w3-6.docx - WEEK 3 \u2013 DISCUSSION 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

w3-6.docx - WEEK 3 u2013 DISCUSSION Mr JD is a 24-year-old...

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WEEK 3 – DISCUSSION 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. 1. Is there any additional subjective or objective information you need for this client? Explain.Acute sinusitis can be diagnosed based on history and physical examination (Hall, 2017). To complete the history and physical, it would be beneficial to include: History of sinusitis (chronic). Chronic sinusitis is thought to result from an acute sinus infection that has not completely resolved with antibiotic treatment due to insufficient sinus drainage. Any recent antibiotic use and other medications prior to this encounter. Recent use of antibiotic for his symptoms would impact treatment based on guidelines. List of medications to include prescription, OTC, and herbal supplements. Any anatomic abnormality that inhibits normal mucus clearance causing incomplete recovery from a sinus infection. Evidence of any sensory deficits. The orbital infection may cause difficulty with vision. Social history – Support system, marital status, smoker. 2. Would you treat Mr. JDs cold? Why or why not?
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