NSG6005 week 3 D10.docx - Case study 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

NSG6005 week 3 D10.docx - Case study Mr JD is a 24-year-old...

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Case studyMr. 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?Additional subjective information would include a list of known allergies, current medication list including over-the-counter and herbal supplements, what relieves his pain, what are the triggers of his symptoms/pain? As the nurse practitioner, it is important to obtain a history of occupational or allergic rhinitis, vasomotor rhinitis, nasal polyps, or immunodeficiency in order to determine a diagnosis of rhinosinusitis. Because rhinosinusitis is more common in individuals with cystic fibrosis or comorbidity of AIDS, it would be important to assess the presence of these disorders affecting his immune system (Smith, Tran & Westra, 2016). Additional objective information would include weight, height, vital signs, and a baseline kidney and liver function tests so that a potential need for antibiotics can be determined. However, antimicrobial drugs pose little efficacy in the treatment of chronic sinusitis (Woo & Robinson, 2015).
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  • Fall '16
  • Christy McCall
  • amoxicillin, Sinusitis, NSG6005 Week 3 Discussion

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