Subjective: You are seeing a 34-year-old multi-race female who is a school counselor. She reports a 3-day history of a sore throat, rhinorrhea, nasal stuffiness, and postnasal drip. She states she thinks she may be running a low-grade fever but reports she has not actually taken her temperature. She reports feeling tired. She has a history of migraine headaches for which she utilizes ibuprofen as needed. She has a script for Maxalt if needed however reports she hasnâ€™t used that in several years.
Objective: She is on hormonal contraceptive management. BP 112/66, P 68, Resp 18, Temp 98.7, SpO2 99% on RA. On your exam you note clear nasal discharge, tympanic membranes are pearly gray, the posterior pharynx is erythematous, and no tonsillar enlargement is noted. Breath sounds are clear bilateral.
Assessment: The patient is a school counselor which puts her more at risk for getting sick working with children. She presents with symptoms of an upper respiratory infection (URI).
Plan: URIs are usually self-limiting and can be an acute illness. URIs involve inflammation in the nose and sinuses which will give rise to the stuffiness and postnasal drip. This can be one of the reasons for a sore throat. Sometimes a fever can be present also. Symptoms can start 10-12 hours after being exposed to the infective organisms and can last for 7-10 days after the exposure (Thomas & Bomar, 2023).
Therapeutics: Obtain a full H&P to see what risk factors could have predisposed her to getting sick such as stress, smoking, or having asthma. We already know because of her job this already puts her at risk of getting sick. Over-the-counter medications such as pain relievers, decongestants, and antihistamines can help with nasal stuffiness and post-nasal drip. Cough drops for the sore throat or cough syrup. Increase her fluid intake. The goal is to achieve relief from the symptoms.
Educational: As soon as symptoms take OTC as needed, get plenty of rest, and stay hydrated. Staying hydrated will help keep the throat moist and thin out her secretions. Gargling with salt water can also soothe a sore throat. Using a menthol rub can help open the nasal passage and improve breathing (Arcangelo & Peterson, 2021). Advise her to stay home when she is not feeling well so she doesnâ€™t infect others. Remind her to cover her coughs and sneezes and wash her hands afterward.
Consultation/Collaboration: Follow up with her PCP in 10 days to see if symptoms have resolved or if they have gotten worse and developed into something more severe such as pneumonia or bronchitis.