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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