Mr. Smith brings his 4-year-old son to your primary care office. He states the boy has been ill for three days. Mr. Smith indicated that he would like antibiotics so he could send his son back to preschool the next day. Pediatric URI Case Study Pediatric URI Case Study History – The child began with sneezing, mild cough, and low-grade fever of 100 degrees three days ago. All immunizations UTD. The father reports that the child has had only two incidents of URI and no other illnesses. Social – non-smoking household. The child attends preschool four mornings a week and is insured through his father’s employment. No other siblings in the household. PE/ROS -T 99, R 20, P 100. Alert, cooperative, in good spirits, well-hydrated. Mildly erythemic throat, no exudate, tonsils +2. Both ears have mild pink tympanic membranes with good movement. Lungs clear bilaterally. All other systems are WNL. Do not consider COVID-19 for this patient’s diagnosis. For the assignment, do the following: Di

Pediatric URI Case Study

Upper respiratory tract infections (URIs) are common in the outpatient setting. Most URIs are self-limiting. Poorly managed URIs are associated with both acute and long-term complications. Complications are common in children. As such, concerted efforts to manage childhood URIs should be adopted. This requires collaboration between parents and healthcare providers. This paper discusses the diagnosis and management of a patient with a URI.

Diagnosis

The child is likely to have an acute viral upper respiratory tract infection. URI presents with rhinitis, fever, sore throat, nasal congestion, coughing, headache, and sneezing (Wei et al., 2019). Furthermore, manifestations such as rhinorrhea, watery red eyes, and mucoid discharge are present in the common cold (Wei et al., 2019). A bacterial URI is ruled out by various observations. Firstly, the patient presents with a low-grade fever that has not worsened over the past three days. Bacterial URIs present with a fever of about 102oF and above (Wei et al., 2019). This fever is usually of severe onset. Secondly, the patient’s sneezing and mild cough have not demonstrated a worsening course that is a characteristic of bacterial URI. Thirdly, further evaluation revealed the absence of exudate and indicated that the tonsils are normal. This rules out bacterial URIs that present with exudates and swelling of the tonsils and the pharynx (Wei et al., 2019).

More specifically the patient is likely to have rhinitis. Viruses that have been implicated include parainfluenza, rhinoviruses, adenoviruses, respiratory syncytial viruses, influenza viruses, and coxsackie viruses (Dykewicz et al., 2020). This infection is highly contagious and may not be accompanied by sinusitis. Differential diagnoses for the patient include acute pharyngitis, laryngotracheobronchitis, rhino sinusitis, and otitis media. Acute pharyngitis presents with throat pain of sudden onset, edema, fever, headache, and soft palate petechiae (Mustafa & Ghaffari, 2020). The absence of these findings formed the basis for ruling out this diagnosis. Laryngotracheobronchitis presents with hoarseness of voice, odynophagia or dysphagia, fever, barking cough, and stridor (Ernest & Khandha, 2022). This diagnosis is ruled out because the patient lacks these hallmark features. Rhino-sinusitis is usually accompanied by inflammation of the sinuses. Furthermore, it presents with facial pressure, halitosis, sore throat, and earache (Çatl et al., 2020). The diagnosis is ruled out because the patient lacks these manifestations. Suzuki et al. (2020) report that otitis media presents with congestion of the ears, ear aches, and severe fever. As such, this diagnosis is ruled out.

Treatment Plan

The management should accomplish three goals. To begin with, it should provide adequate symptom control. Secondly, it should prevent the development of complications. Complications are likely to occur in the presence of bacterial colonization. Thirdly, it should avert the transmission of the infection. The patient can benefit from antitussives and decongestants. Notably, antitussives work by blocking the cough reflex mechanism. Examples of these agents include dextromethorphan and benzonatate (Dykewicz et al., 2020). Analgesics medications such as acetaminophen are relevant to this patient. Notably, these medications should be administered to relieve mild fever. The patient should be monitored continuously to modify the analgesics as needed. Antihistamines will help to control sneezing. In this context, first-generation antihistamines such as chlorpheniramine should be used (Dykewicz et al., 2020). Nasal dryness and congestion are likely to occur when antihistamines are administered. As such, they should be accompanied by decongestants such as oxymetazoline spray to prevent the exacerbation of nasal congestion (Dykewicz et al., 2020). However, it should be noted that decongestants have shown minimal efficacy in managing pediatric symptoms (Çatl et al., 2020). Intranasal saline should be given to promote thinning of secretions (Çatl et al., 2020). Antibiotics should not be administered because the patient’s illness is not of bacterial origin.

Various non-pharmacological approaches can be embraced. Increased fluid intake will promote hydration, prevent the formation of tenacious secretions, and soothe an inflammatory throat (Çatl et al., 2020). Also, enough rest builds body strength and promotes symptom control. If the inflammation progresses, the patient will use saline gargles to manage sore throats. Dykewicz et al. (2020) report that petrolatum ointments will be used to manage nasal dryness that may be caused by antihistamines and the disease process.

Communication Plan

Communication will occur via fac