Runny Nose

HISTORY:

Runny nose for ‍ ‍hoursdays

Type: ‍clearcolored, ‍waterymucoidthick, ‍mildmoderateabundant

Pattern: ‍constantintermittent

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective

‍nasal congestion

‍sneezing

‍postnasal drip

‍sinus pressure

‍itchy nose

‍watery eyes

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍sore throat

‍fatigue

‍headache

‍earache

‍loss of smell

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍difficulty breathing

‍wheezing



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



ASSESSMENT:

‍Rhinitis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Allergy testing

- CT scan of the sinuses

- ‍Nasal saline irrigation

- ‍Nasal Steroids

- ‍Antihistamines

- ‍Decongestants

- ‍Montelukast

- Avoidance of irritants and allergens

- Referral to allergist

- Referral to ENT specialist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as facial pain, fever, or persistent headache