Telemedicine

Confirm Name / DOB

Telemedicine Standard HPI:

Onset:
Course:
Primary sx:
Associated sx:
Better w/:
Worse w/:
Sick contacts:
Tx so far:
RFs:

NKDA. Not pregnant.


ROS:
Const: f/c.
Neuro: weakness in arms or legs.
CV: palpitations, CP
Pulm: no wheezing
GI: no RUQ / RLQ pain, no n/v, no d/c.
GU: no dysuria/hematuria


Physical Exam:
Head / ENT: nasal drainage, sinus tenderness
Pulm : deep breath (cause cough/wheeze)?
CV: HR (fast/slow/irregular), take a deep breath (pain?)
Abdo: push on abdomen (any pain?)



Telemedicine Standard Recs

> OTC naproxen 500mg BID PRN fevers / pain and/or tylenol 650mg q4 hr PRN fevers/pain.
> conservative measures; inc hydration (honey ginger tea, gatorade); inc warm humidified air (scarf/mask use); salt gargle for sore throat
> rec seek further care (UC/ER) if sx worsen - notably:
> rec set up w/ or f/u with PCP within the next 2-3 weeks for resolution.

> rx: tessalon perles 100mg q8 hr as needed cough cough
> rx: zpac
> rx: prednisone 20mg #7 tabs, PO 2 tabs day 1, 2 then 1 tab day 3, 4, 5.
> rx: ventolin inhaler 1-2 puffs q4 hr PRN wheeze
> rx: zofran 4mg q8hr as needed for nausea.

• no opiates or bentos.
• excuse note limit 48hr.