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. Additional subjective information I would collect includes whether there is facial pain while bending over, headache, halitosis, or toothache which are characteristics of acute bacterial sinus infection in combination with the previously reported symptoms (Caspersen, Walter, Walsh, Rosenfeld, & Piccirillo, 2015). I would also inquire information regarding occupational/environmental exposures and whether he has ever had these symptoms before.
Would you treat Mr. JDs cold? Why or why not? I would opt for “watchful waiting” for 7 days, and not prescribe antibiotics immediately. Acute bacterial sinus infections typically can resolve on their own (Rosenfeld, 2016), and reduces the likelihood of antibiotic resistance and/or side effects of the medication.
What would you prescribe and for how many days? Include the class of the medication, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings. Would this treatment vary if Mr. JD was a 10 year-old 78 lb child? Amoxicillin clavulanate 500/125 mg orally every 8 hours or 875/125 mg orally every 12 hours should be initiated as a first-line therapy for 5 to 7 days (Chow, Benninger, Brook, Brozek, Goldstein, Hicks, Pankey…File, 2012). Amoxicillin is penicillin-like class of antibiotic, that works by stopping the growth of bacteria. Clavulanic acid is a beta-lactamase inhibitor that prevents bacteria from destroying amoxicillin (MedlinePlus, 2019). Amoxicillin clavulanate (Augmentin) is administered orally by tablet, chewable tablets, or by suspension (MedlinePlus, 2019). More than half of the amoxicillin and approximately 25% to 40% of the clavulanic acid are excreted unchanged in urine (U.S. National Library of Medicine, 2019). Half-lives of amoxicillin and clavulanic acid are roughly 1.3 hours and 1 hour, respectively in otherwise healthy adults that have normal renal function (U.S. National Library of Medicine, 2019). Contraindications for Augmentin include history of hypersensitivity to amoxicillin, clavulanate or to beta-lactam drugs such as penicillin, and/or in patients with a history of cholestatic jaundice/hepatic dysfunction that is associated with Augmentin (U.S. National Library of Medicine, 2019). The dosage for Augmentin would change for a pediatric patient. The dosage for a child weighing 40 kg or more is up to 1750mg/day of amoxicillin and up to 4000 mg/day of the XR tablets (U.S. National Library of Medicine, 2019).
What health maintenance or preventive education is important for this client based on your choice medication/treatment? There are several health maintenance topics and preventative education points to address with the patient. The patient should be educated on symptoms that patient should promptly report such as allergic reaction, headache with stiff neck or difficulty turning head (Mayo Clinic, 2019). Additionally, the patient should be instructed on side effects of medication which include nausea, diarrhea, tooth discoloration, and indigestion (Mayo Clinic, 2019). Finally, the patient should be educated on prevention which include good hand hygiene, avoiding ill contacts, using a humidifier, and avoiding air pollution.
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.
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