Fever

HISTORY:

Fever for ‍ ‍hoursdays

Up to: ‍°, ‍persistentintermittent

Treatments tried: ‍noneacetaminophenibuprofenNSAIDs, ‍effectiveineffective

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍runny nose, ‍clearcolored

‍sore throat

‍shortness of breath



EXAM:

General appearance: ‍well-appearing

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

Ears: -R: ‍normal, -L: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

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

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness

Genital: ‍normal, testicles ‍normal, penis ‍normal

Skin: ‍no rash

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

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Viral infection ‍likelysuspectedpossible

DDx: ‍



PLAN:

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

- Urinalysis, Urine culture

- Covid test, Influenza test

- Chest X-ray

- Throat swab

- ‍Acetaminophen as needed

- ‍Ibuprofen as needed

- Over-the-counter cold and flu remedies

- Encourage hydration

- Antibiotics

- Avoid contact with others

- Follow-up in ‍ ‍hoursdays

- Return if fever persists for more than 3 days, if new symptoms develop, or if condition worsens

- Go to ER if severe headache, stiff neck, or other signs of serious illness occur