URI URTI Complete note CJ

S: 
Unwell for • days
Fever: •
Cough: •
Dyspnea:•
«Chest pain: •»
Congestion: •
Sore throat: •
Ear pain: •
Sinus pain: •
Painful glands: •
«Muscle/joint pain: •»
Conjunctivitis: •
Rash: •
NVD: •

-Intake/output: •
-Sick contacts/daycare: •
-Flu-shot UTD: •«, will give today»«, declined»
«-Improved with: •»
«-Worse with: •»
«-Immunization UTD: •»

«-Pneumovax UTD: •»
«-Hx asthma/COPD: •»
«-Hx smoking/exposure: •»
«-Hx travel: •»

O: NAD, AVSS«, interacts appropriately with examiner»«, speaking in full sentences»
Gen: «MMM»
Resp: «GAEB, ins>exp, no crackles, no wheeze»
CVS: «CR<2 sec, NHS, no murmur»
«Abdo: «non-distended, soft, nontender, no masses or HSM, BS N X 4»»
Neck: «supple, no LN»
Throat: «mild erythema, no oral lesions, symmetrical features, no tonsillar swelling or exudate»
Ears: «canals and TM nontender and normal bilaterally»
Eyes: «no conjunctivitis or discharge bilaterally»
Skin: «no rash»

A:
P:
-Reassurance, d/ antibiotic «not needed»«side-effects»
-Reviewed conservative measures: rest, fluids, honey, Tylenol/Advil prn
«-Investigations: •»
«-Rx: •»
-Advised RTC if no improvement 1-2 days on abx, persistent fever, dyspnea, not tolerating fluids, other concern