NU-664B Week 1 Discussion 1: Telehealth/Transgender

Week 1 Discussion 1: Telehealth/Transgender

Discussion Prompt

Value: 100 points

Due: Create your initial post on Day 3, Initial Response post by Day 5, and Reflective Response by Day 7.

Gradebook Category: Simulated OV Discussions

Instructions

Prior to completing this first discussion forum, please watch the Discussion Board Directions video for more information on how to complete the forums.

Discussion Board Instructions (2:53 Minutes)

Discussion Board Instructions Video Transcript

Initial Post

Imagine that you are a primary care provider in the middle of your busy Thursday. Your 10:30 a.m. telehealth appointment is as follows:

HPI: An otherwise healthy 35-year-old transgender woman on hormone suppressant therapy presents with a chief complaint of sinus congestion and runny nose that began 2 days ago. She tells you that her sinus infections always start off this way, and she has a wedding to go to this coming weekend and does not want to be sick for this event. She is requesting antibiotics and is quite insistent that she requires this treatment.

Past Medical History: Unremarkable. History of seasonal allergies and recurrent sinus infections. She does have some history of episodes of elevated blood pressure without a diagnosis of hypertension.

Family History: Noncontributory. No one else at home is sick.

ROS (completed by the medical assistant):
Constitutional: The patient denies fevers, chills, sweats, and weight changes.
EYES: The patient denies any visual symptoms.
EARS, NOSE, AND THROAT: No difficulties with hearing. Endorses sinus congestion and rhinitis.
Cardiovascular: Patient denies chest pains, palpitations, orthopnea, and paroxysmal nocturnal dyspnea.
RESPIRATORY: No dyspnea on exertion, no wheezing or cough.
GI: No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia, or melena.
GU: No urinary hesitancy or dribbling. No nocturia or urinary frequency. No abnormal urethral discharge.
Musculoskeletal: No myalgias or arthralgias.
Neurologic: No chronic headaches, no seizures. The patient denies numbness, tingling, or weakness.

Complete the following:

Initial Post by Wednesday (Day 3) at 11:59 p.m.

  • List 10–20 additional questions of subjective information that you would need to elicit from your patient to help formulate your differential diagnoses and plan. You may not ask questions that were already addressed in the HPI/ROS. Make sure to watch the telehealth modules, which include how to complete the physical exam via telehealth. You will need two scholarly references for the questions that you ask of your patient. See the rubric for more detail.
    • Make sure to address a health maintenance item for this patient (primary or secondary) and the social determinants of the health barrier questions. (See Reply Post for additional information.)
    • If there is a screening tool for the disorder, this would count as ONE question. Example PHQ-9 has nine individual questions but would count as one for the purpose of this assignment.

TIP | Watch the following videos on Telehealth:

Introduction to Conducting Physical Exams via Telehealth with Devices (1:51 Minutes)

Introduction to Conducting Physical Exams via Telehealth with Devices Video Transcript


Telehealth Physical Exam: ENT (9:10 Minutes)

Telehealth Physical Exam: ENT Video Transcript

Initial Response Post by Friday (Day 5) 11:59 p.m. Choose a classmate’s questions to answer:

  • Every peer post should only have one response post. Please do not reply to a peer if a response is already posted.
  • You are answering as the patient. Make it case appropriate but imaginative. Be creative and answer thoroughly. No references are needed.

Reply Posts

Reflective Response Post by Sunday (Day 7). Please respond with the following:

  • Four appropriate differential diagnoses and rationales with references. For each differential diagnosis, explain why this is an appropriate differential and how it was/would be ruled in or out. Support your answers with references.
  • Pick one differential and create a plan of care for that patient.
    • Plans must include Pharmacology, Non-Pharmacology, Labs/Diagnostics, Referrals/Interprofessional Communications, Patient Education (10–15 individual items minimum) and follow up.
    • Make sure to pick one health maintenance item for this patient (primary or secondary) and explain to the patient why this is important.
    • Address one social determinant of the health this patient may face during your visit. How will you help the patient overcome this obstacle to health care?

Please refer to the Grading Rubric for details on how this activity will be graded.

Posting to the Discussion Forum

  1. Select the appropriate Thread.
  2. Select Reply.
  3. Create your post.
  4. Select Post to Forum.

Initial Post
Imagine that you are a primary care provider in the middle of your busy Thursday. Your 10:30 a.m. telehealth appointment is as follows:
HPI: An otherwise healthy 35-year-old transgender woman on hormone suppressant therapy presents with a chief complaint of sinus congestion and runny nose that began 2 days ago. She tells you that her sinus infections always start off this way, and she has a wedding to go to this coming weekend and does not want to be sick for this event. She is requesting antibiotics and is quite insistent that she requires this treatment.
Past Medical History: Unremarkable. History of seasonal allergies and recurrent sinus infections. She does have some history of episodes of elevated blood pressure without a diagnosis of hypertension.
Family History: Noncontributory. No one else at home is sick.
ROS (completed by the medical assistant):
Constitutional: The patient denies fevers, chills, sweats, and weight changes.
EYES: The patient denies any visual symptoms.
EARS, NOSE, AND THROAT: No difficulties with hearing. Endorses sinus congestion and rhinitis.
Cardiovascular: Patient denies chest pains, palpitations, orthopnea, and paroxysmal nocturnal dyspnea.
RESPIRATORY: No dyspnea on exertion, no wheezing or cough.
GI: No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia, or melena.
GU: No urinary hesitancy or dribbling. No nocturia or urinary frequency. No abnormal urethral discharge.
Musculoskeletal: No myalgias or arthralgias.
Neurologic: No chronic headaches, no seizures. The patient denies numbness, tingling, or weakness.

Questions for Patient pertinent to diagnosis: In addition, it would be important to ask the patient for consent for telehealth as well as how the patient would like to be addressed.
1. I noticed you have seasonal allergies; do you have any allergies to any food or medications that you know of? (C-TIER, 2020; Dunphy et al., 2021).
2. Are you taking any medications daily? (Dunphy et al., 2021).
3. Are you currently on hormone replacement therapy? (Dunphy et al., 2021).
4. Do you have any loss of sense of smell or taste? (Old Dominion University, Center for Telehealth Innovation, Education, and Research [C-TIER], 2020).
5. When was the last sinus infection? (Dunphy et al., 2021).
6. Have you been taking any over-the-counter medications to help with the symptoms? (C-TIER, 2020).
7. Do you have a headache? If so, where is the headache? (Dunphy et al., 2021)
8. How long has the headache occurred and is it constant or does it come and go? (Dunphy et al., 2021).
9. Can you lean over and touch your feet? How do you feel when you do that? (C-TIER, 2020).
10. Can you tap around your forehead? Does it hurt anywhere? (C-TIER, 2020).
11. Can you tap underneath your eyes? Do you feel any pain in there? (C-TIER, 2020).
12. Do your ears hurt? Or do you hear a popping noise when you swallow? (C-TIER, 2020).
13. Do you find any difference in your hearing? (Dunphy et al., 2021).
14. Do your eyes itch or do you notice any redness or drainage? (C-TIER, 2020).
15. You state you have a runny nose; what color is the discharge? Is it thick or thin? Do you know if it is salty? (Peden, 2023).
16. Do you have a sore throat or pain when swallowing? (C-TIER, 2020).
17. Bite down on your teeth like grinding. Any pain or pressure? (C-TIER, 2020).
18. Do you use any illicit drugs? (Dunphy et al., 2021).
19. Do you still have your tonsils? (C-TIER, 2020).
20. Assess via telehealth any structural defects. Do you snore? Assess for nasal polyps, deviation, or tumors (Peden, 2023).

ReferencesDunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2021). Primary care: Art and science of advanced practice nursing – An interprofessional approach. (6th ed.). Philadelphia, P.A., F.A. Davis.

Old Dominion University, Center for Telehealth Innovation, Education, and Research (C-TIER). (2020, May 7). Telehealth Physical Exam: ENT. [Video]. https://www.youtube.com/watch?v=W_d9L89C4m0&t=1s

Penden, D. (2023, July 20). An overview of rhinitis. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/an-overview-of-rhinitis?search=rhinitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H14


Differential Diagnosis

1. Covid-19: due to symptoms of headache, congestion, and loss of smell the coronavirus cannot be ruled out. The most reported symptoms are headache, malaise, and cough in which this patient exhibits (McIntosh, 2023). This patient also exhibits loss of taste and smell, as well as nasal congestion. Nasal congestion, with loss of taste and smell are also initial presentations of the Covid-19 virus (McIntosh, 2023).

2. NAR Rhinitis. Non allergic rhinitis is accompanied by congestion and clear nasal drainage (Dunphy, 2023). Though there is usually cough associate with rhinitis this can not be ruled out and should be considered if Covid tests come back negative.

3. Common cold. The patient exhibits nasal congestion and nasal drainage which correlates with a common cold/ upper respiratory infection (URI) (Sexton, 2022). However, patient does not exhibit sore throat, fever, or cough which makes the common cold a less likely diagnosis (Cohen & Gebo, 2022). Since it has been two days from onset patient could potentially develop these symptoms.

4. Acute Rhinosinusitis – Acute Rhinosinusitis correlates with nasal congestion from inflammation in the nasal sinuses and nasal cavity (Patel & Hwang, 2022). Rhinosinusitis is typical viral and can be associated with the common cold. This diagnosis cannot be ruled out however this is a self-limiting virus that does not require antibiotics unless worsening or no resolution within 7-10 days (Patel & Hwang, 2022).

Plan
Pharmacology
• Tylenol 325mg 1-2 tabs PO q 4hrs PRN pain. Max dose 4000mg/day for pain
• Ipratropium bromide 0.06% 2 spray in nares 3-4x daily for 2-3 days for congestion
• Mucinex 600 mg 1-2 tablets PO q 12hrs PRN for congestion

Non-pharmacology
• Humidified area
• Rest
• Increase fluids

Labs/Diagnostics
• Nasopharyngeal Covid swab

Referrals/Interprofessional communications
• No referrals needed at this time.

Patient education (10)
• Educate patient on diagnosis and why sinusitis most likely not the cause of the patients’ symptoms which includes the lack of facial pain/ pressure (Dumphy, 2023).
• Take medication as prescribed.
• Educate pt to only take Atrovent for 2-3 days because it could cause rebound congestion (rhinitis medicamentosa) (Dunphy, 2023).
• Hand hygiene to prevent spread of infection.
• Wear a mask, even at home to prevent the spread of infection.
• Stay hydrated.
• Rest – stay home if possible.
• If Covid test positive – recommend not going to wedding.
• Assess for signs of infection or worsening symptoms that including change in appearance of drainage from clear to purulent, fever, productive cough, dyspnea and shortness of breath.
• Educate patient if unable to afford prescriptions and provide resources to help to offset costs of medications (Dumphy, 2023).
• When symptoms resolve advise patient to received Covid and flu vaccine. Receiving the Covid and Flu vaccines decreases chances of having a severe exacerbation of the virus and can also protect other around you (Edwards & Orenstein, 2023).

Cohen, P. & Gebo, K. (2022, December 15). COVID-19: Evaluation of adults with acute illness in the outpatient setting. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/covid-19-evaluation-of-adults-with-acute-illness-in-the-outpatient-setting?search=covid%2019&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Edwards, K.M. & Orenstein, W.A. (2023, May 9). COVID-19: Vaccines. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/covid-19-vaccines?search=covid%20vaccine&source=search_result&selectedTitle=2~141&usage_type=default&display_rank=1

McIntosh, K. (2023, March 27). COVID-19: Clinical features. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/covid-19-clinical-features?search=covid%2019&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=5

Patel, Z.M. & Hwang, P.H. (2022, November 7). Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/uncomplicated-acute-sinusitis-and-rhinosinusitis-in-adults-treatment?search=sinusitis%20&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Sexton, D.J. (2022, March 24). The common cold in adults: Treatment and prevention. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/the-common-cold-in-adults-treatment-and-prevention?search=COMMON%20COLD&source=search_result&selectedTitle=1~150&usage_type=default&displa

1. I noticed you have seasonal allergies; do you have any allergies to any food or medications that you know of? (C-TIER, 2020; Dunphy et al., 2021).

Not that I’m aware of

2. Are you taking any medications daily? (Dunphy et al., 2021).
multivitamin and occasionally a benadryl

3. Are you currently on hormone replacement therapy? (Dunphy et al., 2021).

no I am not

4. Do you have any loss of sense of smell or taste? (Old Dominion University, Center for Telehealth Innovation, Education, and Research [C-TIER], 2020).

yes. cant enjoy any food

5. When was the last sinus infection? (Dunphy et al., 2021).
last month

6. Have you been taking any over-the-counter medications to help with the symptoms? (C-TIER, 2020).
just the benadryl. doesnt work as well for me anymore

7. Do you have a headache? If so, where is the headache? (Dunphy et al., 2021)
sometimes. behind my eyes

8. How long has the headache occurred and is it constant or does it come and go? (Dunphy et al., 2021).
it happens when my symptoms are the worst and it comes and goes.

9. Can you lean over and touch your feet? How do you feel when you do that? (C-TIER, 2020).
yeah. it feels fine

10. Can you tap around your forehead? Does it hurt anywhere? (C-TIER, 2020).

no pain
11. Can you tap underneath your eyes? Do you feel any pain in there? (C-TIER, 2020).
no pain
12. Do your ears hurt? Or do you hear a popping noise when you swallow? (C-TIER, 2020).
no ear pain

13. Do you find any difference in your hearing? (Dunphy et al., 2021).
sometimes sounds are a bit muffles if Im really stuffy.

14. Do your eyes itch or do you notice any redness or drainage? (C-TIER, 2020).
no itchiness or drainage but my eyes are red a lot

15. You state you have a runny nose; what color is the discharge? Is it thick or thin? Do you know if it is salty? (Peden, 2023).
sometimes yellow and white. always thick. not sure if its salty

16. Do you have a sore throat or pain when swallowing? (C-TIER, 2020).
no

17. Bite down on your teeth like grinding. Any pain or pressure? (C-TIER, 2020).
no

18. Do you use any illicit drugs? (Dunphy et al., 2021).
no

19. Do you still have your tonsils? (C-TIER, 2020).
yes

20. Assess via telehealth any structural defects. Do you snore? Assess for nasal polyps, deviation, or tumors (Peden, 2023).

sometimes I snore.