URI

HISTORY:

 Upper respiratory symptoms  for ‍  days 

‍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:  normal 

Neck:  normal 

Heart:  RRR ,  normal S1 and S2 

Lungs:  clear , ‍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