Nu636U3URIpeerresponse2

Scenario: 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.
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, posterior pharynx is erythematous, no tonsillar enlargement noted.
Breath sounds are clear bilateral.

Subjective

3-day history of sore throat, rhinorrhea, nasal stuffiness, and postnasal drip.
Self-reported low-grade temperature.
Lethargy
Migraines treated with Ibuprofen.
Script for Maxalt, noncompliance.
Hormonal contraceptive.

Objective

Blood pressure 112/66, Pulse 68, Respirations 18, Temperature 98.7, and oxygen saturation 99% on room air.
Clear nasal drainage.
Pearly, gray tympanic membranes.
Erythematous posterior pharynx.
Clear, bilateral breath sounds.

Assessment

This patient has postnasal drip, rhinorrhea, fever, sore throat, nasal stuffiness, and migraines. These symptoms indicate an upper respiratory infection (URI) (Arcangelo, 2021, p. 403). The patient also has an erythematous posterior pharynx, which indicates a possible viral or bacterial infection. A swab needs to be done to rule out bacterial pharyngitis (Thomas & Bomar, 2023). A URI is mostly self-limiting and commonly involves rhinitis (Arcangelo, 2021, p. 403). A few other symptoms are tenderness over the sinuses, fever, headache, and malaise (Arcangelo, 2021, p. 403). This patient has all these symptoms.

Plan

The therapeutic treatment plan is dependent upon the cause (bacterial or viral) and really aimed at symptom relief.

Therapeutics

Nonpharmacological treatment remains the first-line treatment for URI (Arcangelo, 2021, p. 404). It is essential that this patient remains hydrated, gets some rest, and isolates. Before beginning any medication, the patient must be questioned about any other prescribed medicine and CAM therapies. Allergies also need to be checked.

This patient has nasal stuffiness and can benefit from an oral or topical decongestant. Examples of a decongestant are Afrin, which is a nasal spray (topical), and Sudafed, which is oral (Arcangelo, 2021, p. 405). She reports taking Ibuprofen for a headache, which can also help with a low-grade temperature. An antihistamine can assist her rhinorrhea, preferably a second generation such as Loratadine. Anticholinergics such as ipratropium bromide can also be helpful for rhinorrhea (Arcangelo, 2021, p. 409). Antibiotics will be used depending on the results of the throat swab and if it is a bacterial infection.

Educational

The patient must be educated on the difference between symptoms of bacterial URIs and viral URIs (Arcangelo, 2021, p. 416). If the patient is started on antibiotics, teach the patient the importance of completing the course of treatment (Arcangelo, 2021, p. 416). Adverse drug reactions need to be taught as well (Arcangelo, 2021, p. 416). Also, encourage vaccinations for flu season.

Consultation/Collaboration

The patient, healthcare provider, pharmacist, and possible infectious disease experts.

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