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Review of Colds

Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patient’s symptoms, including:
a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) Patient’s mother says that patient has been complaining of a runny nose, mild congestion, headache, and itchy eyes for 1 week.
b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient’s symptom(s) Symptoms appeared about the same time the family moved into a new home.
c. description of the patient’s efforts to relieve the symptoms Patient’s parents have not tried anything.
2. Gather essential patient history information:
a. patient’s identity Christy Bates
b. patient’s age, sex, height, and weight 4-year-old female, 3 ft 5 in, 40 lb
c. patient’s occupation N/A
d. patient’s dietary habits Normal healthy diet with occasional junk food
e. patient’s sleep habits Patient sleeps 5-6 hours at night; takes 1-hour nap during the day. Sleep is disturbed by symptoms.
f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements Flintstone’s vitamins 1 tablet every morning
g. allergies NKA
h. history of other adverse reactions to medications None
i. other (describe) Patient has mild wheezing when breathing.
Assessment and Triage
3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). Allergic rhinitis symptoms (runny nose, mild congestion, itchy eyes) seem to be associated with the move to a new location. Headache may be due to congestion. Wheezing may indicate new onset of asthma.
4. Identify exclusions for self-treatment Patient is younger than 12 years and has symptoms of undiagnosed asthma (wheezing).
5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the parent. Options include:

(1)   Recommend a separate OTC product for each symptom: nonsedating or sedating antihistamine for runny nose and itchy eyes; topical or systemic decongestant for congestion; analgesic for headache.

(2)   Refer Christy to PCP for evaluation and treatment.

(3)   Recommend self-care until Christy’s parents can consult PCP.

(4)  Take no action.

Plan
6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Refer Christy to PCP for differential diagnosis.
7. Describe the recommended therapeutic approach to the parent. N/A
8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Christy needs to see her PCP, because she has symptoms of asthma and is not eligible for self-care.
Patient Education
9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the parent. Criterion does not apply in this case.
10. Solicit follow-up questions from parent. Is there anything we can do to help prevent these symptoms?
11. Answer parent’s questions. Yes. Inspect the house for indoor allergens (mold and cockroaches) and take steps to remove them if needed. Find out if the previous owners had pets, because pet dander may be present in the home even after the pet is removed.

Wash Christy’s bed linens in hot water every week. Encase her pillows and mattress in mite-impermeable materials. Change air filters, dust, and vacuum frequently. Consider removing carpets, upholstered furniture, books, and stuffed toys from Christy’s bedroom.

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