[Solved]: Location: Outpatient clinic Time: 1300 Report from…

Location: Outpatient clinic Time: 1300 Report from provider: Situation: The patient, Danielle Young Bear, came to the clinic today with complaints of a persistent cough and fatigue that have lasted for 2 weeks. It started as a common cold, but she was concerned that it was something more serious since the cough and fatigue have not resolved yet. The signs and symptoms are consistent with the aftermath of a common cold. However, she is taking several different prescription drugs, and is also self-medicating with OTC medication and using herbal therapies. Background: Ms. Young Bear is a 32-year-old female. She is not one of our regular patients, but her usual provider is on vacation, so she was referred to our clinic. She has a history of low back pain acquired at her job as a construction worker, and she is also being medicated for depression. The low back injury occurred approximately 1 year ago. At the time of injury, Ms. Young Bear was seen in the Emergency Department and a lumbar spine x-ray was performed. The report noted possible mild degenerative disc changes in the lumbar spine, negative for fractures. A follow-up CT scan and orthopedic consultation was recommended. Ms. Young Bear was given a referral to outpatient physical therapy and a plan for pain treatment with prescription medication was set up. Assessment: Ms. Young Bear is alert and oriented. I have performed an initial assessment and found her lung sounds to be clear and equal. She has mild posterior pharyngeal redness, but her throat is otherwise benign. She has full range of motion in the lumbar spine and demonstrates no edema, redness, or ecchymosis in the area of her lower back pain. Medication reconciliation still remains to be done. Recommendation: I would like you to take vital signs and do a focused pain assessment. Please also make sure to go through her medications, including prescription medication, OTC medications, and herbal therapies, and perform medication reconciliation. Please notify me with your findings when you are done. When preparing for Danielle’s discharge, the nurse develops a teaching plan to include which of the following? (Select all that apply.) Selection of over-the-counter (OTC) medication Side effects of opioid medication Encouraging the patient to continue use of the herbal supplements Encouraging regular medical follow-up to evaluate the effects of acetaminophen Encouraging nonpharmacological measures for pain Safety precaution when taking medications that affect the CNS