HISTORY:
for
,
,
, up to °, over
,
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Skin:
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Chest X-ray
- Blood work: , , , ,
- Sputum culture
- Pulmonary function tests
- Increase dose of rescue inhaler
- If mild increase shortness of breath, dougle dose of inhaled corticosteroids:
- If moderate increase shortness of breath, add oral corticosteroids:
- If change in sputum color, add antibiotics:
- Oxygen therapy if SpO2 < 90-92%
- Ensure proper inhalation technique and spacer use
- Smoking cessation counseling
- Immunization: pneumococcal, annual influenza, covid
- Referral to pulmonologist
- Follow-up in
- Return sooner if symptoms do not improve in 72h or if symptoms worsen
- Go to ER if severe shortness of breath, chest pain, or high fever