URTI in child
Age: old
Gender:
HISTORY:
Presents with a - history of upper respiratory symptoms
Symptoms include:
, of phlegm
,
, up to °, over
, , , ,
, episodes , ,
, , ,
Alleviating factors: ,
Contributing factors:
no history of: , , ,
no use of:
Vaccination status:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: fontanelles ,
Eyes: conjunctiva/sclera , lids/lashes , , extraocular movements , red reflex , corneal light reflex , fix and follow test
Ears: tympanic membranes , auditory canal on , hearing
Nose: , , discharge ,
Throat: , ,
Neck: , , , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Genitourinary: external genitalia , testes , penis , Tanner stage
Extremities: , , , , Barlow , Ortolani , , cap refill sec
Skin: on
Musculoskeletal: joints ,
Neurologic: cranial nerves , overall motricity , muscle tone , gait , reflexes
Mental status: , , reactive to
ASSESSMENT:
DDx: URI, bacterial pharyngitis, sinusitis, influenza, allergic rhinitis, postnasal drip, bronchiolitis, asthma exacerbation, acute bronchitis, pneumonia, COVID-19, croup, epiglottitis, tonsillitis, adenoiditis, laryngitis, laryngopharyngeal reflux, herpangina, hand, foot, and mouth disease, foreign body aspiration
PLAN:
Investigations:
- Chest X-ray
- , ,
- Blood work: , , ,
Treatments:
- Nasal saline irrigation
- Hydration maintenance
-
-
-
Further care:
- Follow-up in
- Return if symptoms worsen or if new symptoms develop
- Referral to ER if severe shortness of breath, signs of dehydration, or high fever occur
HISTORY: EXAM: ASSESSMENT: PLAN: