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  • Cough or Cold Visit Template

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    Sean Anthony Capote
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    This medical document contains a patient's history, subjective complaints, objective findings, assessment, and treatment plan. The patient presented with nasal congestion, discharge, fever, cough, and sore throat for several days. On examination, the patient had injected sclera, inflamed nasal turbinates, and pharyngeal erythema. The assessment was viral upper respiratory infection or acute bronchitis. The treatment plan included over-the-counter medications and a 5-day course of antibiotics.

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    This medical document contains a patient's history, subjective complaints, objective findings, assessment, and treatment plan. The patient presented with nasal congestion, discharge, fever, cough, and sore throat for several days. On examination, the patient had injected sclera, inflamed nasal turbinates, and pharyngeal erythema. The assessment was viral upper respiratory infection or acute bronchitis. The treatment plan included over-the-counter medications and a 5-day course of antibiotics.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    25 views1 page

    Cough or Cold Visit Template

    Uploaded by

    Sean Anthony Capote
    This medical document contains a patient's history, subjective complaints, objective findings, assessment, and treatment plan. The patient presented with nasal congestion, discharge, fever, cough, and sore throat for several days. On examination, the patient had injected sclera, inflamed nasal turbinates, and pharyngeal erythema. The assessment was viral upper respiratory infection or acute bronchitis. The treatment plan included over-the-counter medications and a 5-day course of antibiotics.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    Name_____________________________________________ __nl heart sounds __murmur __/6__________________

    DOB_________________ Allergies: ___ None ABDOMEN


    DOV_________________ _____________________ __soft, non-tender __tenderness____________________
    __no HSM __organomegaly or masses________
    Subjective: ________________________________
    Presents with the following for past _______ days/weeks: __NABS ________________________________
    _____runny nose or nasal congestion. SKIN
    _____purulent nasal discharge __nl, no rashes __rash__________________________
    _____fevers, to _____degrees ___tactile only ________________________________
    _____cough-- ___ productive ___ dry OTHER FINDINGS ________________________________
    _____wheeze or shortness of breath
    ________________________________
    _____swollen glands
    _____sore throat ________________________________
    _____relief with OTC products:____________________
    Assessment:
    ___________________________________________
    __viral upper respiratory infection
    _____other:______________________________________
    __acute bronchitis
    ___________________________________________
    __allergic rhinitis
    ____________________________________________
    __acute sinusitis
    __acute otitis media
    PMH reviewed on face sheet, specifically:
    __persistent otitis media
    _____smoker or around second-hand smoke
    __acute pharyngitis
    _____asthma
    __pneumonia
    _____history of environmental allergies
    __other___________________________________________
    _____COPD
    ________________________________________________
    Additional ROS:_____________________________________ ________________________________________________
    ____________________________________________________
    Plan:
    Objective: __Robitussin DM or equivalent prn
    VITALS: _____ temp _____ BP _____ P _____ RR _____ wt __Dimetapp or equivalent
    GENERAL: ___Alert ___NAD ___non-toxic appearing __Tylenol/Motrin prn fever/pain
    HEENT __Humabid LA, 2 tabs po Q12 hr prn, #____, ____RF
    __lids/conjunc. nl __sclera injected __exudate __Humabid DM, 2 tabs po Q12 hr prn, #____,____RF
    __PERRLA __Allegra 180mg po QD prn, #____, ____RF
    __ears nl __TM erythema/dullness…R…L __Clarinex 5mg po QD prn, #____, ____RF
    __loss of TM landmarks…R…L __Zyrtec 10mg po QD prn, #____, ____RF
    __TM obscured by cerumen…R…L __Amoxil 250mg, 500mg or by weight x ____days
    __TM obscured by exudate…R…L __Augmentin ES-600 by weight x ____days
    __nose nl __nasal turbinates inflamed __Zithromax, “Z-pack” or susp.by weight x 5 days
    __nasal turbinates blue/boggy __other___________________________________________
    __pharynx nl __pharyngeal erythema ________________________________________________
    __tonsillar exudates ________________________________________________
    __tonsillar hypertrophy ________________________________________________
    __other _______________________________
    ________________________________________________
    _______________________________
    NECK __return in ____days/weeks if not improved, sooner
    __nl __lymphadenopathy…R…L should symptoms worsen or change.
    __supple __thyromegaly
    __meningismus
    RESPIRATORY
    __no resp. distress __resp. distress__________________
    __nl breath sounds __wheezing_____________________
    __rhonchi_______________________ ______________________________________
    __rales__________________________ Maria Medina-Capote, M.D.
    __stridor________________________
    HEART
    __RRR __irregularities__________________

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