Minor Urgent Care Form (Respiratory)
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Chief Complaint:
Patient presents with seasonal allergy symptoms and upper respiratory complaints. Reports recent exposure to COVID-19, influenza, and/or strep throat.
History of Present Illness (HPI):
Patient reports congestion, rhinorrhea, postnasal drip, sore throat, and/or cough consistent with seasonal allergies and viral upper respiratory irritation. Denies fever, chest pain, shortness of breath, or worsening severity at this time. Reports recent known exposure to COVID, influenza, and strep but denies positive rest results to date. No history of asthma exacerbation or hospitalisation for similar complaints.
How many days have you experienced the above symptoms?
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Review of Symptoms (ROS):
Constitutional: Denies fever, chills fatigue, weight loss. HEENT: Reports congestion, rhinorrhea, sore throat, postnasal drip. Denies vision changes, ear pain, severe sinus pain, or difficulty swallowing. Respiratory: Reports cough (dry or mild productive). Denies shortness of breath, wheezing, hemoptysis, or respiratory distress. Cardiovascular: Denies chest pain, palpitations, syncope. Gastrointestinal: Denies nausea, vomiting, diarrhea, abdominal pain. Neurological: Denies dizziness, headache, confusion, or focal weakness. Skin: Denies rash or new skin changes.
Physical Exam:
General: Alert, oriented, in no acute distress. HEENT: Mild congestion; nasal mucosa erythematous; oropharynx with mild erythema, no exudates. Tympanic membranes intact. Lungs: Clear to auscultation bilaterally; no wheezing, rales, or rhonchi. Normal respiratory effort. Heart: Regular rate and rhythm; no murmurs, rubs, or gallops. Abdomen: Soft, non-tender, non-distended. Bowel sounds present. Neuro: Cranial nerves grossly intact. No focal deficits. Skin: Warm, dry, intact.
Assessment:
1. Seasonal Allergic Rhinitis. 2. Upper Respiratory Complaint - viral etiology suspected (recent exposure to COVID/flu/strep). 3. Rule out acute bacterial infection.
Plan:
Continue supportive care: hydration, rest, OTC antihistamines/decongestants as needed. Offered testing for COVID, influenza, and strep as indicated. Discussed warning signs and red flag symptoms that require emergent care (see below). Patient verbalized understanding and agrees with plan.
Prescribed medications:
Injections given in office:
Red Flag Symptoms (Patient Denies):
Fever > 101.5°F. Shortness of breath or wheezing. Chest pain or pressure. Hemoptysis (coughing up blood). Severe sore throat with difficulty swallowing or drooling. Neck stiffness or severe headache. Persistent vomiting or dehydration. Confusion, dizziness, syncope. Progressive or rapidly worsening symptoms.
Stacy Sims, FNP-C
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