HISTORY:
for
, up to °, over
,
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , ,
- Throat culture
- Rest and hydration
-
- Avoidance of contact sports or heavy lifting
- Avoid alcohol
- leave for
- Follow-up in with repeat LFTs
- Return if symptoms worsen or if new symptoms develop
- Go to ER if severe abdominal pain, shortness of breath, or difficulty swallowing occurs