HISTORY:
for
,
,
,
, up to °, over
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: fontanelles ,
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose: , , discharge ,
Throat:
Mouth:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Extremities: , , cap refill
Skin:
Mental status: , , reactive to
ASSESSMENT:
DDx:
PLAN:
- RSV swab
- Chest X-ray
- Blood work: , , , ,
- Admission to hospital with apnea monitoring if aged less than 3 months
- Nasal saline rinse
- Encourage oral hydration
-
-
-
- Follow-up in
- Return if symptoms worsen or if new symptoms develop
- Go to ER if severe shortness of breath, signs of dehydration, or high fever