Ihuman management plan

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Chamberlain University College of Nursing *

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Course

509

Subject

Medicine

Date

Feb 20, 2024

Type

docx

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6

Uploaded by Rachael.park

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Statement This is an 18-year-old male college student with a history of childhood asthma who presents acute onset of nonproductive cough, fatigue, myalgias, and headache for 4 days. He has not had annual flu vaccine or COVID booster. Physical examination reveals a temperature of 101 F, Tachycardia, anterior cervical lymphadenopathy and erythematous pharynx, But is negative for adventitious breast sounds and hepatosplenomegaly. Subjective The patient reported dry cough, fatigue, sore throat and headache. Objective Febrile (101F), Palpitation (HR: 106 bpm) Sore throat - 6-8 pain scale. Swab for Influenza: Positive Assessment Problem: dry cough, myalgias, sore throat, headache Potential: history of asthma Progress Plan Antiviral treatment for Influenza Stay at home and rest. Avoid close contact with people. Drink plenty of water to prevent fluid loss. Treat fever with PRN Ibuprofen 1. Diagnostic tests: no need to do this time 2. Pharmacologic Care Acetaminophen OTC 325mg 1-2 Tabs PO q 4-6 hours, maximum dose 10 tablets per day prn headache Zofran Sumatriptans for migraine: Dose: 25-100 mg PO x1; Max: 200 mg/24h; Info: may repeat dose x1 after at least 2h; may give up to 100 mg/24h PO if following initial inj. dose. 3. Suggested consults / referral: None need this time. 4. Special education Reduce the amount of caffeine you drink. Reduce the amount of alcohol. Eat a regular meal. Stress management and strategy. Drink plenty of fluid to stay hydrated. Rest References
Epocrates (n.d.).Imitrex. Retrieved from https://www.epocrates.com/online/drugs/1681/imitrex Mayans, L., & Walling, A. (2018). Acute migraine headache: treatment strategies.   American family physician ,   97 (4), 243-251. Follow-up/Disposition 1. Follow up in the student health center if not improving within 48 hours of headaches worsens or if shortness of breath develops 2. At future visit, address vaccinations status- encourage flu vaccine and COVID booster Pharmacologic Care 1. Acetaminophen OTC 325mg 1-2 Tabs PO q 4-6 hours, maximum dose 10 tablets per day prn fever and headache 2. Amoxicillin [immediate-release form] Dose: 1000 mg PO q24h x10 days; Alt: 500 mg PO q12h x10 days [extended-release form] Dose: 775 mg ER PO q24h x10 days; Info: give w/ in 1h of a meal; do not cut/crush/chew ER tab Supportive CARE 1. Rest Patient Education 1. Avoid direct contact with sick people such as roommate or others such as contact through nasal secretion, saliva and secretions 2. Hand washing and oral hygiene Follow-up/Disposition
1. Follow up in the student health center or call PCP if not improving within 48 hours of headaches worsens 2. No referral needed References Centers for disease control and prevention (n.d.). Pharyngitis (Strep Throat). Retrieved from https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html#:~:text=Penicillin%20or %20amoxicillin%20is%20the,is%20common%20in%20some%20communities Epocrates (n.d.). Amoxicillin. Retrieved from https://www.epocrates.com/online/drugs/139/amoxicillin For the management plan for infectious colitis salmonella enteritidis enterocolitis, dehydration and electrolyte needs to be corrected by hydration and (Icahn school of medicine at Mount Sinai, n.d.). 1. Get hydrated (Icahn school of medicne at Mount Sinai, n.d.) Drink 8 to 10 glasses of clear fluids every day Eat some salty foods. Eat some high-potassium foods such as bananas and potatoes. If dehydration is not corrected, get prescribed for fluid via intravenous route. 2. Pharmacological care: if symptoms such as diarrhea lasts longer, antibiotics need to be given (Cleveland clinic, n.d.) Ciprofloxacin Ceftriaxone Trimethoprim-sulfamethoxazole (TMP/SMX) Azithromycin 3. Treat diarrhea by OTC medication Loperamide (Imodium) Bismuth subsalicylate (Pepto-Bismol, Kaopectate) 4. Referral to infectious disease specialist if the symptom does not relieved. Reference
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