Upper Respiratory Infection

S- 
[text size=80 default="«»-year-old child presents to clinic with «». "]
[text size=80 default="Child has had a fever for «» days. "]
[text size=80 default="Parents have «not» measured the fever. "]
[text size=80 default="Fever was measured at maximum of «» C, measured «oral»«rectal»«axillary». "]
[text size=80 default="Fever has been treated with «Advil»«Tylenol» with good results. "]
[text size=80 default="The child is eating and drinking normally "]
[text size=80 default="No vomiting or diarrhea. "]
[text size=80 default="No foul smelling urine. "]
[text size=80 default="No complaining of ear pain or pulling at ears "]
[text size=80 default="No rash noted in mouth, on cheeks, on hands or feet» "]
[text size=80 default="No rhinorrhea. "]
[text size=80 default="No cough»«Cough present»,«productive»«non productive», for «» days. "]
[text size=80 default="No ill contacts. "]
[text size=80 default="Child attends daycare»«child is in contact with other children "]
[text size=80 default="No travel recently outside the country. "]

O- 
[text size=80 default="Vitals: «» "]
[text size=80 default="Height: «» inches; Weight: «» lbs. "]

A- 
[text size=80 default="General: Child appears «normal»«agitated»«lethargic». Awake and alert. No distress. "]
[text size=80 default="Head normocephalic. Conjunctiva pink and moist; sclera white; lids without ptosis, edema, or erythema; extraocular movements intact; PERRL. Clear external auditory canals; TM’s visualized, pearly grey bilaterally with no erythema or discharge. Nose clear. Buccal mucosa moist and intact. Oropharynx with no signs of erythema or ulceration. "]
[text size=80 default="Cardiovascular: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "] 
[text size=80 default="Respiratory: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions. "] 
[text size=80 default="Gastrointestinal: Abdomen soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. Bowel sounds x 4. "]
[text size=80 default="Integumentary: Normal turgor and without lesions or rash. "]

P- 
[text size=80 default="Dx.: URI, Cough "]
[text size=80 default="«Medication prescribed» "] 
[text size=80 default="Vaporizer with normal saline TID. "]
[text size=80 default="Nasal suction for secretions. "]
[text size=80 default="Encourage good intake of fluids and to treat fevers with ibuprofen and/or acetaminophen as directed. "]
[text size=80 default="Return to clinic if symptoms change or worsen. "]
[text size=80 default="Advised parent to come back if fever has lasted more than 5 days total. "]
[text size=80 default="Advised parents to come back if child can not keep fluids down for 12 hours. "]