Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, typically involving:
Runny or stuffy nose (rhinorrhea)
Nasal congestion
Facial pressure or pain (especially around the eyes and forehead)
Cough (may be productive or non-productive)
Sore throat
Sneezing
Possibly low-grade fever, fatigue, and headache
History of Present Illness:
Onset and duration of symptoms
Severity of symptoms (graded on a scale)
Associated symptoms (fever, fatigue, headache, earache)
Recent exposure to other people with colds
Past medical history (sinusitis, allergies)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be slightly elevated with fever.
General examination: Assess for signs of illness (malaise).
Ear examination (otitis media may occur concurrently).
Anterior rhinoscopy (using a light source to examine the nasal cavity) – May reveal nasal congestion, purulent discharge.
Percussion and palpation of the sinuses (may cause tenderness in some cases).
Assessment:
Diagnose acute viral rhinosinusitis based on the clinical presentation (symptoms lasting less than 4 weeks) and absence of facial tenderness on palpation (suggests bacterial sinusitis).
Consider the severity of symptoms and potential complications (e.g., otitis media, sinusitis).
Plan:
Supportive care:
Recommend rest and increased fluids to promote hydration and mucus clearance.
Over-the-counter medications:
Saline nasal irrigation for congestion and drainage
Decongestants (use cautiously and for short periods only)
Pain relievers (acetaminophen or ibuprofen) for fever, headache, and facial discomfort
Humidity: Encourage use of a humidifier to loosen mucus.
Antibiotics are generally not recommended for acute viral rhinosinusitis.
Follow-up:
Advise the patient to return if symptoms worsen (increased facial pain, fever, purulent nasal discharge), last longer than 10-14 days, or new symptoms develop (earache, trouble breathing).
Discharge Instructions:
Continue supportive care measures as mentioned above.
Over-the-counter medications as needed and following recommended dosage guidelines.
Importance of good hand hygiene to prevent the spread of the virus.
Follow-up appointment if symptoms worsen or persist.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis and treatment can help alleviate symptoms and prevent complications.