UPPER RESPIRATORY EXAM - AAFP Home



UPPER RESPIRATORY INFECTION EXAM

Copyright ( 2004 American Academy of Family Physicians.

Physicians may photocopy or adapt for use in their own practices; all other rights reserved. “A Tool for Evaluating Patients With Cold Symptoms.” Weida TJ. Family Practice Management. October 2004:53-54; .

PROVIDER SECTION

Patient name:

Age:

Date:

CC: ________________________

HPI: ο Patient history reviewed

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

EXAM: ο Well-developed/well-nourished; no acute distress

ο Vital signs: See flow sheet in chart

Normal Abnormal

ears ο ο __________________________

eyes ο ο __________________________

nose ο ο __________________________

sinuses ο ο __________________________

pharynx ο ο __________________________

nodes ο ο __________________________

lungs ο ο __________________________

heart ο ο __________________________

abdomen ο ο __________________________

other ____________________________________________

_________________________________________________

_________________________________________________

ASSESSMENT __________________________________

ο Acute bronchitis 466.0 ο Otitis media, serous 381.10

ο Allergic rhinitis 477.9 ο Pharyngitis 462

ο Asthma 493.90 ο Pneumonia 486

ο Conjunctivitis 372.00 ο Sinusitis, 461.9

ο Flu 487.1 ο Strep 034.0

ο Otitis externa 380.10 ο URI 465.9

ο Otitis media 382.9

PLAN:

ο Strep test: ο (+), see antibiotics below

ο (-), do culture and sensitivity

ο Chest X-ray

Over-the-counter drugs:

ο Claritin ο Claritin D bid ο Sudafed prn ο Other: __________________

Prescription drugs:

ο Allegra: 60mg bid or 180mg/day

ο Zyrtec: 10mg/day

ο Phenergan VC with Codeine: 1-2 tsp q 4 hr

ο Other: __________________

Antibiotics:

ο Amoxil: 250mg, 500mg or 200/5mL bid or tid

ο Augmentin: 250mg, 500mg or 875mg bid or tid

ο Erythromycin: 250mg, 333mg or 500mg bid or tid

ο Zithromax ο Zithromax Tri-Pak ο Tessalon Perles 100 mg qid ο Other: __________________

_________________________________________________

_________________________________________________

Patient education? ο Yes ο No

Follow up: ο prn or ____week(s) or ____month(s)

Off work or school from ________ to __________

____________________________________ _________ Physician/provider signature Date

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Please answer the following questions. This will help your physician identify possible problems.

Do you have a runny nose? ο Yes ο No

If "yes," describe the nature of drainage:

ο clear ο yellow/green ο white ο thick ο bloody

Do you have any nasal congestion? ο Yes ο No

Do you have any sinus pain? ο Yes ο No

Do you have post nasal drip? ο Yes ο No

Are your eyes: ο red? ο watery? ο itchy?

Do you have ear pain? ο Yes ο No

Do you have a fever? ο Yes ο No

Do you have nausea? ο Yes ο No

Have you vomited? ο Yes ο No

Do you have diarrhea? ο Yes ο No

Do you have a sore throat? ο Yes ο No

Are you achy? ο Yes ο No

Do you have any pain? ο Yes ο No

If "yes," rate your level of pain:

None 0 1 2 3 4 5 6 7 8 9 10 severe

Do you have any rashes? ο Yes ο No

Do you have a cough? ο Yes ο No

If "yes," describe your cough: ο dry ο productive

Nature of sputum, if any:

ο clear ο yellow/green ο white ο thick ο bloody

Do you have asthma? ο Yes ο No

Do you use tobacco? ο Yes ο No

Other symptoms: ______________________________________________________________________________________________Do you have any allergies? ______________________________________________________________________________________________How long have you felt sick? ______________________________________________________________________________________________What medicines have you tried? (Include herbal or over the counter medicines.) ______________________________________________________________________________________________Was there any improvement? ______________________________________________________________________________________________Do you need a work note? ο Yes ο No

Do you need other medicine refilled? ο Yes ο No

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