Outpatient office with a hacking, raspy cough.

Full Answer Section

• Travel history: Has the patient recently traveled, particularly to areas with endemic infectious diseases?
• Change in medications: Have there been any recent changes in medication or dosage that could be contributing to the cough?
• Risk factors for specific conditions: Ask about any history of pneumonia, COPD, asthma, bronchitis, or chronic upper airway infections.

Problem List:

• Acute productive cough with green phlegm
• Runny nose
• Sore throat
• Fatigue

Nursing Diagnoses:

• Ineffective Airway Clearance related to excessive mucus production or altered respiratory pattern as evidenced by productive cough, rhonchi, and wheeze.
• Acute Upper Respiratory Infection (URI) as evidenced by cough, runny nose, sore throat, and nasal discharge.
• Fatigue as evidenced by verbal report.

Plan of Care:

• Respiratory Management: Administer nebulized bronchodilators, encourage increased fluid intake, provide chest physiotherapy if needed, monitor vital signs and oxygen saturation.
• Symptom Management: Encourage throat lozenges for sore throat, consider analgesics if necessary, address nasal congestion with saline nasal spray or decongestant medication.
• Diagnostic Tests: Obtain sputum culture to identify the causative organism, consider chest X-ray if pneumonia is suspected.
• Education: Teach proper cough hygiene, handwashing techniques, and importance of completing antibiotic regimen if prescribed.

Risk Factors for this Age Group:

• Decreased immune function
• Underlying chronic health conditions (e.g., HTN, DM)
• Increased susceptibility to pneumonia

Most Likely Cause:

Based on the presented information, the most likely cause of M.C.'s cough appears to be an acute upper respiratory infection (URI), possibly bacterial in nature due to the green phlegm. However, further assessment and diagnostic tests are necessary to confirm the diagnosis and rule out other potential causes like pneumonia or bronchitis.

Please note: This information is for educational purposes only and should not be used as a substitute for professional medical advice or diagnosis.

Sample Solution

Option 1: M.C. with Cough

Additional Questions:

• Onset and duration of cough: How long has the cough been present? Has it become progressively worse, stayed the same, or improved?
• Character of cough: Is the cough dry or productive? If productive, is the phlegm clear, white, yellow, green, or bloody? Is the cough worse at any particular time of day (e.g., morning, night)?
• Other respiratory symptoms: Has the patient experienced any other respiratory symptoms like shortness of breath, wheezing, fever, chills, or chest pain?
• Recent exposures: Has the patient been around anyone with a similar cough or been exposed to any potential irritants like environmental dust, pollutants, or smoke?