; pt notified, pt doing rather well with minimal symptoms, pt reported that he has been vaccinated with Moderna; pt instructed to take Vitamin D3, vitamin C and zinc