Mr. JD is a 24-year-old who presents to Urgent Care with a 2-week history of cough and congestion. He says it started out as a "normal cold" and it will not go away. He has a productive cough for green mucous and has green nasal discharge. He says he has had a low-grade temperature for the past 2 days. John reports an intermittent frontal headache with this cold. He is otherwise healthy, with no known allergies. In his assessment it is found that his vital signs are stable, temperature is 99.9 degrees F, tympanic membranes (TMs) are clear bilaterally, pharynx is erythematous with no exudate; there is greenish postnasal drainage; turbinates are swollen and red; frontal sinus tenderness; no cervical adenopathy, and lungs are clear bilaterally. Is there any additional subjective or objective information you need for this client? Explain. I would get a thorough medical history for Mr. JD. I would ask if he smokes. I would get an environmental assessment to see if he works or lives around pollutants or irritants. Wood smoke, smog, fumes, and dust are other common sources of irritants and can make allergies or other sinus problems worse.
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- Fall '17
- Bacteria, Common cold, black box warnings, Mr. JD