Diagnosing a Child With Upper Respiratory Infection

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Table of Contents

Introduction
Treatment Plan
Communication Plan
Resources
Conclusion
References

Introduction

Early diagnostics has gained precedence in the healthcare system to drive efficiency. In turn, this minimizes health effects, lowers morbidity, and enhances the quality of life. Most importantly, early diagnosis allows patients and their families to receive timely treatment and support. The World Health Organization recommends early diagnoses to minimize disease burden and related risk factors (World Health Organization, n.d.). Based on the case scenario, I diagnose the 4-year-old child with an upper respiratory infection (URI) based on a thorough physical examination and the patient’s medical history. Mr. Smith’s son presents vital symptoms, including sneezing, coughing, mild cough, and a low-grade fever of about 100 three days ago. Physical examination findings further revealed that the child had mildly clear lungs, good movement of the tympanic membranes, and a mildly erythemic throat.

I ruled out other diagnoses by taking into consideration the patient’s examination findings, including medical history, symptoms, and immunization status. For one, the child’s throat was mildly erythemic with no exudate or tonsillar swelling. Additionally, the child’s ears had mild pink tympanic membrane and URI often affects the throat and sinuses, including sinusitis, pharyngitis, epiglottis, and common cold (Cleveland Clinic, n.d.). Moreover, the patient’s limited medical history supports URI diagnosis and vital signs were within normal limits. Smith’s son was well-hydrated, cooperative, alert, and in good spirits. Furthermore, Smith’s son attends a daycare facility that exposes him to viral infection. Unlike the symptoms of bacterial infections, the child had a low-grade fever that kept worsening, with other symptoms remaining stable. The lung sounds and absence of exudate is further indicative of an acute viral infection.

Treatment Plan

My treatment plan for Smith’s son consists of symptomatic relief, hydration, and symptom management. I will prescribe over-the-counter (OTC) acetaminophen for the discomfort and fever. An antibiotic prescription will be unnecessary since the patient’s health problem is likely a viral infection. Furthermore, antibiotics are effective against bacterial infections but could potentially heighten antimicrobial resistance in URI. Instead, I recommend OTC cough syrup to help manage the cough and a pain reliever for the sore throat. The National Health Services recommends gargling warm salty water to relieve nasal dryness and reduce soreness to make it easier to cough (National Health Services, n.d.). I will encourage the father to make sure the child drinks plenty of water and remain hydrated with non-caffeinated fluids to soothe the throat.

Pharmacologic and non-pharmacologic interventions are equally important for the patient’s treatment plan. For this reason, I will recommend enough rest, humidification, and keeping the child away from triggers. The child should get plenty of rest for the body to fully recover from the illness. Using a warm mist humidifier in the house or child’s room can help relieve cough symptoms since it increases moisture in the air, soothing nasal and oral tissues that are affected by dry air (WILAmed, n.d.). Mr. Smith should ensure the child eats a healthy and balanced meal to strengthen their immune system. In terms of triggers, I would advise Mr. Smith to keep his son away from cigarettes and any other forms of smoke since this could worsen the child’s health status (National Health Services, n.d.). In case the symptoms persist, the child should be brought back for further medical evaluation.

Communication Plan

Patients may fail to understand the emergency of their care, especially when treating children and young adults. Consequently, consulting with their caregiver helps fill the gap in provider-patient communication. According to WHO, health literacy improves the quality of provider-patient communication, which correlates with treatment effectiveness and health outcomes (World Health Organization, n.d.). For Smith to be an active decision-maker in his son’s healthcare, he should understand every aspect of the treatment plan, which is achieved through quality communication. In this case, the first step that I will take is to explain the child’s diagnosis to Mr. Smith. Patients’ knowledge and understanding of their diagnosis are central to health awareness and promotion. Nonetheless, patients should understand their health condition and the care that they will receive. Therefore, I must explain to Mr. Smith the reason for excluding antibiotics from my prescription.

Additionally, Smith needs to understand the factors that might trigger his son’s condition. I will provide clear instructions on how Smith should administer OTC medication to his son, including their side effects and how to manage them. I will also explain the benefits of non-pharmacologic interventions, including reasons for keeping the patient hydrated. Further, this will ensure a shared and increased understanding of the patient’s needs and care (World Health Organization, n.d.). Additionally, I will advise Mr. Smith to seek immediate medical care for his son if his symptoms worsen or persist. Tracking Smith’s cognition and emotions will help me articulate empathy and give him undivided and complete attention while guiding him through his son’s care.

Resources

The provider-patient interaction must be motivated and responsive to unique patient needs. However, for the patients and involved family members to realize the importance of effective treatment, health literacy is important. According to the WHO, health literacy refers to a person’s ability to “gain access to, understand, and use information in ways which promote and maintain good health” (World Health Organization, n.d.). Thus, low health literacy would imply that the communication plan was ineffective. Interventions such as the provision of relevant resources help patients navigate healthcare services for positive outcomes. I will provide the American Academy of Pediatrics website as a key resource that will give Smith access to extensive data on various childhood illnesses, including how to manage them as a parent (American Academy of Pediatrics, n.d.). Health providers have a primary responsibility of proactively enabling patients and families to freely access information that promotes their health and well-being. Another resource that I will provide is the Centers for Disease Control and Prevention website, which provides general health information on children’s health (Centers for Disease Control and Prevention, n.d.). In addition, I will give Mr. Smith a list of emergency contacts in case of any emergency. Smith should use these resources to make rational and sound health decisions for his son.

Conclusion

The patient’s symptoms and further physical examination suggested URI as the primary diagnosis. The child’s environment may exacerbate his health problem, and thus, timely and effective care is necessary. I recommended pharmacological and non-pharmacological interventions to improve the patient’s health and overall well-being. In addition to administering OTC medication, natural remedies, including hydration and gargling warm water can help with the sore throat. Humidification is equally important in the treatment plan. Nonetheless, ensuring that Smith understands the importance of adhering to his son’s treatment plan is crucial. Building an effective communication plan and providing resources to understand the child’s diagnosis will influence the health outcome.

References

American Academy of Pediatrics (n.d.). Dedicated to the health of all children. American Academy of Pediatrics. Web.

Centers for Disease Control and Prevention. (n.d.). Centers for Disease Control and Prevention. Web.

Cleveland Clinic (n.d.). Upper respiratory infection. Cleveland Clinic. Web.

National Health Services (n.d.). Respiratory tract infections (RTIs). National Health Services. Web.

WILAmed (n.d.). Respiratory humidification: Basics. WILAmed Equipment for Professionals. Web.

World Health Organization (n.d.). Health promotion and disease prevention through population-based interventions, including action to address social determinants and health inequity. World Health Organization. Web.

World Health Organization. (n.d.). Ninth global conference on health promotion, Shanghai 2016. World Health Organization. Web.

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