URI

HISTORY:

‍Upper respiratory symptoms for ‍ ‍hoursdays

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍runny nose, ‍clearcolored

‍congestion

‍sore throat

‍earache

‍sinus pain

‍headache

‍shortness of breath

‍wheezing

‍chest pain

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍fatigue

‍muscle aches

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

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

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Skin: ‍no rash



ASSESSMENT:

‍URI ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Chest X-ray

- Throat swab

- ‍Influenza test, ‍Covid test

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍CRP

- Nasal saline irrigation

- ‍Nasal Steroids

- Over-the-counter decongestants

- Cough suppressants

- Ibuprofen or acetaminophen as needed

- ‍Antibiotics

- Encourage hydration

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop, such as fever, shortness of breath, or chest pai