Introduction
It is a parental responsibility to ensure the health and well-being of their children; thus, immediate medical attention should be sought when necessary. Over-the-counter drugs should be avoided, as they can cause adverse reactions that worsen the condition. In this case, the father of a four-year-old boy took the child to a healthcare institution due to noticing signs of poor health. This report discusses the diagnosis and subsequent treatment plan, which includes pharmacologic and nonpharmacologic treatments, as well as family communication and engagement. Additionally, the father will be provided with resources to understand better his son’s health and the rationale behind the prescribed plan of action.
A Patient Case Presentation
The subject is a four-year-old child who has been reporting symptoms, including sneezing, a moderate cough, and a low-grade fever of 100 degrees, for three days. The patient has a complete record of vaccinations for his age, as well as two previous cases of Upper Respiratory Infection (URI) and no other infections. The medical history reveals that the subject comes from a non-smoking family and visits preschool four times per week. Physical Examination/Review of Systems (PE/ROS) revealed a temperature of 99°F, a respiration rate of 20 breaths per minute, and a pulse of 100 beats per minute. The child was alert, cooperative, and upbeat and was well-hydrated. Additionally, the patient displayed moderate throat irritation with no evidence of pus, normal tonsils, and pale pink coloring in both ears with clear lungs. All other physical findings were within normal limits.
Diagnosis
After carefully considering the information reported by the child’s father and the physical examination findings, I was able to diagnose the child with an upper respiratory infection (URI). This illness is known to affect the upper respiratory system, including the nasal cavity, throat, and windpipe (Murgia et al., 2020). Common URI symptoms, such as sneezing, tightness, coughing, sore throat, and a runny nose, were present in the case of the child (Murgia et al., 2020). Additionally, the physical examination revealed a moderately erythemic throat with no exudate and a normal lung function, which were all in line with the diagnosis of a URI.
To verify that I had ruled out any other diagnosis, such as strep throat or influenza, I paid particular attention to any other clinical manifestations or signs that may be indicative of a different infection. These include prolonged coughing, migraine, and muscle aches (Faap et al., 2021). In addition, any fevers above 100 degrees were monitored in order to detect a more severe infection (Faap et al., 2021). A thorough medical history and examination of the patient for any other worrisome symptoms were conducted to ensure that all other possibilities had been ruled out. Furthermore, I was able to rule out COVID-19 as a potential diagnosis due to the fact that the child’s immunizations were up-to-date and in accordance with the most recent recommendations, which led to the conclusion of a URI diagnosis. To ensure the accuracy and reliability of the diagnosis, extra precautions were taken in order to provide the child with the appropriate treatment plan.
Treatment Plan
I prescribed the patient ibuprofen for fever relief and scheduled a follow-up appointment in two weeks. Ibuprofen is considered a safe medication for children with a URI. Studies have demonstrated that ibuprofen is efficacious in reducing fever in children and can result in improved comfort levels in those with a URI (Barbagallo & Sacerdote, 2018). Furthermore, researchers did not identify any complications for children with URI due to the use of ibuprofen (Feleszko et al., 2019). Thus, I recommended ibuprofen as a treatment option for this patient.
In addition, I recommended that the patient and his family practice good hygiene to prevent the spread of the infection. These measures include washing hands and avoiding contact with others (Taylor et al., 2022). Moreover, I advised the patient to rest and stay hydrated for the duration of his illness, as well as to limit his exposure to irritants such as dust. To lessen the severity of the infection, I recommended that the patient take warm showers and drink warm fluids (Taylor et al., 2022). Lastly, I instructed the family to promptly contact the pediatrician if the child’s condition deteriorated or any new symptoms emerged.
Communication Plan
During the initial consultation, I employed an open-ended approach to establish a strong rapport with my patient, Mr. Smith, and his son to create a conducive atmosphere for expressing their concerns and worries. My strategy for this session was to adopt a broad opening strategy, and I observed that both Mr. Smith and his son were engaged, indicating their understanding of the issues being discussed. While listening to my patient discuss the issues his son was facing, I made careful observations of his expressions and choice of language since it was paramount to ascertain whether he was cognizant of his emotions. Subsequent to the assessment, I provided Mr. Smith with a comprehensive summary of the diagnosis, treatment, and management plan and ensured that he was in agreement with all elements before concluding the session.
Resources
I referred Mr. Smith to the Centers for Disease Control and Prevention (CDC) website for additional information about the treatment plan for his son. This website provides valuable information about the common symptoms and treatments for upper respiratory infections and other illnesses, as well as guidance on prevention and health promotion. For example, I have recommended a CDC’s (2021) article on the common cold and the use of antibiotics, which is applicable to the case. Additionally, I provided Mr. Smith with a list of trusted websites, such as the American Academy of Pediatrics, that he and his family could access for reliable information about the diagnosis and treatment for his son’s illness. As such, I have included the American Academy of Pediatrics (2020) paper about common childhood diseases. Moreover, I gave Mr. Smith information about the importance of staying up to date on vaccinations, as this can help protect the health of his son and the entire family. Furthermore, I suggested he review any relevant clinical trials to determine if his son was an eligible candidate to participate in a research study that could benefit his overall health.
Conclusion
In conclusion, I was able to accurately diagnose the 4-year-old patient with a URI. I provided a specific treatment plan, which included pharmacologic and nonpharmacologic recommendations, and I communicated the plan to the patient’s family. I also provided resources that the family could access to gain additional information about the diagnosis and treatment of the child’s illness. I believe that this treatment plan and communication plan will help the family to ensure that the child receives the best care possible.
References
American Academy of Pediatrics. (2020). Common child illnesses and exclusion criteria for common child illnesses and exclusion. Web.
Barbagallo, M., & Sacerdote, P. (2018). Ibuprofen in the treatment of children’s inflammatory pain: a clinical and pharmacological overview. Minerva Pediatrica, 71(1). Web.
CDC. (2021). Common cold. Centers for disease control and prevention. Web.
Faap, M. D. K. W., M.D., B. E., Faap, L. R. M., & Faap, M. M. S. H. (2021). Red book 2021: Report of the committee on infectious diseases (32nd ed.). American Academy of Pediatrics.
Feleszko, W., Marengo, R., Vieira, A. S., Ratajczak, K., & Mayorga Butrón, J. L. (2019). Immunity‐targeted approaches to the management of chronic and recurrent upper respiratory tract disorders in children. Clinical Otolaryngology, 44(4), 502–510. Web.
Murgia, V., Manti, S., Licari, A., De Filippo, M., Ciprandi, G., & Marseglia, G. L. (2020). Upper respiratory tract infection-associated acute cough and the urge to cough: New insights for clinical practice. Pediatric Allergy, Immunology, and Pulmonology, 33(1), 3–11. Web.
Taylor, C. R., Lynn, P., & Bartlett, J. (2022). Fundamentals of nursing: The art and science of person-centered care (10th ed.). Wolters Kluwer Health.