URTI

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍symptoms suggestive of an upper respiratory infection

Symptoms include:

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍runny nose, ‍clearcolored

‍congestion

‍sore throat

‍earache

‍sinus pain

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍shortness of breath

‍wheezing

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

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍fatigue

‍muscle aches

‍loss of appetite

‍difficulty sleeping due to symptoms

‍postnasal drip

‍hoarseness



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍similar symptoms in close contacts

‍smoking

‍recent travel

‍incomplete immunization

no history of: ‍asthma, ‍allergies, ‍chronic obstructive pulmonary disease, ‍immunodeficiency

no use of: ‍antibiotics





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal

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

Skin: ‍rashlesions on ‍





ASSESSMENT:

‍URI ‍likelysuspectedpossible

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

- ‍Influenza test, ‍Covid test

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍CRP

Treatments:

- Nasal saline irrigation

- ‍Nasal Steroids

- Over-the-counter decongestants

- Cough suppressants

- Ibuprofen or acetaminophen as needed

- ‍Antibiotics

- Encourage hydration

Further care:

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop, such as fever, shortness of breath, or chest pain