HISTORY:
for
,
,
, ,
, up to °, over
, , , ,
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Ears: -R: , -L:
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Skin:
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Chest X-ray if symptoms persist after 3 weeks or if severe symptoms
- Sputum culture
- Blood work: , , ,
-
-
-
-
- Hydration and rest
- Smoking cessation counseling
- Follow-up in
- Return if symptoms worsen or if new symptoms develop
- Go to ER if severe chest pain, severe shortness of breath, or fever occurs