Communication Plan

/ Samples / By

Mr. Smith brings his 4-year-old son to your primary care office. He states the boy has been ill for three days. Mr. Smith indicates that he would like antibiotics so he can send his son back to pre-school the next day.

History – Child began with sneezing, mild cough, and low grade fever of 100 degrees three days ago. All immunizations UTD. Father reports that the child has had only two incidents of URI and no other illnesses.

Social – non-smoking household. Child attends preschool four mornings a week and is insured through his father’s employment. No other siblings in the household.

PE/ROS -T 99, R 20, P 100. Alert, cooperative, in good spirits, well-hydrated. Mildly erythemic throat, no exudate, tonsils +2. Both ears mild pink tympanic membrane with good movement. Lungs clear bilaterally. All other systems WNL.

Do not consider COVID-19 for this patient diagnosis.

For the assignment, do the following:

  1. Diagnose the child and describe how you arrived at the diagnosis (i.e. how you ruled out other diagnoses).
  2. Provide a specific treatment plan for this patient, pharmacologic and/or nonpharmacologic.
  3. Provide a communication plan for how the family will be involved in the treatment plan.
  4. Provide resources that Mr. Smith could access which would provide information concerning your treatment decisions.
  5. Utilize national standards, your pharm and/or patho book and medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts to support your diagnosis and treatment.
  6. Use references to support your concepts. Utilize correct APA formatting and mechanics of professional communication.

Present this Assignment as a narrative document, with a minimum of 4, and maximum of 5 pages not counting the cover page or reference page. It is not necessary to repeat the facts of the case in your narrative.

communication plan

Based on the provided patient history and physical examination, the most likely diagnosis for the 4-year-old child is acute viral pharyngitis, commonly known as a sore throat. Here is the rationale for this diagnosis and a recommended treatment plan, communication plan, and resources for Mr. Smith:

1. Diagnosis:
The child’s clinical presentation is suggestive of acute viral pharyngitis for the following reasons:

  • Clinical Symptoms: The child started with sneezing, a mild cough, and a low-grade fever of 100°F, which are typical symptoms of a viral upper respiratory infection (URI).
  • Physical Examination: The physical examination findings, such as a mildly erythemic throat with no exudate and +2 tonsils, are consistent with viral pharyngitis. Additionally, both ears have mild pink tympanic membranes with good movement, suggesting no ear infection.
  • History: The child’s immunizations are up to date, and there are no indications of other underlying illnesses.

To rule out other diagnoses:

  • Strep Throat (Streptococcal Pharyngitis): Strep throat could be a concern due to the sore throat and fever. However, the absence of significant tonsillar exudate, severe erythema, or enlarged lymph nodes makes it less likely.
  • Otitis Media (Ear Infection): The child’s normal ear examination makes acute otitis media unlikely.
  • COVID-19: COVID-19 was ruled out as per the instructions.

2. Treatment Plan: Since the most likely diagnosis is viral pharyngitis, the treatment plan should focus on supportive care and symptom management:

  • Nonpharmacologic Treatment:
    • Rest: Encourage the child to rest to promote healing and prevent the spread of the virus.
    • Hydration: Ensure adequate fluid intake to prevent dehydration.
    • Humidification: Use a humidifier in the child’s room to alleviate discomfort from throat dryness.
  • Pharmacologic Treatment:
    • Over-the-counter pain relievers such as acetaminophen or ibuprofen can be given for pain and fever, following appropriate dosing guidelines for the child’s age and weight.
    • Over-the-counter cough drops or lozenges may be considered for throat relief. Ensure they are safe for the child’s age.
    • Antibiotics are not indicated, as the illness is likely viral.

3. Communication Plan: It’s essential to involve Mr. Smith in the treatment plan and educate him about viral pharyngitis:

  • Explanation: Explain the diagnosis and that it is a viral infection, so antibiotics are not necessary.
  • Symptom Management: Provide guidance on how to manage the child’s symptoms at home, including fever reduction, hydration, and rest.
  • Monitoring: Discuss when to seek medical attention if symptoms worsen or do not improve after a certain period.
  • Prevention: Emphasize good hand hygiene to prevent the spread of the virus and remind Mr. Smith of the importance of keeping the child home from preschool until he is no longer contagious.

4. Resources for Mr. Smith:

  • American Academy of Pediatrics (AAP): Mr. Smith can access the AAP website for reliable information on childhood illnesses and guidelines for symptom management.
  • CDC (Centers for Disease Control and Prevention): The CDC provides information on viral pharyngitis and other respiratory infections, including tips on prevention and home care.
  • Prescription Drug Labels: If over-the-counter medications are recommended, Mr. Smith should carefully read and follow the instructions on the labels.

5. References:

  • American Academy of Pediatrics. (2012). Clinical practice guideline: The diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics, 130(3), e262-e282.
  • Centers for Disease Control and Prevention (CDC). Sore throat. Retrieved from https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html

Please note that this treatment plan is based on the provided information, and if the child’s condition worsens or does not improve, Mr. Smith should seek further guidance from a healthcare professional. Additionally, it’s important to comply with any updated guidelines or recommendations in the field of pediatrics.

Scroll to Top