w3-13.docx - Mr JD is a 24-year-old patient who presents to Urgent Care with subjective history of cough and congestion for two weeks The patient

w3-13.docx - Mr JD is a 24-year-old patient who presents to...

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Mr. JD is a 24-year-old patient who presents to Urgent Care with subjective history of cough and congestion for two weeks. The patient reports projective cough, green mucous, nasal discharge, low-grade fever, and intermittent frontal headaches. Objectively, vital signs are stable with a low-grade fever of 99.9 degrees Fahrenheit along with an erythematous pharynx, clear tympanic membranes, red and swollen turbinates, negative cervical adenopathy, frontal sinus tenderness, and lungs clear and equal bilaterally. The nurse practitioner (NP) would take additional time to review the patient’s chart before entering the room to assess the patient. The advanced nurse would review pathways prior to the visit associated with cough, congestion, headache, and potential treatment therapies to prepare questions to ask the patient related to his visit. Although the patient reports a negative medical history or allergies, the NP would want to gather further information from the patient during the interview such as inquiring about shortness of breath during exertion, smoking and alcohol history, medication regimen including prescribed and over-the-counter, family history, and surgical history. It would be important to question the patient on whether they had similar occurrences before, and if any previous treatments with or without complications. Although the patient’s lungs are clear and equal bilaterally, a chest x-ray may be a beneficial test to order to rule out pneumonia due to his low-grade fever. If the NP needed to verify the possibility of an infection in the body, a complete blood count could be drawn to assess the white blood cell count (WebMD, 2019).
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