HISTORY:
Upper respiratory symptoms for
,
,
,
, up to °, over
, episodes , ,
Treatments tried: ,
Other elements:
Vaccination status:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: fontanelles ,
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose: , , discharge ,
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Genital: , testicles , penis , Tanner stage
Extremities: , , cap refill
Skin:
Musculoskeletal: joints ,
ASSESSMENT:
DDx:
PLAN:
- Chest X-ray
- , ,
- Blood work: , , ,
- Nasal saline irrigation
- Hydration maintenance
-
-
-
- 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 occur