Acute upper respiratory infection

Patient comes in today because starting Saturday, he has had some increased nasal congestion and productive cough with yellow thick mucus. He has had some increase in fatigue and feels a little bit under the weather. He has not early been complaining of any fevers or body aches although he is concerned that he has contracted an upper respiratory infection. He does not complain of much sinus pain or pressure but does have some postnasal drip that could be contributing to his cough. He felt that it was necessary to begin his asthma inhalers for his infection-induced asthma starting with Aerospan two puffs twice daily and with signs of any infection. He began that and his lung capacity feels normal. He does not have any reduction in his peak flows or any increasing shortness of breath or wheezing. He has been using his ProAir too as needed between the dosages of Aerospan. He also began Zyrtec daily and Flonase which he uses one spray each nostril twice daily. He does have allergically triggered asthma as well and was concerned that this could be beginning of his allergies. He does feel that Flonase has been helping reduce his nasal congestion and helping him breathe through his nose better. Otherwise, Jack is doing quite well. He did begin the allergy immunotherapy on 09/17/2015 and is slowly making it his maintenance dose. He is hopeful that the immunotherapy will help reduce his allergy symptoms with upcoming spring and through the rest of the season of summer and fall. He was not sure if he should get his shot today or not but want him to do so as he felt that I can send it to it.

ASSESSMENT:
1. Acute upper respiratory infection.
2. Mild intermittent asthma.
3. Allergic rhinitis.
4. Allergic conjunctivitis.

PLAN:
1. At this time, I discussed with that this hopefully is just an acute viral infection that will run its course quickly and resolve without any complications. I encouraged him to continue with Aerospan two puffs twice daily until he feels better and then five days thereafter to help prevent it from going to his lungs. I also encouraged him to continue using ProAir as needed as well as Flonase and Zyrtec to help reduce any allergy triggered reactions as well as reducing his nasal congestion and postnasal drip.
2. I will send him getting his allergy shot today as he was not wheezing on exam and is not having any shortness of breath or lung troubles.
3. I encouraged him to follow up with me and let me know how he does in the next week. If he continues to get worse or is not getting better, then to let me know because we may need to consider secondary bacterial infection occurring.
4. We will follow up for viral results.

Advertisements

Leave a Reply