ihuman Reflection

Case: Problem Statement

This is an 18-year-old male college student with a history of childhood asthma who presents with acute onset of nonproductive cough, sore throat, fatigue, myalgias, and headache × 4 days. He reports a sick contact, and has not had annual flu vaccine or COVID booster. Physical examination reveals a temperature of 101°F, tachycardia, erythematous pharynx, and anterior cervical lymphadenopathy, but is negative for adventitious breath sounds and hepatosplenomegaly.

Case: Management Plan

Pharmacologic Care:

• Acetaminophen OTC 325 mg 1-2 tabs PO q 4-6 hours; maximum dose 10 tablets per day pm fever, headache, myalgias
• Dextromethorphan HBr + guaifenesin 20mg/400 mg 20 mL PO q 4 hrs; maximum dose 6 doses daily pr cough

Supportive Care:

• Increase fluid intake
• Rest – no class attendance – school note provided for 48 hours
• Marvin Webster Jr i-Human Patients Case Study

Patient Education:

• Offered education on the diagnosis and treatments provided
• Educated patient that oseltamivir is not indicated given timeline since symptom onset

Follow-Up/Disposition:

• Follow up in the student health center if not improving within 48 hours or headache worsens or if shortness of breath develops
• At future visit, address vaccination status – encourage flu vaccine and COVID booster
• Marvin Webster Jr i-Human Patients Case Study