Acute Cough

HISTORY:

Cough for ‍ ‍hoursdays

Type: ‍dryproductive, with ‍clearwhiteyellowgreen sputum

Severity: ‍mildmoderatesevere

Treatments tried: ‍none, ‍effectiveineffective

‍rhinorrhea, ‍clearcolored

‍nasal congestion

‍post-nasal drip

‍shortness of breath

‍wheezing

‍chest tightness

‍chest pain

‍hemoptysis

‍sore throat

‍hoarsness

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍fatigue



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍Upper respiratory infection ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Chest X-ray

- Covid test, Influenza test

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍CRP, ‍LFTs, ‍blood culture

- Saline nasal irrigation

- ‍Nasal Steroids

- ‍Cough suppressants

- ‍Expectorants

- ‍Antibiotics

- ‍Inhalers

- Smoking cessation counseling

- Follow-up in ‍ ‍daysweeks

- Return if cough persists for more than 3 weeks, if new symptoms develop, or if condition worsens