URI – Sore throat, Cough

history provided by patient history provided by family member SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA

CC: headache fever malaise fatigue body aches night sweats runny nose nasal congestion PND sinus pain loss of smell/taste earache/ear pressure sore throat hoarseness cough chest tightness/pain w/ breathing recent travel contact with suspected/confirmed c19 case sx suggestive of C19 c19 requested by employer recent c19 POS test recent c19 NEG test recent ER/UC visit no sx

HPI/SYMPTOMS: started today started yesterday started several days ago started more than 1 week ago started months ago started years ago still present increasing in severity persisting occasional decreasing resolved as in cc

MEDICATIONS: allergies reviewed, taking OTC taking RX reports no side effects reports side effects effective partially effective not effective demonstrates knowledge of medications/reasons/dosages unable to name medications/reasons/dosages none reported

REVIEW OF SYSTEMS: negative except as stated in HPI
General:

HEENT:

CV:

Pulmonary:

GI:

GU:

MSK:

Neurologic:

Psychiatric:

Dermatologic:

Endocrine:

Hematologic/lymphatic:

-------------------------------------

OFFICE DIAGNOSTICS: none rapid strep NEG rapid strep POS rapid flu NEG rapid flu POS rapid C19 antigen NEG rapid C19 antigen POS rapid C19 antibody NEG rapid c19 antibody POS CXR

Appearance: well-appearing alert, non-toxic, normal WOB crying but consolable speaking in full sentences ill-appearing tired-looking short of breath diaphoretic drowsy appears impaired slumped heavy built muscular lean well-nourished frail

Skin: warm, dry, grossly intact, no rashes no bruises normal turgor dry tattoos body piercings pallor cyanosis poor turgor diaphoresis rash

Head/Face: normocephalic, atraumatic, symmetrical face CN grossly intact

Eyes: clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus, visual acuity grossly intact conjunctival injection epiphora conjunctival exudate allergic shiners dennie lines palpebral edema palpebral exudates glasses contacts

Ears: symmetrical & intact auricles bilaterally, hearing to conversation intact no mastoid tenderness clear canals without erythema or discharge TMs normal in appearance tragal tenderness swelling of external auditory canal pustule in canal cerumen in canal TM obscured by cerumen HOH hearing aid(s) TM red TM bulging TM perforated TM retracted fluid behind TM tube in TM mastoid tenderness

Nose: nares patent bilaterally, septum midline no facial tenderness mucosa pink & moist allergic salute maxillary tenderness frontal tenderness deviated septum mucosal edema clear discharge purulent drainage

Mouth: tongue normal in appearance w/o lesions and with good symmetrical movements, moist oral mucosa without lesions upper denture lower denture poor dentition tooth decay single oral ulcer multiple oral ulcers gum swelling

Throat: normal voice, no stridor, patent pharynx w/o swelling or exudates uvula midline hoarseness inspiratory stridor muffled voice vesicles on soft palate petechiae on soft palate pharyngeal erythema w/o exudates pharyngeal crowding tonsilar enlargement tonsilar erythema tonsilar exudates tonsilar crypts tonsilar pustules

Neck: symmetric with free painless ROM, no masses noted no LAD anterior LAD posterior LAD

Chest: normal work of breathing, symmetrical chest expansion, chest wall atraumatic and non-tender no retractions clear and equal breath sounds bilaterally no axillary or supraclavicular LAD respiratory distress breath sounds decreased bilaterally coughing poor effort expiratory wheezing crackles regular rhythm no murmurs no ankle edema tachycardia irregular heart rhythm systolic murmur ankle edema varicosities stasis discoloration calf tenderness

Abdomen: normal visual inspection no distension protruding normal bowel sounds soft non-tender guarding diffuse tenderness over entire abdomen w/o RRG direct non-rebound tenderness hypoactive bowel sounds hyperactive bowel sounds not examined

GU: no suprapubic tenderness no CVAT bilaterally normal external genitalia not examined

MSK: no gross deformities, moves all extremities with good ROM for age, full weight-bearing normal curvature & ROM in C- & L-spine for patient’s age

Neuro: normal concentration and attention memory grossly intact balance & coordination grossly intact ambulates w/o limp or alteration in gait extremities strong w/o atrophy no gross motor deficits sensation symmetrical & grossly intact no involuntary movements or tremor tardive dyskinesia tics

Speech/Vocalization: normal for age clear & coherent slurred mumbling to self monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured groaning sighing crying perseveration flight of ideas repetitive questions self-depreciating statements repetitive statements of impending doom repetitive non-health related/financial concerns personal safety concerns suicidal ideation/threats insisting on particular medication, test, referral, or accommodation raising voice defensive/argumentative cursing/swearing previous providers/staff criticisms verbal threats sexual remarks racist remarks

Behavior/Psychomotor Activity: calm, pleasant, respectful, cooperative with history & exam guarded anxious irritable frustrated labile agitated hostile forceful pacing fidgeting picking skin twirling hair cracking knuckles grimacing, furrowing eyebrows tightening jaw breathing hard intense staring threatening gestures fist-clenching withdrawn flat affect bradykinetic indifferent appears to be responding to internal psychotic process

Dx:
viral syndrome
influenza
rhinitis
sinusitis
otitis media
otitis externa
laryngitis
tonsillitis
pharyngitis
dyspnea
acute bronchitis
acute bronchospasm

Discussion:

REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services, previous visits laboratory/diagnostic studies specialty consults hospital visits medications PMP reporting medication side effects immediately medication compliance bringing all medications/labels to all visits home BP checks home BS checks daily weights controlling chronic conditions age- and disease-appropriate screening and immunization lifestyle modification, including: diet, avoiding/limiting alcohol, limiting sugar/carbs, limiting high fat intake, liming salt intake, staying active/daily physical activity/exercise, wt maintenance, stress reduction, sleep hygiene alcohol cessation smoking cessation NSAIDs prn cognitive restructuring in managing chronic conditions symptom exacerbation through rebound mechanism risks of respiratory depression with polypharmacy

DISCHARGE CONDITION/SAFETY: improved stable unchanged no safety concerns at this time safety concerns d/t depressed agitated mood safety concerns d/t impulsiveness safety concerns d/t hostile temper safety concerns d/t past attempts safety concerns d/t current suicidal verbalization

DISPOSITION: home advised to use UC for acute non-emergent problems ER for immediate treatment via 911 ER for immediate treatment via private transport declined emergency transfer left exam room before visit conclusion was asked to leave clinic

FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, here in-person televisit 24 hours 2-3 days 1-2 weeks 3 weeks 30 days 6 weeks 2-3 months 4-5 months 6 months 12 months f/u acute episode f/u labs f/u imaging f/u med change/new

BARRIERS TO CARE: language barrier socio-cultural factors poor effort/cooperation with exam incomplete history history not supported by findings vague complaints supporting documentation unavailable failed to obtain old records failed to complete referrals or testing multiple comorbidities polypharmacy multiple providers/prescribers intolerance of/allergty to/therapeutic failure on multiple meds frequent ER/UC visits frequent office contacts poor compliance with POC negative attitude to proposed tx lack of interest in non-drug tx overreliance on short-acting meds overwhelming focus on Rx drugs poor insight lack of motivation dependent attitude preoccupation with illness unhealthy coping mechanisms somatization catastrophization pessimism overgeneralization unrealistic health beliefs psych comorbidity anxiety depression alcohol or substance use social or occupational dysfunction secondary gain hostile/disruptive behavior affect none noted at this time

TOTAL F2F TIME:
15 minutes or less 15-30 minutes 30-45 minutes visit dominated by counseling

Elias Lu, APRN

URI – Sore throat, Cough

Result - Copy and paste this output: