100%(2)2 out of 2 people found this document helpful
This preview shows page 1 - 2 out of 3 pages.
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 want to know more about his past medical history, or any drug allergies. Does he have a history of respiratory infections or asthma? I would also ask if he has experienced these symptoms before, and how long they lasted if he has. I would also inquire about his social activities whether he drinks alcohol, is a smoker or uses any other drugs. I would ask if he has a job and if so, what is his working environment like? Lastly, I would want to know about current medications he is taking, if he has taken any over the counter (OTC) medications and if they helped relieve any of his symptoms. It is always important to know as much of the patients’history as possible to ensure proper treatment. An accurate patient history can also reveal chronic medical conditions. Knowing a list of up to date medications helps prevent any drug interactions from occurring, when new medications are being added to the patients’treatment plan (Nichol & Nelson, 2020).