Subjective
47 y.o. female presents with 7-day history of persistent rhinorrhea, non-productive cough, and mild pharyngeal discomfort. Pt reports gradual onset of symptoms without fever, chills, or dyspnea. Denies hemoptysis, sinus pressure, or otalgia. Reports adequate hydration and self-medication with OTC Tylenol PRN for mild headache with partial relief. No known sick contacts. No recent travel. Fully vaccinated against influenza and COVID-19. PMH unremarkable.
Objective
VS: T 98.6°F, HR 72, RR 16, BP 128/82, SpO2 99% on RA
Gen: Alert, NAD, well-nourished female
HEENT: PERRL, EOMI. Mild erythema of posterior pharynx without exudate. TMs intact bilaterally. No sinus tenderness to palpation.
Neck: Supple, no lymphadenopathy or thyromegaly
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
CV: RRR, no murmurs, gallops, or rubs
Rapid strep test: Negative
Assessment
1. Acute viral upper respiratory infection (J06.9)
2. Mild pharyngitis, likely viral etiology (J02.9)
Plan
1. Supportive care with adequate hydration and rest
2. Symptomatic management with OTC analgesics (acetaminophen or ibuprofen) PRN
3. Saline nasal irrigation BID
4. Honey/lemon tea for throat discomfort
5. Return if symptoms persist beyond 10 days, worsen acutely, or if develops fever >101°F, dyspnea, or hemoptysis
6. No antibiotics indicated at this time given likely viral etiology
7. Patient verbalized understanding of treatment plan and follow-up instructions
Date: 01/15/2025 14:37
Annual Physical
December 8, 2024
Follow-up - Lab Results
November 22, 2024
Preventive Care Visit
August 15, 2024