Hayden Wilkins DOB: 4/11/2003 MRN: ZC1425385 ZoomCare

Encounter: H3354254 on 10/04/2022 05:46 PM www.zoomcare.com • health@zoomcare.com

1-844 ZOOM-777

Chief Complaint:

Doctor's Note

History of Present Illness

Category Symptom

Notes:
VIDEO VISIT
Patient identity verified: viewed Driver’s License over camera
Patient location verified: in Oregon

person with him got sick and gave it to him

ever since last week he's been feeling lethargic, runny nose and feeling bad, sore throat
signed up for a trip and they wont let him refund it without a doctor's note
also feeling super out of it and bad

tested negative for covid

girlfriend also tested negative for mono, strep etc

doesn't want to spread it to other people

Review of Systems
System Denies Symptoms Comment Complaint Comment
Symptoms
General vomiting,chills,fever,
fatigue,weight loss,
sweats,

Review of Systems Provider Notes

Allergies
No Known Drug Allergies;

Medical Conditions
Notes:

Family Medical History

Notes:

Wellness Information
Social - occupation, living situation, etc.: null
Tobacco use: null
Alcohol consumption: Not Asked
Frequency of exposure to second-hand smoke in the last year: Not Asked
Frequency of recreational drug use in the last year: Not Asked
Weekly vigorous aerobic activity sessions (>/=20min): Not Asked
Weekly moderate aerobic activity sessions (>/=30min): Not Asked
Weekly strength training sessions: Not Asked
% diet whole foods: Not Asked
Ounces of sweetened or chemically sweetened beverages per day: Not Asked
Stress: Not Asked , Anxiety: Not Asked , Depression: Not Asked (Severity on a scale from 1-10)
Social support Not Asked (Strength on a scale from 1-10)
Little interest or pleasure in doing things: Not Asked
Feeling down, depressed, or hopeless: Not Asked
Hayden Wilkins DOB: 4/11/2003 MRN: ZC1425385 ZoomCare
Encounter: H3354254 on 10/04/2022 05:46 PM www.zoomcare.com • health@zoomcare.com
1-844 ZOOM-777

PHQ-2 Sub-Total: Not Asked

Trouble falling asleep, or sleeping too much: Not Asked
Feeling tired or having little energy: Not Asked
Poor appetite or overeating: Not Asked
Feeling bad about yourself: Not Asked
Trouble concentrating: Not Asked
Moving or speaking too slowly, or too quickly: Not Asked
Thoughts that you would be better off dead, or of hurting yourself: Not Asked
PHQ-9 Total: IncompleteNot Asked
Average hours of sleep per night: Not Asked
Sexually active with men, women, both, none: Not Asked

Medication History
Medication History: None
Dose:
Directions:
Comments: Denies any medications

Exam (Vitals)
BP
Pulse
Resp
Pulse Ox
Height
Weight
Temperature
LMP Date
BMI
BMI Percentile
BMI Category
Hip
Waist
W:H Ratio
Head Circumference
Length

Exam Note
video visit
Chaperone:

Exam Results
System Normal Signs Abnormal Signs

Resp talking in full sentences. no accessory

muscle use. normal respiratory effort.
normal symmetric chest
General no acute distress. cooperative. well-
developed. well-nourished
Normal Signs:
Abnormal Signs:

In-Clinic Tests

Sent Out Tests

Hayden Wilkins DOB: 4/11/2003 MRN: ZC1425385 ZoomCare
Encounter: H3354254 on 10/04/2022 05:46 PM www.zoomcare.com • health@zoomcare.com
1-844 ZOOM-777

Radiology Tests

Procedures
Name Code Price

Supplies
Name Code Price

In House Prescriptions
Drug Dose Dispense Refill

Written Prescriptions
Drug Dose Dispense Refill Status

Diagnosis and Plan (Primary Diagnosis: Acute nasopharyngitis (common cold))

J00 Acute nasopharyngitis (common cold)
Plan:
Assessment:
- Problem: acute uncomplicated problem
- Data: 0
- Risk: low

-Cold symptoms, resolving, stable, but still contagious.

Plan:
- Note written for school excusing him from activities until he is feeling better due to ongoing
contagious illness.
- Patient's concerns were addressed and questions answered.
- Discussed worrisome signs and symptoms that would necessitate return to clinic or ED visit.
- Patient expressed understanding and is in agreement with the plan.

* This visit occurred during the COVID-19 pandemic. All reasonable efforts were made to reduce
risk of transmission. Provider and patient masked for the entirety of the visit except when
necessary for purposes of brief examinations. Provider wore gloves for all contact. Eye protection
and gown used as needed for higher risk and symptomatically ill patients.

Exam Details
Reason for Visit: Doctor's Note

Instructions and Handouts

Common Cold

The common cold is an infection of the head and chest caused by a virus. It is a type of upper
respiratory infection (URI). It can affect your nose, throat, sinuses, and ears. A cold can also affect
the tube that connects your middle ear and throat, and your windpipe, voice box, and airways.
How does it occur?
Over 200 different viruses can cause colds. The infection spreads when viruses are passed to
others by sneezing, coughing, or personal contact. You may also become infected by handling
objects that were touched by someone with a cold.
You are more likely to get a cold if:
· You are emotionally or physically stressed.
· You are tired.
Hayden Wilkins DOB: 4/11/2003 MRN: ZC1425385 ZoomCare
Encounter: H3354254 on 10/04/2022 05:46 PM www.zoomcare.com • health@zoomcare.com
1-844 ZOOM-777

· You are not eating enough healthy food.

· You are a smoker.
· You are living or working in crowded conditions.

People tend to get fewer colds as they get older because they build up immunity to some of the
viruses that can cause colds.
What are the symptoms?
You usually start having cold symptoms 1 to 3 days after contact with a cold virus. Symptoms may
include:
· scratchy or sore throat
· sneezing, runny or stuffy nose
· cough
· watery eyes
· ear congestion
· slight fever (99 to 100°F, or 37.2 to 37.8°C)
· tiredness
· headache
· loss of appetite.

How is it diagnosed?
Colds can usually be diagnosed from your symptoms. Your health care provider may need to
examine you to rule out other serious infections, such as strep throat and sinusitis.
Common colds are different from influenza (flu), even though both are caused by viruses.
Influenza usually develops more suddenly than a cold. When you have the flu, you develop fever
and muscles aches within a few hours, even as few as 1 or 2 hours. The symptoms of a cold
develop more slowly.
How is it treated?
There are no medicines that cure a cold. You can treat your symptoms with nonprescription
medicines such as aspirin, acetaminophen, ibuprofen, nose drops or sprays, cough syrups and
drops, throat lozenges, and decongestants. Check with your provider before you take any of these
drugs if you are already taking other medicines.
How long do the effects last?
Colds usually last 1 to 2 weeks. Sometimes you may get a bacterial infection after a cold, such as
an ear infection or sinus infection.
How can I take care of myself?
· Get lots of rest.
· Drink lots of fluids, such as water, fruit juice, tea, and soda.
· Use a humidifier to increase air moisture, especially in your bedroom.
· Use nose drops to relieve nasal congestion. You can buy nose drops or make your own. To make
a solution for nose drops, add 1 teaspoon of salt to a quart of water.

Call your health care provider if you have any of the following symptoms:
· worsening earache
· trouble breathing
· swollen, tender glands in your neck
· chest pain
· skin rash
· worsening sore throat
· white or yellow spots on your tonsils or throat
· a cough that gets worse or becomes painful
· temperature of 102°F (38.9°C) or higher that lasts more than 2 days
· shaking chills
· headache that lasts several days
· confusion
· blue or gray lips, skin, or nails.

What can be done to help prevent the spread of colds?

Hayden Wilkins DOB: 4/11/2003 MRN: ZC1425385 ZoomCare
Encounter: H3354254 on 10/04/2022 05:46 PM www.zoomcare.com • health@zoomcare.com
1-844 ZOOM-777

The following suggestions may help prevent the spread of your cold to others.
· Turn away from others and use tissues when you cough or sneeze.
· Wash your hands after coughing, sneezing, or blowing your nose.
· Wash your hands often and especially before touching food, dishes, glasses, silverware, or
napkins.
· Use paper cups and paper towels in bathrooms.
· Don't let your nose or mouth touch public telephones or drinking fountains.
· Don't share food or eating utensils with others.
· Avoid close contact with others for the first 2 to 4 days.

To lower your risk of catching a cold:

· Avoid close contact with people who have a cold.
· Keep your hands away from your nose and mouth.
· Wash your hands often, especially after coming in contact with someone who has a cold.
· Eat healthy foods, especially fruits with vitamin C, such as oranges.
· Get plenty of rest.
· Do not smoke

Published by McKesson Provider Technologies.

This content is reviewed periodically and is subject to change as new health information becomes
available. The information is intended to inform and educate and is not a replacement for medical
evaluation, advice, diagnosis or treatment by a healthcare professional.
Developed by McKesson Provider Technologies.
Copyright © 2005 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved.

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Encounter Provider: Amy Peck - Urgent Care and Primary Care Team
Final Note Signed By: Amy Peck - Urgent Care and Primary Care Team