S: A 19-year-old woman presents today with slight fever, cough, and fatigue for

Question

S: A 19-year-old woman presents today with slight fever, cough, and fatigue for 4 days. OTC medications were tried with little relief. No other family members are symptomatic. No nausea or vomiting, no shortness of breath. O: Vital Signs: Temp—98.7, BP—100/72; Skin: warm and dry; HEENT: TM's normal; throat is slightly red; Neck: normal; Lungs: clear; Heart: RRR. A: Viral Infection P: I explained to the patient that I think this is a viral infection and could have come on in a variety of different ways. I suggested Advil for comfort and plenty of fluids. The patient requested an antibiotic. I explained that since this infection was viral in nature, an antibiotic would not be effective. She said she would try the Advil and notify us if she does not improve in 7-10 days.

Explanation / Answer

The patient can be advised to take care at home since her Temperature is normal and for BP_100/72 she may be asked to plenty of liquids like juices without ice as she as slight redness in throat which indicates mild sore throat .self care is okay for cough ,she can seek medical care if cough worsens like,persistent cough with chest pain ,wheezing,s shortness of breath or with phlegm .The patient may present with viral infection but then as viral infection shouldn't be neglected should be explained about the symptoms during the advise like blurred vision,dizziness,nausea or vomiting ,neck or back stiffness ,severe head with fever for more than 101 F,i f any of these symptoms occurs once after going back to home she should seek attention and has to take medical care .As of now there is no need of antibiotics or antipyretics for the patient.she can be prescribed with Advil to maintain comfort .You should also instruct her once if she is asymptomatic she can have a review after 7-10 days but if her symptoms worsens she should seek immediate medical care

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