HISTORY:
Fever for
Up to: °,
Treatments tried: ,
,
,
,
Additional symptoms:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Ears: -R: , -L:
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , ,
- Urinalysis, Urine culture
- Covid test, Influenza test
- Chest X-ray
- Throat swab
- as needed
- as needed
- Over-the-counter cold and flu remedies
- Encourage hydration
- Antibiotics
- Avoid contact with others
- Follow-up in
- Return if fever persists for more than 3 days, if new symptoms develop, or if condition worsens
- Go to ER if severe headache, stiff neck, or other signs of serious illness occur