Upper Respiratory Infection
Age: years old
Gender:
HISTORY:
Presents with a - history of
Symptoms include:
, of phlegm
,
, , , ,
, , , ,
, up to °, over
Worsening factors:
Alleviating factors: ,
Contributing factors:
no history of: , , ,
no use of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: conjunctiva/sclera , lids/lashes
Ears: tympanic membranes , auditory canal on , hearing
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Skin: on
ASSESSMENT:
DDx: viral URI, bacterial pharyngitis, sinusitis, influenza, allergic rhinitis, postnasal drip, asthma exacerbation, COPD exacerbation, acute bronchitis, pneumonia, COVID-19, pertussis, foreign body aspiration, epiglottitis, tonsillitis, adenoiditis, laryngitis, laryngopharyngeal reflux, mononucleosis, herpangina, hand, foot, and mouth disease
PLAN:
Investigations:
- Chest X-ray
- Throat swab
- ,
- Blood work: , , ,
Treatments:
- Nasal saline irrigation
-
- Over-the-counter decongestants
- Cough suppressants
- Ibuprofen or acetaminophen as needed
-
- Encourage hydration
Further care:
- Follow-up in
- Return if symptoms worsen or if new symptoms develop, such as fever, shortness of breath, or chest pain
HISTORY: EXAM: ASSESSMENT: PLAN: