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.

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