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URI
HISTORY:
Upper respiratory symptoms
for
days
cough
sputum
runny nose
congestion
sore throat
earache
sinus pain
headache
shortness of breath
wheezing
chest pain
fever
chills
fatigue
muscle aches
Worsening factors:
none
Treatments tried:
none
,
effective
ineffective
Other elements:
similar symptoms in close contacts
smoking
recent travel
incomplete immunization
asthma
allergies
chronic obstructive pulmonary disease
immunodeficiency
recent antibiotics
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:
normal
Neck:
normal
Heart:
RRR
,
normal S1 and S2
Lungs:
clear
,
retractions
Skin:
no rash
ASSESSMENT:
URI
likely
suspected
possible
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
days
weeks
- Return if symptoms worsen or if new symptoms develop, such as fever, shortness of breath, or chest pain