History of Present Illness Template for URI-Like Symptoms
Chief Complaint
Document the primary symptom prompting the visit (e.g., "nasal congestion," "sore throat," "cough") 1.
Onset and Duration
- Timing: Specify exact date/number of days since symptom onset 2, 3
- Acute vs. persistent: Note if symptoms have been present <10 days (typical viral course) or ≥10 days (raises concern for bacterial superinfection) 2, 3
- Pattern: Document if symptoms are worsening, improving, stable, or biphasic (initial improvement followed by worsening after 5-7 days) 2, 3
Cardinal URI Symptoms
Nasal Symptoms
- Congestion/obstruction: Bilateral vs. unilateral (unilateral suggests bacterial sinusitis) 3
- Rhinorrhea: Color (clear, white, yellow, green—note that color alone does NOT indicate bacterial infection) 2, 3
- Postnasal drip 4
- Facial pressure/pain: Location and severity, especially over sinuses 3
Throat Symptoms
- Sore throat/pharyngitis: Severity, difficulty swallowing 5, 1
- Hoarseness/voice changes (laryngitis) 3, 1
Cough
- Type: Productive vs. nonproductive 2
- Sputum characteristics: Color, consistency if productive 2
- Duration: Cough commonly persists 10+ days in viral infections 2
- Timing: Daytime vs. nighttime predominance 2
Constitutional Symptoms
- Fever: Presence, degree, duration (high fever ≥3 consecutive days with purulent discharge suggests severe bacterial infection) 2
- Myalgias/body aches (more common with viral URI) 4
- Fatigue/malaise 4
- Headache: Severity and location 3
Red Flag Symptoms to Exclude
- Unilateral symptoms: Unilateral rhinorrhea, nasal blockage, or facial pain (suggests alternative diagnosis like tumor, CSF leak) 4
- Severe headache 4
- Epistaxis 4
- Anosmia (complete loss of smell) 4
- Projectile or bilious vomiting (in infants/children, suggests surgical emergency) 6
Associated Symptoms
- Ocular symptoms: Itching, tearing, redness (suggests allergic component) 4
- Sneezing: Episodic paroxysms (more common in allergic rhinitis) 4
- Ear symptoms: Fullness, pain, hearing changes 1
- Wheezing or dyspnea (suggests lower respiratory involvement) 5
Aggravating/Alleviating Factors
- Exposure history: Recent sick contacts, daycare/school exposure 5
- Environmental triggers: Smoke, fumes, chemicals (suggests irritant rather than infectious cause) 4
- Allergen exposure: Animals, dust, seasonal patterns (suggests allergic rhinitis) 4
- Response to prior treatments: Over-the-counter medications, home remedies 7
Past Medical History Relevant to URI
- Recurrent URIs: Frequency per year 5
- Chronic rhinosinusitis 4
- Allergic rhinitis or atopy: Personal or family history of allergies, asthma, eczema 4
- Immunocompromising conditions 5
Medication History
- Current medications: Antihypertensives, psychotropic agents, topical decongestants (can cause nasal symptoms) 4
- Recent antibiotic use: Type, duration, response 2
- Over-the-counter treatments tried: Decongestants, antihistamines, analgesics, their effectiveness 7
Social History
- Smoking/vaping: Active or passive exposure 4
- Occupational exposures: Irritants, allergens 4
- Childcare/school attendance: Contagion risk assessment 3
Review of Systems
- Absence of lower respiratory symptoms: No significant dyspnea, chest pain, or productive cough with hemoptysis (would suggest pneumonia or other serious pathology) 5
- GI symptoms: Nausea, vomiting, diarrhea (may accompany viral URI, especially in children) 6
Clinical Reasoning Documentation
Document your assessment of the three ABRS patterns 2, 3:
- Pattern 1 (Persistent): Symptoms ≥10 days without improvement
- Pattern 2 (Worsening/Biphasic): Initial improvement followed by worsening after 5-7 days
- Pattern 3 (Severe): High fever (≥39°C/102.2°F) and purulent discharge for ≥3 consecutive days with ill appearance
Critical pitfall to avoid: Do not diagnose bacterial infection based solely on yellow/green nasal discharge, as mucopurulent secretions are a normal part of viral URI progression due to neutrophil influx 2, 3.