CC: Cold symptoms x 4 days HPI: 38 y/o female with nasal congestion, dry cough, mild sore throat, sinus pressure, fatigue. Low-grade fever 99-100°F. Denies SOB, chest pain.
Vitals: BP 118/74, HR 78, Temp 99.4°F, SpO2 98% RA Nasal mucosa: Erythematous, clear discharge Pharynx: Mild erythema, no exudates Lungs: Clear bilaterally
Primary Dx: Acute Viral URI (J06.9) Classic viral presentation, no bacterial features.
Symptomatic: 1. Rest, fluids 2. Pseudoephedrine PRN 3. Guaifenesin PRN 4. Acetaminophen PRN Education: Viral illness, antibiotics not indicated Return if: Fever >101.5°F, worsening after day 7