NR511_Discussions (A GUARANTEED)

Document Content and Description Below

NR511_Discussions (A GUARANTEED) Further questions and Why? Follow OLDCARTS first then you can ask additional questions r/t your specific differentials. O: Onset: One day ago. Did the symptoms com ... e on suddenly? L: Location: HEENT, legs. Do you fell achy all over your body? D: Duration: Are you symptoms continuous or intermittent? Have you ever had symptoms like this before? C: Characteristics/Associated Symptoms: a runny nose, watery eyes, cough, headache, tired, “can not get warm”, nausea, “feels warm”. A: Aggravating: Does anything make your symptoms worse? R: Relieving Factors: Does anything make your symptoms better? T: Treatments: Motrin and Tylenol for ha without relief and caused nausea. Have you used any other OTC or prescription medications for your symptoms? S: Severity: unable to go to school today. Develop 3 differentials based on an EBP resource for primary care providers or your textbook. Give a one sentence definition of the pathophysiology (cite your reference) The common S & S Document this patient’s current S & S for each differential • Influenza (ICD9 : 487.1)- a viral respiratory illness affecting the upper respiratory tract and lungs (Reference). S & S: Sudden onset of fever, ha, body aches, fatigue, cough sore throat, & nasal discharge (Hart, 2015). • 2. Acute nasopharyngitis ( ICD 9: 460): The common cold, or upper respiratory tract infection, usually is caused by one of several respiratory viruses, most commonly rhinovirus (Reference). These viruses, which concentrate in nasal secretions, are easily transmitted through sneezing, coughing, or nose blowing. S & S: of the common cold include fever, cough, rhinorrhea, nasal congestion, sore throat, headache, and myalgia (Dunphy et al, 2011). • 3. Infectious Mononucleosis (ICD (: 075): Epstein-Barr virus (EBV) infections are often asymptomatic, some patients present with the clinical syndrome of infectious mononucleosis (IM) (Reference). The syndrome most commonly occurs between 15 and 24 years of age. It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petecchiae (Dunphy et al, 2011) ROS General constitutional systems : fever (-), chills (+), fatigability (+), night sweats (-), weight loss/gain(-) • Eyes: Denies Change in vision , blurring, acuity, diplopia, photophobia, pain, redness, discharge, loss of vision. • Ears, nose, mouth, sinuses: Allergy symptoms (-), congestion (-), pain (-), discharge(+), change in hearing(-), tinnitus (-), sense of smell (-), epistaxis (-), sore throat (+), hoarseness (-), change in taste (-). • Chest/lungs: Dyspnea, cyanosis (-), wheezing (-), cough (+), sputum (-), hemoptysis (-), chest pain related to breathing (-), exposure to TB. • Cardiovascular : Denies Chest pain, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, claudication. • Musculoskeletal : Denies Joint pain, stiffness, restriction of motion, redness, warmth, deformity, leg pain (+). • Lymph nodes: Denies Swelling, tenderness, drainage For Julia you would want to assess HEENT, cardiac, respiratory, abdominal, lymphatic systems List which body system you want to examine and include a brief statement of any specialized testing you would want to pay special attention to based on the diagnosis. LAB TEST TO BE ORDERED AND WHY • Influenza: Rapid Influenza Diagnostic Testing (RIDT). Identifies the presence of influenza A and B viruses in nasopharyngeal specimens (Hart, 2015). • Acute nasopharyngitis : none (Dunphy et al, 2011) • Mono: Heterophile antibody test. This quick screening test detects a type of antibody (heterophil antibody) that forms during certain infections. A sample of blood is placed on a microscope slide and mixed with other substances. If heterophil antibodies are present, the blood clumps (agglutinates). This result usually indicates a mono infection. Monospot testing can usually detect antibodies 2 to 9 weeks after a person is infected. (Reference) • S: Subjective • Chief Complaint (CC): cold symptoms x 2 days, worsening. • History of present illness (HPI): O: I started to have cold symptoms yesterday, L & D: no information provided. C: included runny nose, watery eyes, cough and a headache. Was very tired last night and went to bed early. Julia felt even worse this afternoon: throat really hurts, very tired, legs ache feels cold, and can’t get warm. Julia did not go to school today and did not check her temperature. A: no information provided. R & T: Took Tylenol and Motrin for the headache, did not help, and has felt nauseous since she took the last dose of Motrin three hours ago. S: no information provided. • A: ASSESSMENT: Influenza Type A (ICD 10 code J09) : influenza due to certain identified influenza viruses. • Influenza is difficult to diagnose based on symptoms, lab results are important (Hart, 2015). Julia has a positive RIDT for type A flu, which is 90-95% specific (Hart, 2015). P: PLAN 1. Medications Rx: Oseltamivir 75 mg Sig: 1 tab po q 12 hours x 5 days. Disp #10 tabs, no refills. (Hart, 2015; Epocrates, 2015) Early antiviral treatment, symptoms <48 hours, can shorten symptom duration and may reduce complications (Hart, 2015). Encourage patients to take OTC medications for cough, fever, pain and muscle aches (Dunphy et al, 2011; Hart, 2015). • Ibuprofen 600 mg po q 6-8 hours as needed for pain and/or fever, max of 2400 mg/day (Hart, 2015; Epocrates, 2015) • Dextromethorphan 60 mg po q 12 hours as needed for cough, max of 120 mg/day. (Hart, 2015; Epocrates, 2015) • (Influenza vaccine when better (Dunphy et al, 2011; Hart, 2015). [Show More]

Last updated: 3 years ago

Preview 1 out of 99 pages