Fever and Cough

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of fever and cough

Peak temperature recorded: ‍° ‍not measured

Pattern of fever: ‍persistentintermittent

Cough described as ‍drywet, with ‍noclearyellowgreenwhite sputum

Severity is ‍mildmoderatesevere

lleviating factors or self treatments: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍rhinorrhea, ‍clearcolored

‍nasal congestion

‍post-nasal drip

‍shortness of breath

‍wheezing

‍chest tightness

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍hemoptysis

‍fatigue

‍night sweats

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍hoarseness



Contributing factors:

‍smokingpast smoking

‍similar symptoms in close contacts

‍occupational exposure to irritants

‍exposure to tuberculosis

‍recent Covid-19

no history of: ‍asthma, ‍chronic obstructive pulmonary disease, ‍allergic rhinitis, ‍pneumonia, ‍GERD, ‍lung cancer, ‍tuberculosis





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM





ASSESSMENT:

‍Viral URI ‍likelysuspectedpossible

DDx: viral URI, influenza, COVID-19, pneumonia, bronchitis, tuberculosis, asthma exacerbation, COPD exacerbation, sinusitis, croup





PLAN:

Investigations:

- Chest X-ray

- Covid test, Influenza test

- Throat swab

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

Treatments:

- ‍Acetaminophen as needed

- ‍Ibuprofen as needed

- Over-the-counter cold and flu remedies

- Encourage hydration

- Antibiotics

- Avoid contact with others

Further care:

- Follow-up in ‍ ‍hoursdays

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