Plan of Care
Patient: Kyle H
Lindsay O’Hara
Patient History
My plan of care is for a 32-year-old male, Kyle, who has a height of 6’, weight of 195
lbs., with stable vitals. I took a thorough health history of the patient, and found that he was
currently experiencing allergy rhinitis, but experiencing no other medical problems. After
delving into Kyle’s family history, I found he is at risk for two major health illnesses. Kyle’s
brother is a Type I diabetic and his mother is a Type II diabetic. With two immediate family
members with Diabetes, this puts Kyle at an increased risk for developing Diabetes. In addition
to Diabetes, Kyle is at increased risk for Major Depressive Disorder and Bipolar Disorder.
Kyle’s mother has suffered from mental illness for greater than 15 years. While what causes
mental illness is still unknown, there is a genetic predisposition for developing a mental disorder
if a family member has it. After analysis of Kyle’s health history and physical examination, I
decided to use his current health problem of allergy rhinitis for my plan of care, and also include
two major risk for illnesses in Diabetes and Major Depressive Disorder.
Allergy Rhinitis
The only medical problem Kyle was currently experiencing at the time of examination
was signs and symptoms of allergy rhinitis. Kyle stated he was experiencing allergies. Since it is
spring and the trees are in bloom, he stated he had been experiencing an increase in typical
allergy symptoms. An increase in nasal drainage, throat irritation, non-productive cough, and
teary eyes. He also stated he occasionally has a headache. After examination, I suggested a
course of action that would keep the symptoms of allergy rhinitis at a tolerable level for the
patient. Implementation of the plan included over the counter antihistamine. Antihistamines are
Kyle’s Plan of Care 3
one the first lines of defense against allergy rhinitis. “Antihistamines are best administered
before exposure, i.e. two weeks before the start of the hay fever season. For protection to be
maintained, antihistamines should be taken every day, without breaks on days when low pollen
counts are forecast” (Ryan, 2016, p.56). In addition to antihistamines, nasal irrigation and topical
nasal steroid such as fluticasone are suggested. Nasal irrigation will flush out any allergens in the
nasal passages and the topical steroid will decrease the inflammation caused by sneezing and
blowing the nose. Another was to manage symptoms is to avoid going outdoors during high
pollen days, which may not always be possible. Wearing sunglasses and spending as little time
as possible during these days can help manage symptoms. Two weeks after implementation,
Kyle reported his symptoms are at a manageable level. Kyle started a medication regimen of
fexofenadine and fluticasone. While symptoms have not completely subsided, they have
drastically decreased. He also reports using the local weather channel to monitor the pollen
levels.
Kyle’s current medical problem is nothing compared to the two major diseases he is at
risk for. With two immediate family members with diabetes, Kyle is at an increased risk for
developing this life altering disease. The goal to prevent the development of diabetes includes an
evidence based practice plan of dietary education and physical fitness routine. Kyle’s individual
dietary needs include an increased intake of protein, to meet his physical fitness needs and
limiting amounts of sugar. Kyle already has a workout routine that included weight lifting three
times a week. By adding in a cardiovascular routine, Kyle can drastically reduce his risk for
developing diabetes. “Findings demonstrated the effectiveness of combined diet and physical
activity programs in reducing the risk of type 2 diabetes, increasing the likelihood of reverting to
Kyle’s Plan of Care 4
normoglycemia, and reducing weight among people at increased risk of type 2 diabetes. These
programs also were effective at reducing participants' blood glucose and blood pressure, and
improving their lipid levels” (Office of Disease Prevention and Health Promotion, 2015).
Referrals can be made to local diabetes educators for prevention education and to a personal
trainer that will be able to personalize a diet and work out program to meet all of his needs.
The other major medical problem is at risk for is Major Depression Disorder and Bipolar
disorder. Kyle is at an increased risk because his mother suffers from both illnesses. Currently,
Kyle shows no signs or symptoms of either disorder, but it is important to educate on symptoms
and have routine screening by a primary care physician. “Primary care providers are usually
responsible for routine screening for and diagnosing of depressive disorders; initiating treatment
for depression; and referring patients to mental health specialists as needed” (Office of Disease
Prevention and Health Promotion, 2016). By using this evidence based practice, Kyle can be
routinely monitored and potentially lead to early diagnosis and treatment if need be. Stress can
be a major factor in the development of MDD. Coping techniques can help combat stress and
reduce the risk for development of the disorder. It’s important to make sure Kyle is established
with a PCP, in order to have routine screenings, and that the PCP is able to make a referral to a
Evaluation
routine blood work will aid in ensuring that he is following the plan of care. Keeping the routine
bi-yearly primary care appointments will help Kyle continue to monitor his risk for diabetes and
mental illness. If I were to alter this plan of care, I would suggest routine A1C bloodwork every
Conclusion
All in all, Kyle is a very healthy 32-year-old male in good physical shape. His current
health status is good. If he follows the plan of care for prevention of diabetes and mental illness,
References
The Community Guide [Internet]. Mental Health and Mental Illness: Collaborative Care for the
Management of Depressive Disorders. c2010– [cited 2016 Dec 30]. Available from:
https://www.thecommunityguide.org/findings/mental-health-and-mental-illness-
collaborative-care-management-depressive-disorders
The Community Guide [Internet]. Diabetes: Combined Diet and Physical Activity Promotion
Programs to Prevent Type 2 Diabetes Among People at Increased Risk. c2014– [cited
combined-diet-and-physical-activity-promotion-programs-prevent-type-2-diabetes
Ryan, D. (2016). How to identify and manage seasonal allergic rhinitis. Journal Of Community