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Mr. Smith brings his 4-year-old son to your primary care office. He states the boy has been ill for three days. Mr. Smith indicates that he would like antibiotics so he can send his son back to pre-school the next day.
History – Child began with sneezing, mild cough, and low grade fever of 100 degrees three days ago. All immunizations UTD. Father reports that the child has had only two incidents of URI and no other illnesses.
Social – non-smoking household. Child attends preschool four mornings a week and is insured through his father’s employment. No other siblings in the household.
PE/ROS -T 99, R 20, P 100. Alert, cooperative, in good spirits, well-hydrated. Mildly erythemic throat, no exudate, tonsils +2. Both ears mild pink tympanic membrane with good movement. Lungs clear bilaterally. All other systems WNL.
Do not consider COVID-19 for this patient diagnosis.
For the assignment, do the following:
1. Diagnose the child and describe how you arrived at the diagnosis (i.e. how you ruled out other diagnoses).
2. Provide a specific treatment plan for this patient, pharmacologic and/or nonpharmacologic.
3. Provide a communication plan for how the family will be involved in the treatment plan.
4. Provide resources that Mr. Smith could access which would provide information concerning your treatment decisions.
5. Utilize national standards, your pharm and/or patho book and medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts to support your diagnosis and treatment.
6. Use references to support your concepts. Utilize correct APA formatting and mechanics of professional communication.
