URI in child

HISTORY:

Upper respiratory symptoms for ‍ ‍hoursdays

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍runny nose, ‍clearcolored

‍nasal congestion

‍sneezing

‍sore throat

‍fever, up to ‍°, over ‍ ‍hoursdays

‍difficulty breathing

‍lethargy

‍irritability

‍decrease in fluids intake

‍decrease in urine ouput

‍decrease in appetite

‍rash

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍abdominal pain

Treatments tried: ‍none, ‍effectiveineffective

Vaccination status: ‍up-to-datedelayedincompleteunknown



EXAM:

General appearance: ‍well-appearing

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

Head: fontanelles ‍soft, ‍normocephalic

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍clear, ‍nasal flaring, discharge ‍clear, ‍

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

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

Genital: ‍normal, testicles ‍normal, penis ‍normal, Tanner stage ‍

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

Skin: ‍no rash

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM



ASSESSMENT:

‍Viral URI ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Chest X-ray

- ‍Influenza test, ‍Covid test, ‍Strep test

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍CRP

- Nasal saline irrigation

- Hydration maintenance

- ‍Acetaminophen

- ‍Ibuprofen

- ‍Antibiotics

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop

- Go to ER if severe shortness of breath, signs of dehydration, or high fever occur