Notes on Recurring Headache and Sore Throat - Essay Example

? Soap s 2 Dr. Patient S.M. Evaluated as patient admit, hospitalist Follow up. ive: Cc: recurringheadache and sore throat. S.M. is a 60 year old German male who is claiming to have recurring headache and sore throat, and dizziness for the last approximately two weeks to the St. Stephens General Hospital. This claim was directed to the department of the inpatient and emergency. The patient has been experiencing the recurring headache for the last ten days. The patient says that the pain is severe during the morning and the night times, and majorly during the cold weather. The patient further complains of general weakness of the whole body, painful aches all over his body, and itchy eyes, together with a running nose, sore and dry throat. He further complains of coughing. The patient subsequently denies that he has any form of nausea and vomiting. The history of the male patient is that he has been experiencing severe cold and nose blockage since birth. This shows that the patient has been having this problem ever since he was young. Further evidence shows that he has been under medication for the past years. He further claims that the drugs that he is been administered has been giving him difficulties during feeding and moreover during sleep. The patient further has a history of diabetes which he inherited from his parents. This diabetes has led to the lowering of his immune system response and the slow healing of wounds. This is manifested by the presence of the non - healing wounds on his right leg. ROS: Diabetes. Head: The patient claims of severe and recurring headaches. ENT: The patient complains of severe pain and discomfort during eating and also when talking on his throat. Eyes: The patient experiences sore and itchy eyes. He further experiences blurred vision due to the presence of tears on his eyes. Cardio: The patient complains of pain in the chest while breathing and coughing. Respiratory: The patient further complains of chest congestion, and difficulty in breathing. GI: The patient does not complain of any stomach pains or discomfort, nausea, or even diarrhea. GU: The patient is not complaining of any urinary pains and discomfort. Musculoskeletal: The patient is not experiencing any form of numbness on the bilateral lower and the upper limbs. The patient complains of a recurring and severe headache and sore throat. Allergies: The patient is not experiencing any form of allergy towards dust, cold, or drugs. Medications: The patient is under the medication of diabetes that he inherited from his parents. -Acetaminophen drug -Tylenol -Ibuprofen (Advil and Motrin) -Cough syrup -Other diabetes drugs PMH: -Diabetes -Wounds that take time to heal -Severe fever -Chills Past surgical hx: The patient has never undergone any form of surgical operations. Family hx: The patient has diabetes that he inherited from his parents. Social hx: The patient is married. Have three children; one son and two daughters. He denies that he uses drugs, but he smokes and also drinks alcohol. Objectives: Vitals: HR: 71, BP: 118/71, RR: 21, T: 103.0 oral Physical exam: The patient has a blood group of O+ (positive). He has unclear speech, and uses a lot of energy to walk. Cardio: The patient has a regular rhythm and rate. Resp: The bilateral breath of the patient is not very clear because of sore throat and nose blockage. Thus, he is having difficulty in breathing. Skin: Dry, warm, the nose and the cheeks are pink in color. The patient also has flushed skin. Abd: Soft and non - distended. Lymph: There is presence of palpated lymph nodes under the armpits and other locations of the body. Stool for OC: Negative Labs (1/4/12) – pre transfusion: HGB: 7.9, HCT: 25.6, WBC: 12, PLT: 469, RBC: 2.21, MCV: 87, ALBUMIN: 2.0, PRE – ALBUMIN: 20.1, GLOBULIN: 5.0, IRON: 27 Labs (1/10/12) – post transfusion: HGB: 10.6, HCT: 30.9, WBC: 10, PLT: 430, RBC: 4.21, MCV: 84, RDW: 15.3, RETIC COUNT: 1.7, BUN: 29, CR: 1.12, GFR: 43. 2D Cardiac Echo (10/09/11) EF: 50 – 60% MVP ENT Assessment: 1- ENT 2- Severe headache 3- Sore throat 4- Dry throat 5- Coughing 6- Dizziness 7- Painful eyes 8- Chills 9- Body aches 10- Flushed face 11- Energy loss Plan: The patient was to first visit the laboratory where various test were done on him. Blood samples and swabs from the throat and the nose were taken for examination. The patient was later able to receive medications that were prescribed and recommended for him. He was given dosage of the ibuprofen and also the acetaminophen. Later on he was prescribed a dosage of the cough syrup to help him cure his cough. These drugs were prescribed to him on the basis of the diabetes drugs that he is using. This intake of the ibuprofen and the cough syrup showed a great improvement on the patient’s appetite and fever. Later on an assistant or a social worker was appointed to help the patient during his discharge and distribution of the recommended drugs. The social worker additionally gave the patient the adequate advice on how to prevent himself from being infected with the flu virus again. Moreover advice was given to him on how to take good care of his health and how to live a healthier life. ANALYSIS This case of an emergency is quite normal to occur in a society. This is because flu viral infections are common because it can easily be spread through the air in a crowded environment. This is majorly because the patient is experiencing these forms of symptoms since he was young. This is further due to the frequent visit of this patient to the hospital for medication on severe headaches and nose blockage. During the patients visit to the emergency department, he is able to receive treatment by being administered with the required dosage of ibuprofen, acetaminophen and cough syrup for the flu. The patient shows tremendous improvement after the drug administration. However, the patient claims that often after finishing the prescribed dosage, the symptoms normally recur after sometimes. Some of the dosage administered is to improve on the number of the red blood cells and the white blood cells (Jefferson, Jones, Doshi, Mar, Dooley & Foxlee, 2009). The results from the laboratory show that the patient was found to be normal. This shows that the patient has no problem with his blood level and composition. The results indicate that the patient has a low level of the iron component in his body. This shows that the patient has been taking poor diet in addition to having a low intake of the iron component in his food. The patient has thus been practicing poor nutrition. This is chiefly because of the patient has a poor appetite for food thus leading to the poor diet. This is because the patient is forced to be selective by the reduced appetite and thus can eat only those foods his body develop a liking at mealtime (Jefferson et al., 2009). Consequently the patient is experiencing a high level of body temperature, which is approximately 103 degrees. This shows that the patient has fever, which is causing his body temperature to rise to this level (Jefferson et al., 2009). The patient is further showing evidences of body pains with flushed face mostly around the nose and cheeks. The pain was relieved by administering the patient with the painkillers tablets referred to as ibuprofen. This method was effective because the effects were evidently shown in the reduction of the patient’s flushed face (Jefferson et al., 2009). Furthermore, the patient was advised to have much rest because he has less energy. The effects of good rest will have a tremendous improvement on his health. This is to ensure he gains adequate energy that will enable him to carry out his daily routine (CDC, 2010). The patient S.M. further has a low level of red blood cells, the platelets, and also the white cells in his body. This is as a result of the poor response of the patient’s immune system to attack by the flu viruses. This eventually causes the patient to be weak and highly prone to the flu viruses in his body, thus the attack of the influenza viruses becoming severe as manifested by the severe symptoms (Jefferson et al., 2009). The problem with low levels of iron in the diet could also be associated with the reduction of blood cells. The presence of swollen lymph nodes under the armpits is a clear indication of wounds present. The patient has wounds on one leg that takes long to heal. This is because the patient has diabetes, which is manifested by the slow healing wounds. The wounds were cleaned and then dressed to prevent further infection (Jefferson et al., 2009). Another main complication of this flu viral attack is on the lungs of the patient. The lungs are connected to the ENT (ears, nose, and throat) through the respiratory tract. Thus the lungs of the patient are also infected with the influenza virus. This can be extremely dangerous because the lungs can be affected leading to its severe complications. For instance, there can be damage of the lungs leading to poor functioning of the lungs eventually causing death of the patient (Jefferson et al., 2009). The flu affecting the patient is found to be an infection on the nose, the lungs, and also on the throat of the patient. The infections that are seen to spread in the patient’s immune system are because of the influenza virus ability to spread to other body part at a high rate. This virus spreads at a fast rate within an individual’s body leading to the displayed symptoms by the patient. The influenza is majorly caused by the influenza viruses that gains access into an individual’s immune system through the air. The flu disease is thus known to be an air – borne disease. This flu is also related to the common and dangerous swine flu, which is normally referred to as the H1N1 Flu virus (Jefferson et al., 2009). The patient was additionally experiencing a lot of sniffing and also sneezing. These symptoms further led to the itching and tears on the eyes of the patient (Jefferson et al., 2009). Testing of the influenza virus was done on the patient in the laboratory. The testing and examination is done by taking the patient’s swab samples from the nose and also the throat. These samples are then taken to the laboratory microscopic machines for examination purposes. The sample is thoroughly studied to detect the presence of the flu virus that is causing patient S.M. to experience the symptoms of flu. The results are then utilized as the basis for treating the patient. Therefore, running of the laboratory tests on the patients are essential procedures in the treatment of the patient infected with any form of viral, bacterial, or even fungal micro – organisms (Jefferson et al., 2009). Laboratory tests are the best means to establish the actual disease instead of relying on symptoms alone. This is because the signs may be ambiguous and thus result into wrong diagnosis and thus wrong medication, which could eventually compound the current ailment. Later on the patient was prescribed with drugs that were to help in the treatment of the influenza. For instance the patient was administered with a dosage of acetaminophen also termed as Tylenol together with tablets of the drug ibuprofen (Advil, Motrin). These two drugs help in lowering high body temperature because of the recurring and severe fever the patient is experiencing. The patient is then recommended not to use any form of aspirin tablets at all if the ibuprofen dosage gets finished. Instead, he ought to get another subscription from the health center. This is because aspirin has negative and complicating effects on the users and can easily pose danger to the patient using it (Jefferson et al., 2009). The patient was then given a dosage prescription of the cough syrup. This syrup is to assist in the cure of the patient’s sore and painful throat. The drug was taken by the patient and he showed some improvement through the decrease in the level of fever. The dosage recommended was for curing the sore throat and cough (Jefferson et al., 2009). Subsequently, the patient is warned to avoid the use of alcohol and smoking of cigarettes. This is because the drugs that he is given will not work effectively if taken with the combination of alcohol and cigarettes smoking (Jefferson et al., 2009). The patient is further encouraged to drink a lot of fluid substances. This is to aid in the quick cure of the flu and replacing of the lost liquid in the body. The patient is further encouraged to have a lot of rest when at home. This is to aid in the effective working of the drug the patient is using. Moreover, resting will help the patient avoid feeling dizzy most of the time whenever he takes the recommended dosage (Jefferson et al., 2009). The patient can therefore be discharges as long as he is to be put under medical supervision by the wife and his older children. The patient is suppose to observe strict diet and on time administration of the prescribed drugs. This is to improve his condition by curing the influenza virus on time (Jefferson et al., 2009). Severe monitoring is to be done by the wife and the children when the patient was released. This monitoring also includes feeding of the patient with a well balanced diet to improve on the patient’s response by the immune system. Moreover, note books were given to the patient that contains information on how the viral influenza is spread and how to avoid being infected with one. This was vital because it is going to assist the patient together with his family and close friends on how to prevent themselves from being infected with the virus (CDC, 2010). The instructions are also necessary for any visitors to ensure they are also safe from the virus. Eventually, the hospital assures the patient that there will be thorough follow-ups done on him after intervals of time. This was accomplished by assigning the patient with a specific nurse who is to act as his referral. The patient was further advised to report back to the hospital for further check – ups. This is in the case where the flu will persist and become resistant to the drugs prescribed. Moreover the family members were advised to make sure that the patient follows the instructions given by the hospital. This is to make sure that the patient heals faster. Thus, by following all the prescribed instructions, the flu will be cured and the future of the same monitored. References Jefferson, T., Jones, M., Doshi, P., Del Mar, C., Dooley, L., & Foxlee, R. (2009). Neuraminidase inhibitors for preventing and treating influenza in healthy adults: systematic review and meta-analysis. Retrieved from http://www.thecochranelibrary.com/userfiles/ccoch/file/CD001265.pdf CDC. (2010). Seasonal flu: what to do if you get sick. Retrieved from http://www.cdc.gov/flu/whattodo.htm Read More