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 sinustenderness; no cervical adenopathy, and lungs are clear bilaterally.Is there any additional subjective or objective information you need for this client? Explain.As a provider, I would additionally want to know any current medications Mr. JD is taking, and if any alleviate his current symptoms. History of sinusitis or chronic sinusitis would need to be evaluated, as well as his smoking status. I would also want to know if he has recently been on any antibiotics or prescribed medications for this current cough and congestion. I would assess him for any abnormalities that would prevent mucous clearance that could prove he is recovering from a sinus infection. I would also want to understand his home life, social support, marital status, and family history. Assessing any recent irritants or inhalant of irritants would all be information I would obtain. Has he been experiencing any SOB, wheezing, or sore throat in the past 2 weeks? I would also obtain a CBC to check for WBC levels to monitor possible infection. Would you treat Mr. JDs cold? Why or why not?Yes, because of the length of time his cough and congestion has been persisting without getting better. It appears that Mr. JD does have a sinus infection. Sinus infection are caused by viral and bacterial infections. Antibiotics would not work on a common cold since they cannot be used against viruses. They may only be used if the infection is confirmed bacterial and this treatment will alleviate symptoms. Most common colds alleviate after 10 days, but symptoms may last longer in individuals that smoke. According to Mayo Clinic (2019), symptoms of a common cold are runny nose, sore throat, cough, congestion, slight body aches, sneezing, and low-grade fever. Yellow or green discharge from the nose is commonly mistaken as a bacterial infection by non-medical professionals, but it is not an indication of infection.
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- Fall '16