Runny nose and sore throat

Patient: John Doe

Age: 34

Place of Service: Office – Outpatient

Chief Complaint: Runny nose and sore throat for 2 days.

HPI:

The patient presents for evaluation of runny nose and sore throat that started two days ago. Symptoms began gradually and remain mild. He denies fever, chills, cough, shortness of breath, chest pain, nausea, vomiting, or rash. He has not taken any prescription medications and has tried warm fluids with mild relief. No known sick contacts.

ROS:

• ENT: Sore throat, rhinorrhea
• Respiratory: Denies cough or dyspnea
• Constitutional: Denies fever or chills
• All other systems reviewed and negative

PMH: None

Physical Examination:

• General: Alert, no acute distress
• HEENT: Mild pharyngeal erythema, no exudate
• Lungs: Clear bilaterally
• Heart: Regular rate and rhythm

Assessment: Acute upper respiratory infection

Plan:

• Supportive care only
• Hydration and rest
• OTC lozenges as needed