Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Common cold symptoms (present for how long?):
Runny or stuffy nose (rhinorrhea, congestion)
Sore throat
Cough (productive or non-productive)
Sneezing
Malaise (general feeling of unwellness)
Fever (low-grade, usually)
Headache (may be present)
Muscle aches (may be present)
II. History of Present Illness:
Gradual or sudden onset of symptoms?
Any recent exposure to individuals with similar symptoms (cold, flu)?
Worsening of symptoms or new developments (e.g., earache, facial pain)?
III. Past Medical History:
Allergies (seasonal allergies, medications)
Chronic respiratory conditions (asthma, sinusitis)
Recent immunizations (flu shot)
IV. Social History:
Smoking history (current smoker, former smoker, never smoker)
Occupational exposures (dust, irritants)
V. Physical Exam:
Vital Signs:
Temperature (oral, rectal, or tympanic)
Blood pressure
Heart rate
Respiratory rate
General: Appearance of illness (mild, moderate)
Head, Ears, Nose, Throat (HEENT):
Nasal discharge (clear, colored)
Nasal congestion
Redness or swelling of the throat
Swollen lymph nodes in the neck
Ear pain (otitis media possible)?
Lungs: Clear to auscultation (no wheezing)
VI. Assessment:
Acute upper respiratory tract infection (common cold)
Differentiate from influenza (consider influenza testing if high suspicion)
Consider potential complications (sinusitis, otitis media)
VII. Plan:
Supportive care:
Rest
Increased fluids
Over-the-counter medications (decongestants, pain relievers)
Humidifier use (if cough productive)
Reassurance regarding self-limited nature of illness
Advise on appropriate hygiene measures to prevent spread
VIII. Follow-up:
Schedule follow-up appointment if symptoms worsen or do not improve within 1-2 weeks.
Advise on seeking immediate care if high fever, difficulty breathing, or severe ear pain develops.
IX. Notes:
Include any additional observations or concerns.
X. Resources:
Consider providing patient education materials on the common cold and self-care measures.