Ihuman management plan
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School
Chamberlain University College of Nursing *
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Course
509
Subject
Medicine
Date
Feb 20, 2024
Type
docx
Pages
6
Uploaded by Rachael.park
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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Icahn school of medicine at Mount Sinai (n.d.). Salmonella enterocolitis
. Retrieved from https://www.mountsinai.org/health-library/diseases-conditions/salmonella-enterocolitis
Cleveland clinic. (n.d.). Salmonella
. Retrieved from https://my.clevelandclinic.org/health/diseases/15697-salmonella
Treatment
The goal is to make you feel better and avoid dehydration. Dehydration means your body does not have as much water and fluids as it should.
These things may help you feel better if you have diarrhea:
Drink 8 to 10 glasses of clear fluids every day. Water is best.
Drink at least 1 cup (240 milliliters) of liquid every time you have a loose bowel
movement.
Eat small meals throughout the day instead of 3 big meals.
Eat some salty foods, such as pretzels, soup, and sports drinks.
Eat some high-potassium foods, such as bananas, potatoes without the skin, and watered-down fruit juices.
If your child has Salmonella, it is important to keep them from getting dehydrated. At first, try 1 ounce (2 tablespoons or 30 milliliters) of fluid every 30 to 60 minutes.
Infants should continue to breastfeed and receive
electrolyte
replacement solutions as recommended by your child's provider.
You can use an over-the-counter drink, such as Pedialyte or Infalyte. Do not water down these drinks.
You can also try Pedialyte freezer pops.
Watered-down fruit juice or broth may also help.
Medicines that slow diarrhea are often not given because they may make the infection last longer. If you have severe symptoms, your provider may prescribe antibiotics if you:
Have diarrhea more than 9 or 10 times per day
Have a high fever
Need to be in the hospital
If you take water pills or diuretics, you may need to stop taking them when you have diarrhea. Ask your provider.
Emily Green is a 22-year-old college student presented with a complaint of unilateral headache gradually progressively worse over 30 hours. Patient describes the symptoms
of nausea and phonophobia, photophobia. Emily Green is a 22-year-old college student presented with a complaint of unilateral headache gradually progressively worse over 30 hours. Patient describes the symptoms
of nausea and phonophobia, photophobia, disruptive eating pattern and decreased sleep and increased stress from academic work and recent break-up with her boyfriend.
Patient mentions that patient had one episode of seeing flashlight and describes the headache rated at 8 out 10 and throbbing, occurring every 4 to 6 weeks. Family history is significant; sister and mom has a similar headache. The patient reports to taking Tylenol every 4 hours without improvement in symptoms.
Family History
Sister - frequent headache
Mom – similar headache, Daddy - hypertension
Past Medical History
Chicken pox and Mono
No known allergy
Oral contraceptives
Management Plan
Pharmacological care
Acetaminophen 650mg q 4
Patient education 1.
Patient education Reduce the amount of caffeine you drink
Reduce the amount of alcohol
Peptic Ulcer Diseases
1.
diagnostic tests
1)
Laboratory tests: CBC- Anemia, BMP- normal, Lipase panel- normal, LFT-
normal 2)
Esophagogastroduodenoscopy – gastric ulcer close to pylorus
3)
Stomach biopsy – severe acute and chronic inflammation. No evidence of carcinoma 2.
Medication 1) Esomeprazole 40mg once daily PO for 4 weeks. Take medication with an empty stomach.
2)
Amoxicillin 1000mg BID PO for 14 days. 3)
Clarithromycin 500mg BID PO for 14 days. 4)
Multivitamin with Iron once daily PO.
5)
Tylenol 650mg PO Q 6H and as needed.
3.
suggested consults/referrals
Due to age, acute symptoms and complications, a referral of gastroenterology
placed STAT for esophagogastroduodenoscopy.
4.
client education
1) Smoking cessation 2)
Decrease of alcohol consumption
3)
Diet: eat smaller meals, avoid eating 2 hours before sleep. 4)
Drink a lot of fluid
5)
Avoid taking ibuprofen but take Tylenol PRN for Knee pain.
5.
Follow up within 4 weeks. 1)
After a course of antibiotics medication.
2)
Need to repeat esophagogastroduodenoscopy in 6-12 weeks. Reference
Kavitt, R. T., Lipowska, A. M., Anyane-Yeboa, A., & Gralnek, I. M. (2019). Diagnosis and treatment of peptic ulcer disease.
The American journal of medicine
,
132
(4), 447-456.
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