“Complaints of tiredness and body aches; the roof of the mouth hurts since Saturday and gets worse when eating; headaches; a dry cough, sneezing, and fever are present”
|HPI: The patient complains of tiredness, body aches, pain in the roof of the mouth observed since Saturday, and getting worse when eating, headaches, a dry cough, sneezing, and fever. The patient is negative for anxiety, arthritis, asthma, DPH, problems with the back, breast cancer, COPD, CAD, CHF, high cholesterol levels, cancer, dementia, depression, dermatitis, diabetes, epilepsy, GERD, glaucoma, gout, HIV, hepatitis, pneumonia, renal stone, stroke, TB, thyroid problems, and an ulcer (GI). The patient is positive for migraine, headache, hypertension, and anemia.|
|Medications: Norvasc (hypertension, 10 mg/day)|
|PMH: The patient is negative for diabetes, peptic ulcer disease, lung disease, asthma, TB, cancer, kidney disease, thyroid problems, and psychiatric diagnosis. The patient is positive for HTN. |
Allergies: No allergies
Medication Intolerances: No medication intolerances
Chronic Illnesses/Major Traumas: HTN
Hospitalizations/Surgeries: No hospitalizations/surgeries
|Family History –|
|Social History –|
Reports fever, tiredness, headache.
Denies chills, weight change, fatigue, declines in an energy level, sweats.
Denies chest pain, palpitations, PND, orthopnea, edema, varicose veins, heart attacks, rheumatic symptoms.
Denies rashes, bruising, dryness, bleeding or skin discolorations, changes in lesions or moles, nails.
Reports a dry cough and sneezing.
Denies asthma, wheezing, bronchitis, TB, hemoptysis, dyspnea, pneumonia.
Denies blurring, visual changes of any kind, excessive tearing, eyeglasses use, pain, cataracts, glaucoma.
Denies abdominal pain, constipation, N/V/D, jaundice, hepatitis, changes in stools, hemorrhoids, eating disorders, ulcers, liver disease.
Denies discharge, ear pain, hearing impairment and loss, infections, ringing in ears.
Denies urgency, changes in the color of urine and frequency, vaginal discharge, pregnancy.
Reports soreness of the mouth and throat.
Denies nose bleeds and discharge, frequent colds, nasal obstruction, dysphagia, dental disease, and bleeding gums, hoarseness.
Denies arthritis, back pain, joint swelling, stiffness or pain, fracture, osteoporosis, muscle stiffness.
Denies SBE problems, lumps, bumps, any changes, discharge.
Denies syncope, seizures, transient paralysis, dizziness, head injuries, weakness.
Denies HIV status, bruising, blood transfusion, night sweats, swollen glands, increased thirst and hunger, cold/heat intolerance.
Denies anxiety, depression, insomnia, suicidal ideations, mood, and behavioral changes.
|Weight BMI||Temp 98.1||BP 140/80|
|Height||Pulse 75||Resp O2sat 96% room air|
|General Appearance |
The patient is alert, awake, well-developed, well-nourished, and well-groomed, with no acute distress.
Skin is brown, warm, dry, clean, intact; no rashes, lesions.
Head: normocephalic, atraumatic, without lesions; facial contours are normal.
Eyes: no lesions, scleral injection, PERRLA.
Ears: no lesions or masses.
Nose: nasal mucosa congested.
Neck: supple, full ROM, no occipital nodes. The teeth are in good repair.
S1, S2 with regular rate/rhythm. No extra sounds. No edema.
Asymmetric chest wall, regular respirations, lungs are clear. The patient does not use the accessory muscles of respiration.
The abdomen is normal, soft, non-tender, no masses.
No masses, tenderness, discharge, or dimpling.
No tenderness, lesions, masses.
Full ROM, no pain in joints.
Gait is normal, speech is clear, posture is erect.
The patient is alert and well-oriented, maintains eye contact. The mood is neutral.
|Special Tests |
Influenza Assay with Optic (influenza A, B negative)
- 1- Pain in the throat (R07.0)
- 2- Acute nasopharyngitis (J00)
- 3- Acute pharyngitis, unspecified (J02.9)
- Acute maxillary sinusitis, unspecified (J01.00)
- Acute upper respiratory infection, unspecified (J06.9)
- Further testing: Tests for determining bacterial sensitivity and radiography are possible if there are no positive effects of the prescribed treatment. Thus, “radiological tests, such as plain X-ray and computed tomography, may aid the diagnosis” (Baker & Barton, 2013, p. 24). Additional tests, including CRP and ESR, can be proposed.
- Medication: Augmentin (875 mg-125 mg tablet by mouth twice a day) is effective to cope with acute maxillary sinusitis in adults because amoxicillin/clavulanate is used as the first-line therapy for treating different types of sinusitis (Ahovuo-Saloranta et al., 2014). Side effects of Augmentin are nausea, vomiting, diarrhea, skin itching, and these adverse effects are addressed with changing doses. Tamiflu (75 mg capsule by mouth twice a day) is recommended to be used for treating upper respiratory infections and nasopharyngitis as “the neuraminidase inhibitor” to cope with fever, cough, and sneezing (Baker & Barton, 2013, p. 19). The adverse effects of Tamiflu include diarrhea, headache, dizziness, eye redness, and insomnia. To address these symptoms, it is possible to change the medication.
- Education: The patient will be educated to take medications according to the plan, control her body temperature, pay attention to possible adverse effects, and report them to the doctor.
- Non-medication treatments: The patient should be recommended to drink a lot of water and different hot fluids. The patient should adhere to bed rest and avoid feeling cold. A follow-up visit to the PCP doctor is planned in 1-2 days to evaluate the outcomes and receive the ENT doctor’s consultation.
Evaluation of patient encounter
The patient is diagnosed with acute maxillary sinusitis, and the purpose of prescribed antibiotics “is to decrease symptoms and restore the normal function of the sinuses, to prevent complications and the development of chronic sinusitis” (Ahovuo-Saloranta et al., 2014, p. 3). Additionally, Tamiflu is prescribed because “acute bacterial maxillary sinusitis is often preceded by an acute viral upper respiratory tract infection” (Ahovuo-Saloranta et al., 2014, p. 3). The proposed care plan is aimed at relieving symptoms and coping with the bacteria that caused sinusitis.
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Ahovuo-Saloranta, A., Rautakorpi, U. M., Borisenko, O. V., Liira, H., Williams, J. W., & Mäkelä, M. (2014). Antibiotics for acute maxillary sinusitis in adults. Cochrane Database of Systematic Reviews, 2(11), 3-34.
Baker, I., & Barton, E. (2013). URTIs: Recommended diagnosis and treatment in general practice. Prescriber, 24(19), 16-28.