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.

In the above presented case, the nurse practitioner would want to gather additional subjective information from the patient to elicit important details in developing a differential diagnosis and treatment plan. According to Dunphy et al. (2019), rhinitis can have several different etiologies including atrophic, medication related, hormonal, infectious, or irritant related causes. Therefore, the nurse practitioner would want to ask

Have you tried any over the counter or prescription medications or supplements to help relieve symptoms? Use of afrin nasal spray for more than 3-4 days can lead to rebound nasal congestion (Dunphy et al.,2019)

How long have you been on hormone suppressant therapy? Have you had any recent lab tests? Fluctuations in estrogen levels may cause nonallergic rhinitis (Dunphy et al.,2019).

Have you had a fever? Could you describe the nasal discharge? What is the color and quality including thickness? Do you have facial pain? According to Frerichs and Brateanu (2020), bacterial rhinosinusitis is suspected with fever high than 102 degrees Fahrenheit, purulent nasal discharge, and facial pain lasting 3 or more days.

Do you use any recreational drugs? According to Dains et al. (2016), acute or chronic cocaine use can cause rebound nasal congestion.

Have you been diving or swimming? This can help elicit possible causes such as an allergic response to chlorine exposure, infection from contaminated water, or barotrauma from diving (Dains et al.,2016).

In biological women it would always be important to inquire about possibility of pregnancy as pregnancy can cause nasal congestion due to hormonal changes (Dains et al.,2016). Pregnancy status would also need to be known prior to prescribing any medications.

Do your symptoms change with position changes? If the symptoms worsen with bending or leaning forward this suggests maxillary sinusitis (Dains et al.,2016).

Are your symptoms cyclic and seasonal? Do you have sneezing, or itching, or burning eyes? If patient responds positively to these questions it would be suggestive of allergic rhinitis (Dains et al.,2016)

Are the symptoms on one or both sides? Bilateral symptoms would indicate allergic or infectious etiology while unilateral symptoms may be caused by nasal polyps, unilateral choanal atresia, foreign body, or septal deviation (Dains et al.,2016).

Do you have any impairment in your ability to smell? Atrophic rhinitis may cause anosmia or a foul odor (Dunphy et al.,2019).

Have you taken an at home covid-19 test? Have you been exposed to anyone with covid-19? Covid-19 can present with rhinorrhea and nasal congestion (Reiss et al., 2020).

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care. St. louis, MO: Elsevier mosby.

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th ed.). F. A. Davis Company.

Frerichs, N., & Brateanu, A. (2020). Rhinosinusitis and the role of imaging. Cleveland Clinic Journal of Medicine, 87(8), 485–492. https://doi.org/10.3949/ccjm.87a.19092

Reiss, A. B., De Leon, J., Dapkins, I. P., Shahin, G., Peltier, M. R., & Goldberg, E. R. (2020). A Telemedicine approach to covid-19 assessment and triage. Medicina (Kaunas, Lithuania), 56(9), 461. https://doi.org/10.3390/medicina56090461

Week 1 Discussion 1: Telehealth/Transgender

Done: Make forum posts: 1

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:

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.

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

Select the appropriate Thread.

Select Reply.

Create your post.

Select Post to Forum.

This is a question and answer forum. In order to see other responses to these questions, you must first post your answer