URTI Symptoms

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of upper respiratory symptoms

Symptoms include:

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍runny nose, ‍clearcolored

‍nasal 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

‍body aches

‍loss of appetite



Worsening factors: ‍none

Alleviating factors: ‍noneacetaminophenibuprofensaline nasal rinse, ‍effectiveineffective



Contributing factors:

‍smoking

‍exposure to environmental pollutants

‍allergies

‍sick contact

‍recent travel

no history of: ‍asthma, ‍COPD, ‍chronic sinusitis, ‍previous pneumonias





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 ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Upper respiratory infection ‍likelysuspectedpossible

DDx: viral URI, bacterial pharyngitis, sinusitis, allergic rhinitis, postnasal drip, asthma exacerbation, COPD exacerbation, acute bronchitis, pneumonia, COVID-19, influenza, pertussis, foreign body aspiration, epiglottitis, tonsillitis, adenoiditis, laryngitis, laryngopharyngeal reflux, mononucleosis, herpangina





PLAN:

Investigations:

- ‍Influenza test, ‍Covid test, ‍Strep test

- Chest X-ray

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍CRP

Treatments:

- Nasal saline irrigation

- Hydration maintenance

- Rest and sleep

- Over-the-counter decongestants

- Cough suppressants

- Ibuprofen or acetaminophen as needed for pain or fever

- ‍Antibiotics

- ‍Antihistamines

Further care:

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop