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NR509 Week 2 IHuman - I Human Assignment
NR509 Week 2 IHuman - I Human Assignment
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Week 2 I Human: Marvin WebsterROS:
General: Pt is well groomed and appears stated age. Pt appears in no acute
distress with intermittent nonproductive cough.
HEENT/Neck: PERRLA, negative for redness or drainage. The pinna, tragus and ear
canal are non-tender and without swelling. The ear canal is clear without discharge.
The tympanic membrane is normal in appearance. Negative nasal discharge or
polyps. Erythematous pharynx noted. Negative Brudzinski's and Kernig's sign.
Bilateral cervical lymphadenopathy.
Cardiovascular: Heart rate and rhythm normal with no murmurs, gallops, or rubs.
Peripheral pulses are present and equal bilaterally.
Chest/Respiratory: Heart rate and rhythm normal with no murmurs, gallops, or
rubs. Peripheral pulses are present and equal bilaterally. Negative for adventitious
breath sounds. Respiratory rate regular and unlabored, chest rise and fall are equal
bilaterally, skin is pink, warm and dry. SpO2 98% on room air.
Abdomen: Normoactive bowel sounds in all 4 quadrants, Negative for
hepatosplenomegaly
Genitourinary/Rectal: Did not assess
Musculoskeletal/Osteopathic Structural Examination: Did not assess
Neurologic: Alert and oriented
Skin: Did not assess
Psychiatric: Did not assess
Problem Statement: M.W. is an 18-year-old college student with a history of
childhood asthma with complaints of a dry nonproductive cough, sore throat,
headache, fatigue, and myalgias x4days. Patient reports a sick contact with
roommate and had not had an influenza vaccination this year or COVID booster.
Physical examination shows temperature of 101deg F, cervical lymphadenopathy
and erythematous pharynx, negative for adventitious breath sounds, shortness of
breath, and hepatosplenomegaly.
Management Plan:
1. Diagnostics:
Influenza PCR test
SARS-CoV-2 antigen test
2. Medications:
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-06:00
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, Acetaminophen 325-1000mg PO Q 4-6 hrs PRN fever, myalgias. Max of 4000mg/day
(Tylenol: Dosing, Contraindications, Side Effects, and Pill Pictures - Epocrates Online,
n.d.).
Ibuprofen 400mg PO Q 4-6hrs PRN fever, myalgias. Max of 3200mg/day (Ibuprofen:
Dosing, Contraindications, Side Effects, and Pill Pictures - Epocrates Online, n.d.).
Dextromethorphan 30mg PO Q4-6hrs PRN for cough. Max of 120mg/day
(Dextromethorphan: Dosing, Contraindications, Side Effects, and Pill Pictures -
Epocrates Online, n.d.).
3. Referrals:
No referrals at this time
4. Education:
May take OTC acetaminophen and ibuprofen as directed on packaging for fevers
and myalgias. May take OTC Dextromethorphan as directed on packaging for
cough. Rest and drink lots of fluids. Due to symptom timeline, antiviral treatment
is not recommended, Pt encouraged to receive annual influenza vaccination and
COVID booster when patient is feeling better for prophylaxis. Use proper hand
hygiene and cover cough/sneezes to prevent spread of infection. Do not attend
classes for 24 hours after last known fever-school noted given (Epocrates Web,
n.d.).
5. Follow up:
Pt to return to student health center, PCP, or urgent care if symptoms worsen or do
not improve in the next 48 hours, or if headache worsens, or if shortness of breath
develops. Address vaccination status at future visit, encourage annual influenza
vaccination and COVID booster (Epocrates Web, 2024).
6. Rationales:
Influenza can lead to fever, sweating, and respiratory symptoms which can increase
fluid loss and cause dehydration. Dehydration can exacerbate symptoms and
prolong recovery. Increase in fluid intake will help prevent dehydration. Also,
drinking more fluids can help regulate body temperature and support the body’s
efforts in fighting off the infection. Treatment with antivirals is not recommended in
this case due to the timeline of symptom onset. Antiviral treatment should be
started within 48 hours of symptom onset. Due to this patient’s symptoms starting
approximately 4 days ago, antiviral treatment is not recommended (Epocrates Web,
n.d.) OTC medications such as Tylenol, Motrin and Dextromethorphan can lessen
symptoms associated with influenza. According to the CDC, student should not
return to school until 24 hours after last known fever to prevent the spread of
infection (What to Do If Your Child Gets Sick with the Flu, n.d.)
References:
This study source was downloaded by 100000884024057 from CourseHero.com on 11-21-2024 10:38:57 GMT
-06:00
https://www.coursehero.com/file/240999529/NR509-Week-2-IHuman-I-Human-Assignmentpdf/
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