Common Cold Case Study

Common Cold Case Study
Diagnosis
To establish an accurate diagnosis, I would perform a complete assessment of the patient. I would first obtain the history of the presenting illness from the patient’s parent. The parent reports that the child has been ill for the past three days with signs of sneezing, mild cough and low-grade fever. These signs point towards an upper respiratory infection. This could be either common cold, flu, or allergy. To rule out the differential diagnoses, I would perform a comprehensive physical exam and review of systems. On physical examination, the temperature is slightly elevated, indicating that the patient has an underlying infection. The respiratory and pulse rates are within the normal ranges.

Further examination of systems reveals tonsillitis and mildly erythemic throat which are all suggestive of an upper respiratory infection. Based on these findings, I would rule out flu since it presents with a runny nose, strong coughs which might be dry or productive, and fever. I would also rule out allergy since in addition to fever and cough, it would present with wheezing and chest tightness. The results of physical exam indicate that the chest is clear with bilateral air entry. Therefore, the most accurate diagnosis in this case is common cold, which presents with sneezing, fever, mild cough, sore throat, and sometimes swollen tonsils.

Pharmacologic treatment plan

According to the Centers for Disease Control and Prevention (2017), the management of common cold should emphasize on relieving the symptoms. It strongly discourages the use of antibiotics to treat common cold. The use of over-the-counter drugs have also demonstrated neither benefit nor harm in the management of cold in children under six years old. However, the CDC (2017) contend that the OTC drugs are among the top 20 substances that significantly contribute to mortalities in children under the age of five. Therefore, this treatment plan would focus on symptoms relief. To manage fever, I would prescribe acetaminophen 7.5 ml TDS, for five days. The FDA does not recommend the use of antitussive medications for cold in children under the age of six years. This is in order because these medications do not have sufficient evidence on their efficacy and have potential harmful side effects in this category of individuals.

Non-pharmacologic treatment plan

There is no known cure for cold. However, several non-pharmacological strategies can help mitigate the symptoms and enhance comfort in a patient. First, the parent can administer plenty of fluid to prevent dehydration, and help thin the mucus to facilitate its clearance since there is a lot of fluid loss through elevated body temperature. This may include fruit juices, milk, and warm soup. Second, the parent can administer honey mixed with lemon in warm water to manage the coughs. The FDA recommends the use of honey in this age group to clear sore throats and manage coughs.

In the natural history of common cold, the mucus thickens as the days go by, therefore, as a third measure, parents can administer nasal saline drops or spray to clear the mucus from the nasal passages and ease the discomfort. Fourth, the use of a room humidifier in the child’s room can supplement the moisture in the dry air of the room and facilitate faster healing by moistening the nasal passages and the throat (FDA, 2018). As the days progress, the congestion due to mucus tends to increase (FDA, 2018). Elevating the head of the child’s bed when sleeping will ease the congestion and enhance comfort.

Communication plan for family involvement in the treatment plan

Since the patient is a four-year-old son, he is dependent on having several personal activities accomplished. He is dependent on his parents on the having his cold managed appropriately. It is therefore, imperative that the parents are communicated to effectively on how to manage the common cold and intervention measures of mitigating the incidences of other subsequent occurrences. Common cold is a common and highly prevalent illness with lots of information availed on the internet and even hospital brochures to increase the awareness of the public. I would communicate to the father verbally during the health education talk, before discharging the patient home. I would instruct the father on the appropriate preventive measures that would ensure less recurrent episodes of common cold. These measures include basic hand and overall environmental hygiene.

According to the CDC (2017) hand washing is one of the most effective ways of preventing common cold. Creating a regular routine of washing hands with water and soap reduces the number of microorganisms on the hand surface significantly, especially after coughing or sneezing, and before meals. These habits should be instilled in children, when they are still young, by reminding the always because they interact with their mates more frequently and can easily spread the common cold viruses from one person to another. When water is not available as necessary, one can use alcohol-based hand rubs, which are a great alternative and easily portable. They can be used repeatedly without losing their efficacy or irritating the skin. Additionally, it is critical to maintain a clean environment at home, and keep all the surfaces disinfected.

I would advise the parent regarding the child going back to pre-school. Once the fever has been managed, there would be no need to keep the child at home, especially due to the fear of spreading the common cold virus. This is because he might have done so already during the early stages of the infection when he was asymptomatic (CDC, 2017). As such, the child can freely mingle with others once they are stable. Finally, when discharging the patient, I would give the father the hospital brochure containing every vital information regarding common cold so that he is aware of the critical issues.

Resources to access regarding the treatment decisions

Apart from discharging the patient home with a brochure containing the necessary health information, I would provide internet websites and links pertaining to the same. Healthcare has been widely digitized and people can access the health information easily and comfortably on online sites. additionally, software applications such as the mHealth app provide a secure platform on which the healthcare provider and the client can exchange information. I would use this app to relay every information regarding the treatment decisions I would make regarding Mr. Smith’s son. The app has demonstrated consistency and reliability in relaying medical information, keeping medical records, allowing the patients to access the needed medical services, booking medical appointments, and even keeping track of their diagnostic results.

References

Center for Disease Control and Prevention, CDC. (2017). Antibiotic Prescribing and Use In Doctor’s Offices. Pediatric Treatment Recommendations. Retrieved from https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html

Hockenberry, M. J., & Wilson, D. (2018). Wong’s nursing care of infants and children-E-book. Elsevier Health Sciences.

U.S Food & Drug Administration, FDA. (2018). When to give kids medicine for coughs and colds. Retrieved from https://www.fda.gov/consumers/consumer-updates/when-give-kids-medicine-coughs-and-colds

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