Reference no: EM134014788
Assessment:
20 y.o. M PMH: childhood asthma presents to the urgent clinic with complaints of non-productive cough, runny nose, and sore throat for 7 days without improvement with OTC medications and no fever or chills. Reporting congestion and sore throat are improving, but cough with wheezing sometimes disrupts his sleep. Physical examination was unremarkable except for improving erythema to the oropharynx and turbinates, and the strep test was negative. Based on the presentation, viral URI is likely due to sore throat, congestion, and cough and unlikely allergic etiology due to lack of exposure. However, a component of mild asthma exacerbation is a concern with a history of symptoms worse at night and wheezing. Will treat for resolving viral URI with post-viral cough and possible mild asthma exacerbation.
1. Viral upper respiratory infection resolving with post-viral cough (J06.9)
2. Possible mild asthma flare-up (J45.2)
Plan:
Viral upper respiratory infection resolving with post-viral cough (J06.9)
Diagnostic: SARS-CoV-2 RT-PCR. Influenza Viral Panel PCR.
Therapeutics: Nasal saline irrigation per manufacturer instructions as needed for congestion. Menthol rub per manufacturer instructions daily as needed for cough. Honey 1 tsp. by mouth daily as needed for sore throat/irritation and cough. Acetaminophen 500 mg PO Q4H as needed for pain and/or fever (> 101).
Education: Diagnosis of a common cold with expected symptoms and treatment. Knowledge of virus-related illnesses can help patients better understand symptom progression and recovery expectations. Avoid OTC cold medication. Use hand sanitizer/washing for at least 15 seconds frequently throughout the day for prevention. Antibiotics are not an effective treatment for the common cold. On return precautions. Stop taking ibuprofen and replace it with acetaminophen.
Consultation: If you develop a fever (higher than 101), productive cough, shortness of breath, headaches, or facial pain. Reach out to your PCP via call or EMR message for a follow-up appt. Understanding basic concepts of anatomy biology and microbiology may also support learning about respiratory health and infection prevention.