Cough

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Subjective

Danny Rivera is an 8 years old boy presenting with a wet cough. He reports that the cough has lasted three days. He describes the cough as wet and gurly.

Objective

The cough is temporarily treated by the children’s cough medicine his mother gave him. He reports that the cough is not aggravated by activity. He reports the cough gets worse at night, which keep him up at night. He reports tenderness of his throat. He reports a history of frequent rhinorrhea and cough. Risk factor includes second-hand smoke from father, history of pneumonia in the past year, and being overwiegt for his age.

Assessment

He has no acute respiratory distress, his lungs are clear to auscultation and is afebrile, He has current rhinorrhea, examination of the nose reveals boggy turbinate. His throat appears red with visible cobblestoning in the back. His respiratory rate is inscreased, and he present mild tachycardia.

Plan

I recomende calling his grandmother to pick him up from school. He should see his primary care provider within the next few days for an evaluation and tests to rule out asthma and allergies. In the meantime, he should be allowed to rest and should be given cough medicine as needed.

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Week 5: Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

Student’s Name

Institution

Course

Lecturer’s Name

Date

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Week 5: Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

Patient Information

Initials: D.R

Age: 8 years old

Gender: Male

SUBJECTIVE DATA:

Chief Complaint (CC): “I guess I’m kind of sick. . . I’ve been coughing a lot’

History of Present Illness (HPI): The patient Danny Riviera is a boy aged 8, who comes

to the clinic reporting that he has had a cough for the past 4 days. His description of the

cough states that it is watery and clear. His cough becomes worse at night, which affects

his sleep. As such, he does not focus at school and suffers from fatigue. His right ear has

pain. His mother decided to use over-the-counter cough medicine, which offered

temporal relief. Danny states that he suffers from a frequent runny nose as well as a cold

and sore throat. He is also exposed to secondhand smoke from his father. He has also

suffered pneumonia in the past year. However, he does not have a fever, breathing

difficulties, abdominal pain, and chest tightness and chills.

Medications: The patient admits to taking home medications. He also takes a daily

vitamin. He also takes a purple cough medication.

Allergies: NKDA

Past Medical History (PMH): Denies asthma diagnosis. Reports immunizations as

current. Reports past frequent coughs and pneumonia.

Past Surgical History (PSH): None reported.

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Sexual/Reproductive History: No history of reproductive disorders.

Personal/Social History: Reports living in a house with his parents and grandparents.

Reports feeling safe at home. Reports park with playground near home. Reports father

smokes at home. Denies pets at home

Immunization History: Immunizations are current.

Significant Family History: He has a father, mother, and both grandparents. Reports

father with a history of asthma as a child. Denies family history of allergies.

Review of Systems:

General: The patient looks fatigued and also coughs whilst having the interview.

He also appears stable. Denies fever, appetite loss, weight loss, chills, or night

sweats.

HEENT: The mucus membrane is moist; nasal discharge is clear, while he shows

redness and clobbestoning at the back of his throat. His eyes are dull while the

conjunctiva is pink in color. The right tympanic membrane appears red and

inflamed. The patient’s right cervical lymph nodes appear enlarged with a certain

tenderness.

Respiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds

are clear to auscultation, speaks in full sentences while the bronchoscopy is

negative. His chest wall was resonant when percussed while the fremitus was

expected and equal bilaterally.

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Cardiovascular/Peripheral Vascular: No chest pain, chest tightness,

palpitations, edema, cyanosis, dyspnea.

Psychiatric: No depression, anxiety, or history of psychotic disorders.

Neurological: Report’s headache. Denies dizziness, loss of consciousness, or

vision changes.

Lymphatics: Right cervical lymph nodes are tender on palpation.

OBJECTIVE DATA:

Physical Exam:

Vital signs:

Blood Pressure 120/76

O2 Sat 96%

Pulse 100

Resp. Rate 28

Temperature 37.2 c

General: The patient looks fatigued and also coughs whilst having the interview. He also

appears stable.

HEENT: Head is normocephalic and atraumatic. The mucus membrane is moist; nasal

discharge is clear, while he shows redness and clobbestoning at the back of his throat. His

eyes are dull while the conjunctiva is pink in color. The right tympanic membrane

appears red and inflamed. The patient’s right cervical lymph nodes appear enlarged with a

certain tenderness.

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Respiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds are

clear to auscultation, speaks in full sentences while the bronchoscopy is negative. His

chest wall was resonant when percussed while the fremitus was expected and equal

bilaterally.

Cardiology: No murmurs, gallops, or rubs in S1 and S2.

Lymphatics: Right cervical lymph nodes are tender on palpation

Psychiatric: No mental issues noted.

Diagnostics/Labs: Routine lab works were ordered including complete blood count, and

white blood cell count to determine any signs of infection. Spirometric and peak

expiratory flow measurements were collected to further evaluate the patient’s extend of

cough. Bronchoprovocation testing was done to rule out differential diagnosis. Other

investigations are done to assess the cough and cold include upper airway provocation

studies, sinus imaging, CT scan of the thorax, and bronchoscopy (Malesker et al., 2017).

For further assessment of the ear pain, nasolaryngoscopy and MRI of the head and neck

were ordered.

ASSESSMENT:

Priority Diagnosis: Acute Viral Rhinitis: It is also known as common cold. It is

associated with inflammation of the nasal mucosa lining as a result of respiratory viral

infection. It is common among children, characterized by sneezing, running nose,

congestion, cough, postnasal drip, sore throat, watery eyes, ear pain, difficulties in

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swallowing, and fatigue among others (Malesker et al., 2017). The patient in the case

study displayed most of the above symptoms, qualifying for a common cold diagnosis.

Differential Diagnosis:

1. Acute sinusitis: This normally occurs when a cold virus infects the patient’s sinuses.

The patient may display headache, fever, cough which is worse at night, severely

stuffed up nose, green, or thick yellow mucus, itchy and watery eyes, and ear pain.

The patient in the case study displayed most of these symptoms (Shoukat et al.,

2019). However, he denied fever, and the nasal discharge is clear and thin, which

disqualifies the diagnosis.

2. Influenza (flu): This is a common viral infection of the respiratory tract among

children. It is characterized by fever, headache, running nose, fatigue, cough, eye, and

ear pain. The patient in the case study displayed most of the above symptoms

(Badyda et al., 2020). Consequently, this condition is common among patients with a

history of pneumonia, just like in the provided case study.

3. Ear Infection: Sinus and cold infections can lead to the accumulation of fluids in the

patient’s ears behind the eardrum. As a result, viruses and bacteria can grow leading to

infection of the ears. Patients may display ear pressure or fullness, ear pain, drainage,

muffled hearing, and loss of balance (Badyda et al., 2020). Given that most ear

infections among children might start as a common cold, then the patient’s right ear

pain and associated upper respiratory symptoms may be as a result of ear infection.

Treatment Plan:

Previous Diagnosis: Pneumonia and cough which were managed appropriately.

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Present Diagnosis: Acute Viral Rhinitis

Pharmacological Intervention: Cold remedies such as Dimetapp 10mL every 4 hours to

a maximum of 6 doses/24 hours (Malesker et al., 2017). Acetaminophen to manage the

pain and fever. Dexamethasone/gentamicin drops for ear pain.

Non-pharmacological Intervention: Honey and saline nose spray to help with soothing

the sore throat and cough, and managing congested nose respectively (Fernandez, &

Olympia, 2017). Extra fluid and a cool-mist humidifier are also necessary for helping

manage the patients’ cold symptoms.

Patient Education: Inform the patient’s mother on the importance of sticking to the

treatment plan. It is also important to educate the patient’s parents on expected side

effects, and adverse reactions which might call for medical attention (Malesker et al.,

2017).

Health Promotion: Encourage the patient’s mother to ensure that he is always warm,

with a healthy diet, and enough sleep (Badyda et al., 2020).

Follow-up: The patient should be advised to report back to the clinic in case of worsened

symptoms, or if the prescribed drugs fail to relieve the patient’s symptoms within one

week.

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Reference

Badyda, A., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., &

Dąbrowska, A. (2020). Upper respiratory symptoms in children (3-12 years old) exposed

on different levels of ambient particulate matter. DOI: 10.1183/13993003.congress-

2020.1303

Fernandez, F. G., & Olympia, R. P. (2017). Ear pain, nasal congestion, and sore throat. URGENT

CARE MEDICINE, 77.

Badyda, A. J., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., &

D&# 261; browska, A. (2020). Influence of Particulate Matter on the Occurrence of

Upper Respiratory Tract Symptoms in Children Aged 3-12 Years. In D24. LUNG

INFECTION (pp. A6346-A6346). American Thoracic Society. DOI:10.1164/ajrccm-

conference.2020.201.1_

Malesker, M. A., Callahan-Lyon, P., Ireland, B., Irwin, R. S., Adams, T. M., Altman, K. W., … &

Weir, K. (2017). Pharmacologic and nonpharmacologic treatment for acute cough

associated with the common cold: CHEST Expert Panel Report. Chest, 152(5), 1021-

1037. https://doi.org/10.1016/j.chest.2017.08.009

Shoukat, N., Kakar, A., Shah, S. A., & Sadiq, A. (2019). 10. Upper respiratory tract infections in

children age 2 to 10 years in Quetta: A prevalence study. Pure and Applied Biology

(PAB), 8(2), 1084-1091. http://dx.doi.org/10.19045/bspab.2019.80050

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Name:

Section:

Week 5

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Significant Family History (Include history of parents, Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History).
Remember that the information you include in this section is based on what the patient tells you.
You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but
do not restate HPI data here.

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Psychiatric:

Neurological:

Lymphatics:

OBJECTIVE DATA: From head-to-toe, include
what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P.
Do not use WNL or normal. You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

HEENT:

Respiratory: Always include this in your PE.

Cardiology: Always include the heart in your PE.

Lymphatics:

Psychiatric:

Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines.
For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.

1.
Acute Sinusitis

2.
Influenza (flu)

3.
Ear infection

© 2021 Walden University

DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: COUGH

Subjective

Danny Rivera is an 8 years old boy presenting with a wet cough. He reports that the cough has lasted three days. He describes the cough as wet and gurly.

Objective

The cough is temporarily treated by the children’s cough medicine his mother gave him. He reports that the cough is not aggravated by activity. He reports the cough gets worse at night, which keep him up at night. He reports tenderness of his throat. He reports a history of frequent rhinorrhea and cough. Risk factor includes second-hand smoke from father, history of pneumonia in the past year, and being overwiegt for his age.

Assessment

He has no acute respiratory distress, his lungs are clear to auscultation and is afebrile, He has current rhinorrhea, examination of the nose reveals boggy turbinate. His throat appears red with visible cobblestoning in the back. His respiratory rate is inscreased, and he present mild tachycardia.

Plan

I recomende calling his grandmother to pick him up from school. He should see his primary care provider within the next few days for an evaluation and tests to rule out asthma and allergies. In the meantime, he should be allowed to rest and should be given cough medicine as needed.

RUBRIC FOR GRADING

Subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.= Documentation is detailed and organized with all pertinent information noted in professional language….Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Objective Documentation in Provider Notes – this is to be completed using the documentation template that is provided. Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). = Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language….Each system assessed is clearly documented with measurable details of the exam.

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