Treatment Of Signs And Symptoms Of The Common Cold Assignment

Treatment Of Signs And Symptoms Of The Common Cold Assignment

Assignment Description: Assess the HEENT system of Tina Jones, a Digital Standardized Patient. Interview and examine the patient, document your findings, and complete post-exam activities. On average, this assignment should take from 90-120 minutes to complete.

INSTRUCTIONS TO WRITER:::::::
1. You need to submit a Subjective, Objective and Assessment documentation (no PLAN). Documentation should be completed using a Word document. Type N/A on the Shadow Health documentation boxes.

2. Please log on to my shadow health from my institution page. Its on BlackBoard. My log in credentials are: username – virmanip
Password – Chinoo@1000 Please use these credentials to log in the webpage mentioned in next point. Treatment Of Signs And Symptoms Of The Common Cold Assignment

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3. instituition is William Paterson University. webpage to get in : https://bb.wpunj.edu/ultra/courses/_28718_1/cl/outline

4. Interview is being conducted by NP – Puneet Virmani, so intorduce yourself as Ms. Puneet while conducting an assessment on HEENT.

5. Deadline is 2 days please. Must remember.

6. Follow Rubric v v strictly. Writer will Submit the Shadow health part. I will submit the word document part.

7. V V IMPORTANT :::: SOAP note (no PLAN) must be in a separate word document attached to my order. Type N/A on the Shadow Health document

8. A score of above 95% is must

Subjective Data

Chief complaint: throat pain

History of presenting illness: tina jones is a 28years old African American female at the emergency department due to throat pain when swallowing. The pain is gradual onset, intermittent, and on a scale of 4 out of 10 in the morning. It has no specific aggravating factors. The patient reports severe and recurrent itchiness in the throat, eyes, and nose. She complains of a runny nose all day and a weekly headache. She denies environmental exposure to irritants. She refuses changes in her hearing, vision, and taste, shortness of breath, wheezing, cough, fevers, chills, and night sweats.

Current medication: Tylenol 1g po daily for headache, lozenges one tablet to relieve sore throat, and inhaler 2-3 times per week for asthma Treatment Of Signs And Symptoms Of The Common Cold Assignment.

Past medical history: the patient has had asthma since the age of 16 years. Her immunization schedule is up to date. Her last covid booster vaccine was three months ago. She denies hospitalization and blood transfusion.

Past surgical history: none

Allergies: the patient is allergic to dust and cats.

Family history: she is the firstborn in a family of three. Her mother has asthma and recurrent upper respiratory tract infections. Her father has hypertension and recurrent allergic rhinitis. Her younger sister develops hay fever when exposed to pollen. Her younger brother has allergic rhinitis. She denies a family history of cancer, mental health disorders, and lifestyle diseases.

Social history: the patient is single and lives alone. She works as an accountant in a cooperative savings society. She has a bachelor’s in commerce and accountancy. She occasionally takes two bottles of beer in the company of her friends. She denies using tobacco and bhang. She enjoys coffee, deep-fried fish, and fries for lunch. Her house has smoke detectors, she uses seat belts when driving, and she does not use her phone in the pathways.

Health maintenance history: the patient regularly goes for a pap smear, dental, and eye check-up.

Reproductive health: her menarche was at the age of 11 years. She has a regular 21days cycle with three days of moderate flow. She denies the use of contraception. Her first sexual encounter was at the age of 19 years. She is heterosexual and has had three partners in her lifetime. She uses condoms and denies a history of sexually transmitted infections Treatment Of Signs And Symptoms Of The Common Cold Assignment.

Review of systems

General: the patient denies fever, chills, rigors, malaise, weight loss, and fatigue.

HEENT: the patient has headaches, rhinorrhea, nasal stuffiness, sneezing, itching, previous allergy, a sore throat, and burring of vision with increased tearing after prolonged reading. She denies head trauma, hearing loss, tinnitus, vertigo, ear discharge, earache, bleeding gums, swollen lymph nodes, or wounds in the mouth.

Respiratory system: the patient denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, and tuberculosis.

Cardiovascular system: the patient denies claudication, lower limb swelling, orthopnea, dyspnea, paroxysmal nocturnal dyspnea, and syncope.

Gastrointestinal system: the patient denies abdominal pain, diarrhea, vomiting, nausea, heartburn, and reflux.

Genitourinary system: the patient has dysuria, polyuria, hematuria, and urine incontinence.

Musculoskeletal system: the patient denies joint pain, muscle spasms, and stiffness.

Neurological system: the patient denies facial droop, muscle weakness, paresthesia, and paralysis.

Objective data

General: Tina Jones is an obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout the interview and examination.

Vitals: blood pressure at 110/78mmhg, pulse rate 78beats per minute, respiratory rate is 16cycles per minute, and BMI at 33kg/m².

HEENT: the head is normocephalic and atraumatic with no scalp masses and has a normal hair distribution. Her eyes have equal hair distribution, with no lesions, ptosis, edema, or conjunctiva. Extraocular movements are intact bilaterally, with the pupils equal, round, and reactive to light. The left fundoscopic exam reveals sharp disc margins and no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. The ear shape is equal bilaterally. The nasal septum is midline; nasal mucosa is boggy and pale bilaterally with no pain with palpation of frontal or maxillary sinuses. The mouth is moist, with no wounds visualized. There is adequate dental hygiene. The uvula is at the midline, and the tonsils are 1+ without inflammation. The posterior pharynx is slightly erythematous with mild cobblestoning. There is no cervical or infraclavicular lymphadenopathy. The thyroid is smooth without nodules or goiter Treatment Of Signs And Symptoms Of The Common Cold Assignment.

Cardiovascular system: the heart sounds s1 s2 are present. There is bilateral carotid artery auscultation without bruit. The carotid pulses are current at 2+ with no thrills.

Respiratory system: the chest is symmetrical with respirations. There is a resonant percussion note. There is a vesicular breath sounds without wheezes and crackles on auscultation.

Abdominal examination: the abdomen is distended and round. The bowel sounds are present in the four quadrants. There is no shifting dullness, areas of tenderness, and organ enlargement.

Assessment

Differential diagnoses

Allergic rhinitis is the inflammation of the nasal membrane due to a complex interaction of inflammatory mediators triggered by an immunoglobulin-mediated response to an allergen. The mediators cause the release of mast cells and histamine (Meng et al., 2020). The exchange of these two drives rhinorrhea, sneezing, itchiness, redness, tearing, swelling, post-nasal drip, increased secretions,  and plasma exudation. Vasodilation of the mucus membrane causes nasal congestion and increased pressure. The persistence of these mediators leads to the production of inflammatory cells, increasing nasal congestion and mucus secretion. The presenting symptoms are sneezing, itchiness of the nose, eyes, palate, and nose, rhinorrhea, post-nasal drip, congestion, anosmia, intermittent headache, eye swelling, and nasal congestion (Meng et al., 2020)Treatment Of Signs And Symptoms Of The Common Cold Assignment. The causes of these symptoms are exposure to dust, smoke, environmental allergens, and a positive family history of allergic rhinitis. Allergic rhinitis is the patient’s diagnosis because she presents with similar symptoms, has a positive family history of allergic rhinitis, and was exposed to smoke before the onset of the symptoms.

Pharyngitis is the irritation of the pharynx and the tonsil gland due to group a streptococcus, trauma, toxins, and neoplasia (Anderson et al., 2022). Group a streptococcus is the common bacteria causing infections. When the pathogen invades the mucosa, it causes an inflammatory response, hence the symptoms of throat pain when swallowing, sore throat, headache, coughing, vomiting, runny nose, fatigue, chills, body aches, and fever. The patient presents with a sore throat, intermittent headache, runny nose, and throat pain when swallowing. However, pharyngitis is not diagnosed because she has no fever, vomiting, or coughing.

The common cold is an upper respiratory tract infection caused by a rhinovirus that causes a local inflammatory response hence the symptoms of nasal discharge, nasal congestion, sneezing, throat irritation, headache, facial pressure, loss of sense of smell and taste, posttussive vomiting, irritability, and low-grade fever (Schapowal et al., 2019)Treatment Of Signs And Symptoms Of The Common Cold Assignment. The risk factors are smoking, advancing age, exposure to contacts, overcrowding, touching conjunctiva, and chronic medical condition. The common cold is not the diagnosis because the patient has no facial pressure, loss of sense of smell and taste, posttussive vomiting, irritability, and low-grade fever.

Plan

Diagnostic tests

1. Allergy skin test to determine the sensitivity to a specific allergen
2. Total serum immunoglobulin e sensitivity helps to determine early phase reaction
3. Total blood eosinophil count to determine the diagnosis of allergic rhinitis
4. Complete blood count to determine the cause of infection. The total eosinophil count is high in allergic rhinitis.

Pharmacological treatment

1. Levocetrizine 5mg po daily
2. Claritin 10mg po daily
3. Budesonide nasal drops twice daily
4. Prednisolone 5mg po daily

Non-pharmacological treatment

1. Avoid environmental triggers such as dust and cold weather, and avoid allergens
2. Increase intake of fluids and frequent handwashing
3. Schedule a revisit clinic after two weeks to monitor symptoms Treatment Of Signs And Symptoms Of The Common Cold Assignment
   

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References

Meng, Y., Wang, C., & Zhang, L. (2020). Advances and novel developments in allergic rhinitis. Allergy, 75(12), 3069-3076. https://doi.org/10.1111/all.14586

Anderson, J., Imran, S., Frost, H. R., Azzopardi, K. I., Jalali, S., Novakovic, B., & Pellicci, D. G. (2022). Immune signature of acute pharyngitis in a Streptococcus pyogenes human challenge trial. Nature Communications, 13(1), 769. https://doi.org/10.1038/s41467-022-28335-3

Schapowal, A., Dobos, G., Cramer, H., Ong, K. C., Adler, M., Zimmermann, A., & Lehmacher, W. (2019). Treatment of signs and symptoms of the common cold using EPs 7630-results of a meta-analysis. Heliyon, 5(11), e02904. https://doi.org/10.1016/j.heliyon.2019.e02904

FOCUSED SOAP Note Format

 SUBJECTIVE

CC – the reason for the visit as stated in the patient’s own words

Example: “I have a painful rash on my left side that started 2 days ago.”

HPI (History of Present Illness) – include symptom dimensions, chronological narrative of patient’s complains. Use PQRST or OLDCARTS mnemonic to guide you in obtaining pertinent information. If the information is obtained from other sources, always identify source.

PMH (Pertinent past medical history)

Medications – Current medications (list with daily dosages)Treatment Of Signs And Symptoms Of The Common Cold Assignment.

Allergies

Pertinent Family History, Social History and other subjective data if relevant to the patient’s presenting problem and diagnosis.

ROS (Pertinent review of systems) – a system- based list of questions that help uncover symptoms not otherwise mentioned by the patient.  In a focused SOAP note, only include systems pertinent to the presenting problem and/or diagnosis.

OBJECTIVE

Vital signs

PE – focused physical exam finding limited to systems pertinent to the problem

Laboratory or diagnostic data if applicable

ASSESSMENT (Problem List)

Differential diagnoses (with ICD 10 code)– distinguishing a particular disease or condition from others that present with similar clinical features.  Identify 2.  Provide a brief rationale (3-4 sentences) and cite – rationale should provide data that support your differential diagnoses – presentation, PE finding and/or lab/diagnostic test results that make it similar to the diagnosis and explain the difference between the differential and working diagnoses and/or the laboratory/diagnostic tests that would make the diagnosis.

Working Diagnosis (with ICD 10 code)– what do you think the problem is, provide supporting data (cite)Treatment Of Signs And Symptoms Of The Common Cold Assignment.

PLAN 

This has to be evidence based (cite) using the latest clinical guideline.  This should include pharmacologic, non-pharmacologic, education, referrals and follow-up – when applicable. The plan should be personalized and appropriate for the patient.

Cite and provide references.

	Unacceptable	Needs Improvement	Proficient	Excellent
Shadow Health DCE Score (20 points)	<70% will be considered a zero.	A DCE score of 70 – 79%.   5 points	A DCE score of 80-89%.   10 points	A DCE score of 90-100%.   20 points
HPI (10 pts)	Focused HPI is missing or missing 4 or more pertinent information. 0 points	Focused HPI is present but missing 2-3 pertinent information. 5 points	Focused HPI is present but missing 1 pertinent information. 7 points	Focused HPI is present and includes all elements of a comprehensive and thorough HPI. 10 points
ROS (10 pts)	Missing >3 key elements of the focused ROS.  Insufficient or inaccurate data included. 0 points	Missing 3 key elements of the focused ROS.  Or, data provided is missing > 2 pertinent details. 5 points	Missing 1-2 key element of the focused ROS.  Or, data provided is missing 1 or 2 pertinent details. 7 points	Focused ROS is included.  All information is pertinent, accurate and appropriate. 10 points
Other Health History Components (10 points)	Health history is missing more than >4 components.  Information included are incomplete or inaccurate. 0 points	3 – 4 components of the health history are missing.  Or, 3 key components are lacking sufficient information 5 points	1-2 components of a focused health history are missing.  Or, 1-2 component is lacking sufficient information 7 points	All pertinent components of a focused health history are present.  All information is accurate and appropriate. 10 points
OBJECTIVE DATA (30 points)	4 or more elements needed for adequate evaluation of the client’s problem are missing. 0 points	3-4 elements needed for adequate evaluation of the client’s problem are missing. 10 points	Focused objective assessment is missing a1-2 elements to adequately evaluate the client’s problem. ORDER A PLAGIARISM-FREE PAPER HERE   20 points	Objective assessment of health status is fully explicit.  Focused PE documentation is complete, organized and appropriate. 30 points
Assessment (Diagnoses) (20 points	Lacks differential diagnoses and/or final diagnosis are inappropriate for assessments. No references provided.   0 points	Limited differential diagnoses considered and/or final diagnoses, missing evidence based rationale to support diagnoses.   References may not be appropriate.   10 points	Appropriate final diagnosis selected, limited differential diagnoses, may be missing ICD 10 or limited evidenced based rationale to support diagnoses. Includes appropriate reference.   15 points	Appropriate identification of working diagnosis and two differential diagnoses considered, includes ICD 10 and brief evidence based rationale to support diagnoses. Appropriate references used.   20 points

NUR 6001 SUBJECTIVE, OBJECTIVE, ASSESSMENT DOCUMENTATION RUBRIC Treatment Of Signs And Symptoms Of The Common Cold Assignment