Unit 3 Treatment of URI. 1000w. 4 references. Due 25
Scenario: You are seeing a 34-year-old multi-race female who is a school counselor.
· She reports a 3-day history of a sore throat, rhinorrhea, nasal stuffiness and postnasal drip.
· She states she thinks she may be running a low-grade fever but reports she has not actually taken her temperature.
· She reports feeling tired.
· She has a history of migraine headaches for which she utilizes ibuprofen as needed. She has a script for Maxalt if needed however reports she hasn’t used that in several years.
· She is on hormonal contraceptive management. BP 112/66, P 68, Resp 18, Temp 98.7, SpO2 99% on RA
· On your exam you note clear nasal discharge, tympanic membranes are pearly gray, posterior pharynx is erythematous, no tonsillar enlargement noted.
· Breath sounds are clear bilateral.
Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.
Utilize the information provided in the scenario to create your discussion post.
1. Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
2. Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]
3. Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
4. Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
5. Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
Support the interventions outlined in your ‘P’ with scholarly resources.
Please be sure to validate your opinions and ideas with citations and references in APA format.
Respond to the additional questions below.
6. What role does disease prevalence play among groups such as the patient in the study?
7. Summarize a scholarly article that pertains to the case study and provide feedback.
Unit 3 Discussion 2 – Treatment of URI
For the 34-year-old multi-race female who is a school counselor, the chief complaint
based on the presented subjective and objective data is Upper Respiratory Tract Infection. Details
of the patient’s history are key in differentiating common cold condition with lower respiratory
tract infections. In the course of this discussion, the patient’s subjective and objective data will
be used to understand the patient through the SOAP model.
Subjective
The patient reports a 3-day history of a sore throat, rhinorrhea, nasal stuffiness and
postnasal drip. In addition, the patient explains to be running a low-grade fever. However, the
patient reports not to have taken her temperature numbers. The patients adds that she has been
feeling tired for the last three days. From the assessment, the patient reports to have a history of
migraine headaches. To deal with the migraine, the patient reports to use ibuprofen. The
subjective data provides a number of possible diagnosis including group A streptococcal
pharyngitis, bacterial sinusitis, and lower respiratory tract infections. However, further
assessment through collection of objective data is key to improving patient’s recovery.
Objective
The patient’s blood pressure is 12/66, which is normal. On the other hand, the patient’s
respiratory rate is 18. For humans, a healthy respiratory rate for an adult at rest is 12–18 breaths
per minute (Sommer, 2019). Therefore, the patient’s respiratory rate is normal. The patient’s
body temperature is 98.7. The body temperature in this patient is indicative of mild fever.
Another important data for this patient is SpO2 99 percentage on RA. A normal healthy person
has a normal blood-oxygen saturation level of 94% to 99% (Bickley, 2013). Therefore, the
patient’s oxygen saturation levels are normal and healthy. For patients with mild respiratory diseases, the SpO2 should be 90% or above. The patient has a clear nasal discharge. Similarly,
the tympanic membranes are pearly gray, posterior pharynx is erythematous, and had no tonsillar
enlargement noted. Lastly, the patient’s breath sounds are clear bilateral.
Assessment
The diagnosis of upper respiratory infection is through assessment and reviewing of
symptoms, physical examination, and laboratory tests (Eccles & Mallefet, 2019). In this patient,
the presenting subjective and objective data are indicative of upper respiratory infection. The key
presenting symptoms supporting this diagnosis is sore throat, rhinorrhea, nasal stuffiness and
postnasal drip.
Plan
The treatment plan for this patient would include medication and patient education. In
terms of medication, the patient would need to continue with ibuprofen for the headaches. In
dealing with fever and body aches, the patient should be prescribed Acetaminophen at 325 to 650
mg every 4 hours or 500 mg every 8 hours. To treat nasal secretions and congestions, the patient
would need diphenhydramine prescribed at 25-50 mg every 4-6 hours. Part of the education plan
would include educating the patient on making steam in the shower by turning on the hot water
and then breathing the steamed air (Eccles & Mallefet, 2019). The patient would also need to
avoid cold and dry hair while drinking warm beverages. For the next few days, the patient needs
to monitor the symptoms and engage with the provider in case of exacerbation. References
Bickley, LS. (2013). The skin, hair, and Nails. Bates’ guide to physical examination and historytaking,
11 ed. New York: Lippincott, Williams & Wilkins. ISN-13: 978-1609137625.
Eccles, R., & Mallefet, P. (2019). Observational study of the effects of upper respiratory tract
infection on hydration status. Multidisciplinary respiratory medicine, 14(1), 36.
doi:10.1186/s40248-019-0200-9
Sommer, A. (2019). Upper respiratory tract infection symptoms as a herald sign of Metamizole-
Induced Neutropenia. Journal of Military and Veterans Health, 27(4), 24.
This study source was downloaded by 100000756143814 from CourseHero.com on 05-22-2023 11:22:07 GMT -05:00
https://www.
