Is the assessment and plan for a patient with throat pain, cough, and fever, diagnosed with Upper Respiratory Infection (URI), reasonable?

Assessment of URI Documentation Quality

This assessment and plan is reasonable and clinically appropriate for a patient with uncomplicated upper respiratory infection, though it could be strengthened with more specific documentation of clinical decision-making regarding testing and antibiotic withholding. 1

Strengths of the Documentation

Appropriate Diagnosis and Supportive Care

• The diagnosis of URI with supportive management (analgesics, nasal spray, fluids, rest) aligns with evidence-based guidelines for viral respiratory infections. 1
• The provision of ibuprofen for fever and throat pain is appropriate symptomatic treatment for uncomplicated URI 1
• Chloraseptic for throat pain and nasal spray for congestion represent reasonable symptomatic management 1
• The 48-hour quarters (sick leave) is appropriate given the 4-day symptom duration 1

Appropriate Testing Strategy

• Ordering SC2/FLU A/FLU B/RSV PCR is reasonable given the clinical presentation with fever, though the rationale could be better documented 2
• Testing for strep was appropriate given throat pain as a presenting complaint 3

Good Safety Netting

• The instruction to return if symptoms worsen is essential and follows guideline recommendations 1, 4
• BRAT diet counseling for diarrhea and hydration advice are appropriate supportive measures 1

Areas for Improvement

Missing Critical Documentation Elements

• The documentation should explicitly state why antibiotics were NOT prescribed, as this is a common pitfall in URI management 1
• The note should document that symptoms are improving (as stated in HPI) and therefore do not meet criteria for bacterial infection requiring antibiotics 1
• No documentation of respiratory rate or oxygen saturation, which are important for ruling out pneumonia 5

Incomplete Physical Examination Documentation

• While breath sounds are documented as clear, there is no mention of focal chest findings, which would increase pneumonia probability from 5-10% to 39% if present 5
• No documentation of throat examination findings beyond implied negative strep test 3
• Tachycardia assessment (>100 bpm) not documented, which is relevant for pneumonia risk stratification 5

Fever Documentation Concerns

• A low-grade fever of 100.0°F on day 4 of symptoms warrants specific mention that this does not meet criteria for bacterial infection, which typically requires fever >4 days without improvement 1, 4
• The note should clarify that symptoms are "getting better" per patient report, which argues against bacterial superinfection 4

Follow-up Instructions Could Be More Specific

• Return precautions should specifically mention: symptoms persisting beyond 3 weeks, fever exceeding 4 days total duration, worsening dyspnea, or decreased consciousness 1
• Current instruction "if symptoms got worse" is vague and could be more specific about red flags 1, 5

Recommended Documentation Additions

Clinical Decision-Making

• Add statement: "Antibiotics not indicated as symptoms are improving and patient does not meet criteria for bacterial infection (no persistent symptoms >10 days, no severe symptoms with high fever and purulent discharge for ≥3 consecutive days, no worsening after initial improvement)" 1

Physical Examination

• Document: "No focal chest findings on examination, no tachypnea, no tachycardia" to support ruling out pneumonia 5
• Document throat examination findings if strep test was performed 3

Enhanced Return Precautions

• Specify: "Return if symptoms persist beyond 3 weeks, fever continues beyond 4 days total, difficulty breathing worsens, stops drinking fluids, or develops confusion" 1

Common Pitfalls Successfully Avoided

• Did not prescribe antibiotics for viral URI, which would be ineffective and contribute to antibiotic resistance 1
• Did not rely solely on purulent nasal discharge (if present) as indication for bacterial infection 1
• Provided appropriate symptomatic treatment rather than ineffective treatments like expectorants or antihistamines for acute LRTI 2