HISTORY:
for
,
,
, up to °, over
, ,
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
ASSESSMENT:
DDx:
PLAN:
- Chest X-ray
- Blood work: , , , ,
- Sputum culture
- CT scan of the chest
- Oxygen therapy if SpO2 < 92%
-
-
-
- Hydration and rest
- Smoking cessation counseling
- Vaccination for , ,
- Repeat chest X-ray in 6 weeks
- Follow-up in
- Return if symptoms worsen or if new symptoms develop
- Go to ER if severe chest pain, severe shortness of breath, or high fever occurs