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18 y.o. female who presents for evaluation of cold and flu like symptoms. Symptoms include congestion, runny nose, cough, body aches, fatigue, fever, sweats, and chills. They have been present for 1 day. Patient has tried to alleviate the symptoms with NyQuil/DayQuil with minimal relief. The patient denies sore throat, nausea, vomiting, SOB, wheezing, and CP. Patient has known exposure to a sick roommate.
BP: 124/83
Pulse: 120
Resp: 18
Temp: (!) 101.3 °F (38.5 °C)
SpO2: 98%
Weight: 217 lb
Height: 5' 7"
General: patient appears ill but nontoxic, alert, appears stated age, cooperative and NAD. Voice is hoarse
Head: Normocephalic, without obvious abnormality, atraumatic.
Eyes: b/l conjunctivae/corneas clear, PERRL. No edema, swelling, or erythema of periorbital skin.
Ears: Bilateral serous effusions. EAC patent without discharge b/l
Nose: Turbinates mildly edematous. Rhinorrhea is present
Throat: mildly erythematous, uvula midline. Negative for exudate, petechiae, edema. No visible masses or obstructions, patient able to manage their own secretions. No trismus. PND is present.
Neck: no adenopathy, supple, trachea midline, full ROM, no unilateral swelling
Lungs: clear to auscultation bilaterally, no signs of respiratory distress including but not limited to nasal flaring, accessory muscle use, and retractions, breathing is unlabored
Heart: tachycardic rate and regular rhythm, S1, S2 normal, no murmur, click, rub or gallop
Skin: Skin color, texture, turgor normal. No rashes or lesions
POC COVID is negative
POC Influenza is positive for B
Assessment:
1. Influenza B
Differential includes: COVID, common cold, sinusitis, allergies, URI, pneumonia, bronchitis
Tachycardia and fever are secondary to influenza B virus.
Plan:
1. Labs and orders from today's visit: I have started the patient on oseltamivir phosphate 75 mg BID X 5 days, benzonatate 200 mg TID PRN cough, and pseudoephedrine-brompheniramine-DM.
2. Supportive care with acetaminophen, ibuprofen, and Mucinex per package/bottle directions and additional non-pharmacologic options such as saline rinses and salt water gargles. Increase fluids to prevent dehydration and get plenty of rest.
3. Discussed cautions for taking OTC medications: be sure to check each ingredient list to prevent accidentally doubling a medication dose. If using oral decongestants or products containing them (like pseudoephedrine) do not take for more than 7 days in a row. If using decongestant nasal sprays (like Afrin), do not use for more than 3 days in a row. Taking these products longer than the aforementioned time, may result in rebound congestion that is typically WORSE than the original congestion.
4. Advised patient to follow up with their PCP this week or to go directly to the ED if new or acutely worsening symptoms occur. We have discussed the symptoms which are most concerning and necessitate immediate presentation to the ED, including, but not limited to: difficulty breathing or swallowing, fever, changing or worsening SOB, CP, inability to keep fluids down, severe headache, neck stiffness, vision changes, and blood in stool/vomit/cough.
18 y.o. female who presents for evaluation of cold and flu like symptoms. Symptoms include congestion, runny nose, cough, body aches, fatigue, fever, sweats, and chills. They have been present for 1 day. Patient has tried to alleviate the symptoms with NyQuil/DayQuil with minimal relief. The patient denies sore throat, nausea, vomiting, SOB, wheezing, and CP. Patient has known exposure to a sick roommate.
BP: 124/83
Pulse: 120
Resp: 18
Temp: (!) 101.3 °F (38.5 °C)
SpO2: 98%
Weight: 217 lb
Height: 5' 7"
General: patient appears ill but nontoxic, alert, appears stated age, cooperative and NAD. Voice is hoarse
Head: Normocephalic, without obvious abnormality, atraumatic.
Eyes: b/l conjunctivae/corneas clear, PERRL. No edema, swelling, or erythema of periorbital skin.
Ears: Bilateral serous effusions. EAC patent without discharge b/l
Nose: Turbinates mildly edematous. Rhinorrhea is present
Throat: mildly erythematous, uvula midline. Negative for exudate, petechiae, edema. No visible masses or obstructions, patient able to manage their own secretions. No trismus. PND is present.
Neck: no adenopathy, supple, trachea midline, full ROM, no unilateral swelling
Lungs: clear to auscultation bilaterally, no signs of respiratory distress including but not limited to nasal flaring, accessory muscle use, and retractions, breathing is unlabored
Heart: tachycardic rate and regular rhythm, S1, S2 normal, no murmur, click, rub or gallop
Skin: Skin color, texture, turgor normal. No rashes or lesions
POC COVID is negative
POC Influenza is positive for B
Assessment:
1. Influenza B
Differential includes: COVID, common cold, sinusitis, allergies, URI, pneumonia, bronchitis
Tachycardia and fever are secondary to influenza B virus.
Plan:
1. Labs and orders from today's visit: I have started the patient on oseltamivir phosphate 75 mg BID X 5 days, benzonatate 200 mg TID PRN cough, and pseudoephedrine-brompheniramine-DM.
2. Supportive care with acetaminophen, ibuprofen, and Mucinex per package/bottle directions and additional non-pharmacologic options such as saline rinses and salt water gargles. Increase fluids to prevent dehydration and get plenty of rest.
3. Discussed cautions for taking OTC medications: be sure to check each ingredient list to prevent accidentally doubling a medication dose. If using oral decongestants or products containing them (like pseudoephedrine) do not take for more than 7 days in a row. If using decongestant nasal sprays (like Afrin), do not use for more than 3 days in a row. Taking these products longer than the aforementioned time, may result in rebound congestion that is typically WORSE than the original congestion.
4. Advised patient to follow up with their PCP this week or to go directly to the ED if new or acutely worsening symptoms occur. We have discussed the symptoms which are most concerning and necessitate immediate presentation to the ED, including, but not limited to: difficulty breathing or swallowing, fever, changing or worsening SOB, CP, inability to keep fluids down, severe headache, neck stiffness, vision changes, and blood in stool/vomit/cough.