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

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

SAMPLE 2

35-year-old transgender women on hormone suppressant therapy presents with complaints of sinus congestion and runny nose that starts 2 days ago. Patient shares she has postnasal drip, and the color of the sputum is clear. She had a sinus infection about 2 months ago and was treated with a z-pack. Patient has a history of allergies. Patient is otherwise healthy. Here four differential diagnosis:

Differential Diagnosis
1. Allergic rhinitis: Patient is experiencing many symptoms that is consistent with the diagnosis of allergic rhinitis. Some of the symptoms includes sinus congestion, nasal obstruction, postnasal drip, clear discharge, and itchiness of the inner ear (deShazo et al., 2022). Allergic rhinitis occurs in the setting of an exposure to an allergen (deShazo et al., 2021). After exposure to the allergen, the body starts to produce allergen-specific immunoglobulin E (IgE), which bind to the cells in the respiratory mucosa and blood (deShazo et al., 2021). Every time the person becomes exposed to the allergen, the body will activate the IgE antibodies and release chemical mediators that cause the symptoms of allergic rhinitis to initiate (deShazo et al., 2021). Patient shares that she starts to develop symptoms after exposure to smoke, dust, hot and spicy food, seasonal changes, and weather changes. Allergic rhinitis develops symptoms in both the nose and sinuses (deShazo et al., 2022). It is common to see that untreated rhinitis will lead to the development of sinusitis (deShazo et al., 2022). Allergic rhinitis is a possible diagnosis given the patient symptoms, history of allergens, and frequency in recurrence of illness. To confirm diagnosis, patient will need to undergo a detailed health history and physical examination (deShazo et al., 2022). During physical examination, provider will look for exam the eyes, ears, nose, and throat to look for any signs of inflammation or swelling (deShazo et al., 2022). Allergy skin testing can help confirm the allergens (deShazo et al., 2022).

2. Hormonal Related Rhinitis: Hormonal related rhinitis occurs when there is a change in the hormonal level in the body that leads to activation of the inflammatory process (Lieberman et al., 2022). When there is a change to the hormone levels in the body, it can lead to increased production of clear and thin nasal secretion, develop nasal congestion and postnasal drip (Lieberman et al., 2022). Patient is undergoing female hormonal therapy. Patient states that recently the dose of the hormones was increased. Hormonal related rhinitis if more common in females during pregnancy and menopause. However, since patient is a transgender female receiving female hormones, the development of nonallergic rhinitis can be a possibility as a consequence of the hormone treatment. There are no indicated tests to confirm hormonal related rhinitis, diagnosis is made by health history and physical examination. Based on patients health history of being highly allergic to many pollutants, it is less likely symptoms developed as a result of the hormone therapy.

3. Common cold: Common cold is a highly contagious acute viral illness that primarily affects the upper respiratory system (Sexton et al., 2022). Some of the symptoms that are consistent with the diagnosis is nasal congestion, nasal discharge, sneezing, sore throat, cough, fever, headache, and body aches (Sexton et al., 2022). The patient is experiencing nasal congestion, clear nasal discharge, and postnasal drip. Patient does not report other symptoms commonly seen with the common cold. There are no tests available to confirm the diagnosis. The common cold symptoms will usually last between 3-10 days (Sexton et al., 2021). The virus is short lived and will resolve on its own without medications. Medications are usually taken for symptom management such as nasal congestion, cough, fever, and headache.

4. Acute viral rhinosinusitis: Acute viral rhinosinusitis is an infection that occurs in the nasal cavity and sinuses as a result to exposure to the contagious virus (Patel et al., 2022). The most common viruses are the rhinovirus, influenza virus, and parainfluenza virus (Patel et al., 2022). Symptoms start to develop as soon as 1 day after exposure to virus (Patel et al., 2022). Some common symptoms with acute viral rhinosinusitis include fevers lasting for 1 to 2 days, purulent nasal discharge, cough, body aches, and headaches (Patel et al., 2022). Patient is complaining of nasal congestion, clear nasal discharge, and postnasal drip. Patient does not have any fevers, which makes the diagnosis less likely to occur. Diagnosis can be made by doing nasal swabs such as influenza PCR, and sending to laboratory to confirm presence of virus. There is no treatment indicated for acute viral rhinosinusitis, symptoms should resolve after 10 days (Patel et al., 2022).

Confirmed diagnosis: Allergic Rhinitis

Plan
Diagnostics: No diagnostics exam is indicated to diagnose allergic rhinitis (deShazo et al., 2022).

Laboratory: No laboratory exam is indicated to confirm the diagnoses of allergic rhinitis (deShazo et al., 2022).

Pharmacological intervention:
• Claritin 10 mg by mouth daily for allergic rhinitis (deShazo et al., 2022).
• Flonase Allergy Relief 50 mcg/spray one spray in each nostril two times per day for nasal congestion (deShazo et al., 2022).
• Ocean Nasal Spray 0.65% 2 to 3 spays in each nostril as needed for nasal congestion (deShazo et al., 2022).

Non-pharmacological interventions.
• Use saline nasal spray to irrigate and wash out allergens and diminish nasal congestion (deShazo et al., 2022).
• Maintain the house clean and well ventilated to avoid dust or molds.
• When going outside during high pollen season, always take a shower and wash clothes to get rid of pollutants.
• Increase fluid intake. Warm caffeine-free fluids can help loosen nasal congestion.
• Humidify the air to help loosen secretions.
• Take warm showers to help loosen nasal stuffiness.

Referrals: See an allergist to perform skin testing to confirm allergens (deShazo et al., 2022).

Education:
• Avoid exposure to allergens such as smoke, dust, and outdoor pollutants (deShazo et al., 2022).
• Claritin is an antihistamine which will help reduce itching, sneezing, and runny nose (deShazo et al., 2022).
• Flonase Allergy Relief spay is a glucocorticoid spray and will assist with nasal congestion and postnasal drip (deShazo et al., 2022). It is important not to exceed the indicated amount to optimize the effects of the medication (deShazo et al., 2022). Once congestion improves, you can transition to use the nasal spray once per day, or as needed for recurring nasal congestion (deShazo et al., 2022).
• If nasal congestion persists after Flonase Allergy Spray, alternate with nasal saline sprays.
• The correct method to administer a nasal spray is by inserting the tip of the spray halfway inside the nares, tilting head slightly downward, pressing the spray, and gently inhale the medication (deShazo et al., 2022). Do not advance the tip of the spray too far to prevent touching the septum (deShazo et al., 2022).

Follow-Up: In 2 weeks if symptoms of sinus congestion, runny nose, and postnasal drip has not improved, return to health center for a follow-up appointment with provider.

References deShazo, R., D., Kemp, S., Corren, J., Feldweg, A. M. (2021). Pathogenesis of allergic rhinitis (rhinosinusitis). UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/pathogenesis-of-allergic-rhinitis-rhinosinusitis?search=allergic%20rhinitis&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3

deShazo, R. D., Kemp, S. F., Corren, J., & Feldweg, A. M. (2022). Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/allergic-rhinitis-clinical-manifestations-epidemiology-and-diagnosis?search=allergic%20rhinitis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H7950204

deShazo, R. D., Kemp, S. F., Corren, J., & Feldweg, A. M. (2022). Pharmacotherapy of allergic rhinitis. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/pharmacotherapy-of-allergic-rhinitis?search=allergic%20rhinitis&topicRef=7525&source=see_link

Lieberman, P. L., Corren, J., Feldweg, A. M. (2022). Chronic nonallergic rhinitis. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/chronic-nonallergic-rhinitis?search=nonallergic%20rhinitis%20treatment&topicRef=7533&source=see_link

Sexton, D. J., McClain, M. T., Aronson, M. D., Hirsch, M. S., & Givens, J. (2021). The common cold in adults: Diagnosis and clinical features. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/the-common-cold-in-adults-diagnosis-and-clinical-features?sectionName=Incubation%20period%20and%20symptom%20duration&search=common%20cold&topicRef=6868&anchor=H11414490&source=see_link#H11414490

Sexton, D. J., McClain, M. T., Aronson, M. D., Hirsch, M. S., & Givens, J. (2022). 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&display_rank=1

Patel, Z. M., Hwang, P. H., Deschler, D. G., File, T. M., Givens, J., & Bond, S. (2022). Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/acute-sinusitis-and-rhinosinusitis-in-adults-clinical-manifestations-and-diagnosis?search=acute%20bacterial%20rhinosinusitis&source=search_result&selectedTitle=6~63&usage_type=default&display_rank=5

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:

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.

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.

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