DICKINSON COLLEGE HEALTH SERVICES
COLD/COUGH/flu/H1N1
NAME: ____________________________________________ CLASS_________ DATE _____/_____/_____ TIME _________
S:
CC _____________________________________________________________________________ __________________
SYMPTOMS
YES
NO
DURATION / LOCATION / CHARACTER
NOSE STUFFY/RUNNING
Mucous color?
POST NASAL DRIP
SORE THROAT
EAR PAIN
FEVER / CHILLS
COUGH DRY / PRODUCTIVE
FACIAL PAIN / HEADACHE
TEETH ACHE OR HURT
FATIGUE
DECREASED APPETITE
OTHER
Does student have combination of fever (or perceived fever-sweating/chills) AND cough or sore throat in the absence of other
known cause?  Yes;  No
Additional HX:_________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
PMH :
PMH
SMOKER
SINUSITIS
EAR INF.
ASTHMA
BRONCHITIS
PNEUMONIA
STREP TH.
MONO
OTHER/ high
risk?
YES
NO
CURRENT MEDS: (including BC pills): ___________________________________________________________________________________
ALLERGIES (medication):____________________________________________________ NKDA_ (environment)____________________
O:
TEMP __________
WNL
ABN
COMMENTS
Vital Signs if appropriate BP ______/_______ Pulse ___________ Resp._________
APPEARANCE
NECK(NODES)
SINUSES
NOSE
EARS
THROAT
LUNGS
HC LABS:  MONO _____________(_______)*
 Pt. told to call for results tomorrow
A:
 TC (________)*
 Other _____________________(_______) *
 Pt. told we would contact them if TC Pos.
_________________________________________________________
* (______) Prov. Initials
 ILI___________Provider.___________________________________
OVER
NAME: _______________________________________ CLASS_________ DATE _____/_____/_____ TIME _________
P:






 AMOXICILLIN 500 MG TID X 10 DAYS
 ERYTHRO 333 MG TID X 10 DAYS
 ALBUTEROL INHALER 1-2 PUFFS QID PRN
 Z-PACK #1 Unit dose as directed on package
MUCINEX-D 2 tabs Q12h. #18
Or
BACTRIM DS 1 BID X 10 DAYS
PCN VK 500 MG BID X 10 DAYS.
TESSALON PERLES TID




TAMIFLU 75mg caps: One BID for 5 days
TAMIFLU 75mg QD X 10 for prevention after exposure
RELENZA Diskhaler: 5mg blister in AEPB: 2 inhalations BID for 5 days - Do not use if asthma or pulm.dis.


WARNED OF POSSIBLE EFFECTS OF ANTIBIOTIC ON ORAL CONTRACEPTIVES







AMOXICILLIN 250 mg TID X 10 days
__________________________________




AFRIN NASAL SPRAY Q12 h.
ENTEX PSE 1 BID #10
PHENYLEPHRINE 5mg 2 Q4h.
TYLENOL 325 mg 2 Q4h.
GARGLE

REST

INCREASE FLUIDS
Labs:  CXR
 CBC

 OTHER__________________________________
MONO

C. SUPP.

N/A
C. EXPECTORANT
2 tsp q 4-6 HOURS
IBUPROFEN 200mg 2 Q4-6 h. prn with food
TROCAINE LOZ. Q 4-6 h. not to exceed 4 in 24 hours
_____________________________________________________



STEAM BREATH
OTHER__________________________________________
OTHER__________________________________________
STICKERS
RTC ______________________________________________________________________________
Patient discharge instructions given.
Referred to __________________________________________
Additional instructions:
Prov. Signature____________________________________________________________________________

Class absence note given , out of class ________________
DATE ________/_________/_________


Appt. card given .

Class absence note not appropriate
TC RESULTS _________________________ PROV. __________________________
PATIENT NOTIFIED TC RESULTS via ______________________________. DATE ____________
INITIALS__________
Health Education:
Does patient fall into high risk category?
 Yes;  No;  N/A
Does patient know if their roommate is in high risk category?  Yes  No
If yes: Roommate’s name ___________________________; If No, pt instructed tell roommate he/she has flu
and if roommate
feels he/she is at high risk, they must make an appointment.

Pt does not meet criteria at this time for ILI. Pt .told if they develop fever and cough or sore throat he/she should e-mail
[email protected] and stay in room as per CDC guidelines.
 Is pt. within driving distance and can someone come pick him/her up?  Yes;  No  N/A

Pt. told to RTC (here or family health care provider if home) if any of the following symptoms present: Difficulty breathing, chest pains
or wheezing; Feeling worse, or severe symptoms, ie: high fever, signs of dehydration; Vomiting or diarrhea not resolved in 24 hours.

Pt. instruction sheet given
DICKINSON COLLEGE STUDENT HEALTH SERVICES
COLDCOUGH.CCK REV:9/27/01; 2/03; 4/04,9/04; 11/08 MA; 9/4/09MA