Mr. Smith brings his 4-year-old son to the primary care office. The child presents with
coughing,sneezing, mild cough, and a low-grade fever of about 100 three days ago. Vitalsigns
are within normal limits. The child a
...
Mr. Smith brings his 4-year-old son to the primary care office. The child presents with
coughing,sneezing, mild cough, and a low-grade fever of about 100 three days ago. Vitalsigns
are within normal limits. The child appears well hydrated, alert, and cooperative. Mildly
erythema noted in the throat without exudate, bilateral tympanic membrane mildly pink as
well, lungs are clear.
The diagnosis for this child is acute upper respiratory tract infection (URTI), more than
likely viral in nature. The child goes to a daycare facility exposing him to virus’, he has a lowgrade fever that does not seem to be worsening and his symptoms appear to be stable and not
progressing, as they would with a bacterial infection over time. The absence of exudate as well
as adventitious lung sounds also support the diagnosis of acute viral infection. Both ears show
mild pink tympanic membrane; respiratory viruses have been shown to account for 40%-70% of
acute otitis media. URTI’s can be caused by several different viruses including parainfluenza,
respiratory syncytial virus, rhinovirus, coronavirus, and adenovirus.
Pharmacologic and nonpharmacologic treatment plan
Management of URTI’sincludessymptom relief of fever, coughing and nasal congestion.
Treatment will consist of nasopharynx treatmentsuch as a nasalspray, and analgesics. There
will be no antibiotic prescription necessary for this patient as this is more than likely viral in
nature. Using antibiotics for a viral infection can increase the possibility of antimicrobial
resistance in secondary bacterial infections in the upper respiratory tract. Some over the
counter medications that can be encouraged to minimize the symptoms include:
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