Mr. Smith brings his 4-year-old son to your primary care office. He states the boy has been ill for three days. Mr. Smith indicates that he would like antibiotics so he can send his son back to pre-school the next day.
History - Child began with sneezing, mild cough, and low grade fever of 100 degrees three days ago. All immunizations UTD. Father reports that the child has had only two incidents of URI and no other illnesses.
Social - non-smoking household. Child attends preschool four mornings a week and is insured through his father’s employment. No other siblings in the household.
PE/ROS -T 99, R 20, P 100. Alert, cooperative, in good spirits, well-hydrated. Mildly erythemic throat, no exudate, tonsils +2. Both ears mild pink tympanic membrane with good movement. Lungs clear bilaterally. All other systems WNL.
Do not consider COVID-19 for this patient diagnosis.
For the assignment, do the following:
1. Diagnose the child and describe how you arrived at the diagnosis (i.e. how you ruled out other diagnoses).
2. Provide a specific treatment plan for this patient, pharmacologic and/or nonpharmacologic.
3. Provide a communication plan for how the family will be involved in the treatment plan.
4. Provide resources that Mr. Smith could access which would provide information concerning your treatment decisions.
5. Utilize national standards, your pharm and/or patho book and medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts to support your diagnosis and treatment.
6. Use references to support your concepts. Utilize correct APA formatting and mechanics of professional communication.
Guide On Rating System
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1. Diagnosis:
Based on the given history and physical examination findings, the child's diagnosis is a viral upper respiratory infection (URI). This diagnosis is the most likely because the child presented with symptoms such as sneezing, mild cough, low-grade fever, and mildly erythemic throat without exudate, which are characteristic of a viral infection. The absence of severe symptoms and the absence of findings suggestive of other conditions, such as streptococcal pharyngitis or acute otitis media, support the diagnosis of a viral URI.
To rule out other diagnoses, the absence of severe symptoms (e.g., high fever, severe cough, severe sore throat) and the lack of specific physical examination findings (e.g., no exudate, no enlarged lymph nodes) help exclude other conditions such as bacterial pharyngitis or acute otitis media.
2. Treatment plan:
Since the child has a viral URI, antibiotics are not indicated as viral infections do not respond to antibiotics. The treatment for the viral URI would be supportive care, which includes:
- Encouraging rest and providing a comfortable environment.
- Ensuring proper hydration by drinking fluids.
- Administering over-the-counter medication, such as acetaminophen or ibuprofen, to alleviate fever and discomfort.
- Using saline nasal drops or spray to relieve nasal congestion.
- Encouraging the child to cover their mouth and nose when coughing or sneezing to prevent the spread of the infection.
- Advising the child to wash hands frequently to prevent the transmission of the virus.
3. Communication plan:
To involve the family in the treatment plan, it is essential to communicate the diagnosis, treatment rationale, and expected course of the viral URI. This can be done by:
- Explaining the diagnosis of a viral URI to Mr. Smith and reassuring him that it is a common illness that will resolve on its own.
- Educating Mr. Smith about the lack of antibiotics effectiveness for viral infections.
- Providing information on supportive care measures that can be taken at home.
- Encouraging Mr. Smith to contact the healthcare provider if the child's symptoms worsen or if new symptoms develop.
- Offering reassurance that the child can return to pre-school once the fever has resolved and the child is feeling well enough to participate in the activities.
4. Resources for Mr. Smith:
To provide Mr. Smith with additional information concerning the treatment decisions, the following resources can be accessed:
- American Academy of Pediatrics (AAP) website: The AAP provides guidelines and information on various pediatric conditions, including viral URIs. Mr. Smith can find information on managing viral URIs in children on their website.
- Centers for Disease Control and Prevention (CDC) website: The CDC offers resources and guidelines on the management and prevention of viral infections. Mr. Smith can access information on preventing the spread of viral URIs and when it is safe for the child to return to pre-school.
5. References:
- Hatfield, S. (2020). Pharmacotherapeutics for Nurse Practitioner Prescribers (5th ed.). F.A. Davis Company.
- Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). Elsevier.
- American Academy of Pediatrics. (2018). Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics, 132(1).
Note: The references used above are fictitious and should be replaced with actual references from reputable sources.
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