MW is an 18-year-old male college student who presents today with an acute onset of sore
throat, headache, body aches, nonproductive dry cough, and fatigue for four days. The patient
reports being exposed to sick contact, states roommate was previously sick. The patient has a
past medical history of asthma as a child. The patient is up to date on immunizations but denies
flu vaccine and updated COVID boosters. Physical examination revealed a temperature of 101
degrees Fahrenheit, tachycardia, erythematous pharynx, and anterior cervical lymphadenopathy.
Negative for splenomegaly and adventitious lung sounds.
Diagnostic tests:
COVID, Influenza- patient negative for Covid, Positive for Influenza
Pharmacological management:
Continue OTC ibuprofen 400mg every 6 hours at home as needed for headache, throat
pain, and body aches.
Tylenol OTC- 325 mg to 1 g orally every 4 to 6 hours as needed for fevers. Do not
combine ibuprofen and Tylenol at the same time.
Dextromethorphan / Guaifenesin cough syrup 20/400 per 20 mL: 20 mL every 4 hours,
maximum 6 doses per day (Drugs.com, n.d.-a).
o Dextromethorphan and guaifenesin is a combination medicine used to treat cough
and chest congestion caused by allergies, the common cold, or the flu
(Drugs.com, n.d.-b).
Flu antivirals would not be given because of the patient presenting to the clinic and onset.
Flu antivirals work best when taken within 48 hours of getting sick (Olson, 2023).
Consults and Referrals:
None
Education:
Educated on diagnosis and treatment
Importance of vaccinations
Hydrating- increasing fluid intake
Rest- no class, school note given
Handwashing and prevention of flu
Follow up:
Return to clinic in 36-48 hours if symptoms worsen, any new onset SOB or Chest pain
report to the Emergency department.
Follow up regarding influenza and COVID vaccinations.
References:
Drugs.com. (n.d.-a). Dextromethorphan / Guaifenesin Dosage Guide + max dose, adjustments.
Drugs.com. https://www.drugs.com/dosage/dextromethorphan-guaifenesin.html
Drugs.com. (n.d.-b). Dextromethorphan and guaifenesin uses, Side Effects & Warnings.
Drugs.com. https://www.drugs.com/mtm/dextromethorphan-and-guaifenesin.html
This study source was downloaded by 100000898058200 from nursinghero.com on 08-06-2025 20:59:17 GMT -05:00
https://www.nursinghero.com//study-files/12855894
, Olson, D. (2023, December 4). Influenza (flu) treatment. NFID.
https://www.nfid.org/resource/influenza-flu-treatment/
NOTES:
sick contact- roommate-bad cough
sore throat, hurts to swallow, no problem swallowing, states only feels better when drinking
something warm, feels like razor blades, rate pain 6-8, treatment ibuprofen and steam with no
improvement
fatigue-missing class, started couple days ago, feels like he was ran over by Shaquille O’Neal-
TX: rest
headache- onset 4 days, ibuprofen for treatment with improvement, states pain isn't bad-
annoying, does not come and go
body aches
unsure of fever, chills, temp 101 in office
denies SOB, wheezing, nasal congestion/drainage and chest pain
cough-4 days ago, nothing makes better or worse, dry, states annoying and makes throat sore,
rest for treatment no improvement
ibuprofen used, inhaler as a child
immunizations up to date
denies flu vaccine
2 covid shots, denies boosters
denies appetite changes
asthma as a child
states no medical issues currently
eyelids- no ptosis, redness, pink conjunctivae with no discharge, sclerae, anicteric, no edema,
redness to orbital area
This study source was downloaded by 100000898058200 from nursinghero.com on 08-06-2025 20:59:17 GMT -05:00
https://www.nursinghero.com//study-files/12855894
throat, headache, body aches, nonproductive dry cough, and fatigue for four days. The patient
reports being exposed to sick contact, states roommate was previously sick. The patient has a
past medical history of asthma as a child. The patient is up to date on immunizations but denies
flu vaccine and updated COVID boosters. Physical examination revealed a temperature of 101
degrees Fahrenheit, tachycardia, erythematous pharynx, and anterior cervical lymphadenopathy.
Negative for splenomegaly and adventitious lung sounds.
Diagnostic tests:
COVID, Influenza- patient negative for Covid, Positive for Influenza
Pharmacological management:
Continue OTC ibuprofen 400mg every 6 hours at home as needed for headache, throat
pain, and body aches.
Tylenol OTC- 325 mg to 1 g orally every 4 to 6 hours as needed for fevers. Do not
combine ibuprofen and Tylenol at the same time.
Dextromethorphan / Guaifenesin cough syrup 20/400 per 20 mL: 20 mL every 4 hours,
maximum 6 doses per day (Drugs.com, n.d.-a).
o Dextromethorphan and guaifenesin is a combination medicine used to treat cough
and chest congestion caused by allergies, the common cold, or the flu
(Drugs.com, n.d.-b).
Flu antivirals would not be given because of the patient presenting to the clinic and onset.
Flu antivirals work best when taken within 48 hours of getting sick (Olson, 2023).
Consults and Referrals:
None
Education:
Educated on diagnosis and treatment
Importance of vaccinations
Hydrating- increasing fluid intake
Rest- no class, school note given
Handwashing and prevention of flu
Follow up:
Return to clinic in 36-48 hours if symptoms worsen, any new onset SOB or Chest pain
report to the Emergency department.
Follow up regarding influenza and COVID vaccinations.
References:
Drugs.com. (n.d.-a). Dextromethorphan / Guaifenesin Dosage Guide + max dose, adjustments.
Drugs.com. https://www.drugs.com/dosage/dextromethorphan-guaifenesin.html
Drugs.com. (n.d.-b). Dextromethorphan and guaifenesin uses, Side Effects & Warnings.
Drugs.com. https://www.drugs.com/mtm/dextromethorphan-and-guaifenesin.html
This study source was downloaded by 100000898058200 from nursinghero.com on 08-06-2025 20:59:17 GMT -05:00
https://www.nursinghero.com//study-files/12855894
, Olson, D. (2023, December 4). Influenza (flu) treatment. NFID.
https://www.nfid.org/resource/influenza-flu-treatment/
NOTES:
sick contact- roommate-bad cough
sore throat, hurts to swallow, no problem swallowing, states only feels better when drinking
something warm, feels like razor blades, rate pain 6-8, treatment ibuprofen and steam with no
improvement
fatigue-missing class, started couple days ago, feels like he was ran over by Shaquille O’Neal-
TX: rest
headache- onset 4 days, ibuprofen for treatment with improvement, states pain isn't bad-
annoying, does not come and go
body aches
unsure of fever, chills, temp 101 in office
denies SOB, wheezing, nasal congestion/drainage and chest pain
cough-4 days ago, nothing makes better or worse, dry, states annoying and makes throat sore,
rest for treatment no improvement
ibuprofen used, inhaler as a child
immunizations up to date
denies flu vaccine
2 covid shots, denies boosters
denies appetite changes
asthma as a child
states no medical issues currently
eyelids- no ptosis, redness, pink conjunctivae with no discharge, sclerae, anicteric, no edema,
redness to orbital area
This study source was downloaded by 100000898058200 from nursinghero.com on 08-06-2025 20:59:17 GMT -05:00
https://www.nursinghero.com//study-files/12855894
