Feb 23, 2024 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
Assignment 2: Digital Clinical Experience: Focused Exam: Cough
Assignment 2 Digital Clinical Experience Focused Exam Cough
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA:
Danny Rivera is an 8 year old Hispanic American male who came to the hospital due feeling sick, coughing a lot and feeling tired as his chief complaint. He lives in a house together with his parents and grandparents. The patient has been brought in by his Abuela.
Chief Complaint (CC):
Feeling sick, coughing a lot and feeling tired.
History of Present Illness (HPI):
The patient’s symptoms started 5 days ago and has stated the cough is worse at night. The cough has been described to be gurgly and watery and he is coughing every few minutes. He has no chest pain or breathing problems. He has also reported pain in his right ear at a scale of 3/10, throat pain at a rate if 2/10 that is felt even as he swallows. He hasn’t experienced a fever and has not been around anyone who is ill. He has been given cough medicine by his mother as a form of relief.
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Medications:
He takes multivitamins daily and the cough medicine that he doesn’t know its name given by his mother, a spoonful that is purple in color.
Allergies:
He has no known food or drug or environmental or seasonal allergies.
Past Medical History (PMH):
The patient hasn’t been to the hospital prior to this.
Past Surgical History (PSH):
The patient hasn’t gone under any surgical procedures prior to this.
Sexual/Reproductive History:
The patient is not yet sexually active.
Personal/Social History:
The patient performs well in the third grade. Though doesn’t engage in sports enjoys physical activity with friends. He lives in a house with his parents and grandparents who care for him. He enjoys video games in the house and hasn’t travelled recently. He has been exposed to second hand smoking by his father and all his immunizations as a child were given.
Immunization History:
All his immunizations as a child were given.
Family History
Mother is alive though suffers from-Diabetes, hypercholesterolemia, hypertension, spinal stenosis, obesity.
Father is also alive still is a smoker and suffers from hypertension, hypercholesterolemia, and asthma as a child.
Maternal Grandmother is alive and has type two diabetes, Hypertension.
Maternal grandfather is alive though has issues with being a smoker, eczema. Paternal grandmother: Deceased – car accident age 52.
Paternal grandfather the history is yet to be obtained.
Review of Systems:
General: admits to increased fatigue, no changes in appetite or activities. Denies fevers or chills, or night sweats. Skin: denies any rashes or skin changes. Head, Ears, Eyes, Nose, Throat
(HEENT): Denies headaches. Denies vision changes, diplopia or blurred vision. Right ear pain 3/10.
Assignment 2 Digital Clinical Experience Focused Exam Cough
Denies hearing changes, tinnitus or vertigo. Increased rhinorrhea, clear drainage. Throat pain 2/10. Respiratory: no history of asthma. Denies shortness of breath or wheezing. Admits to constant cough beginning 5 days ago, worse at night. Cardiovascular: Denies chest pain, tightness, or palpitations. Gastrointestinal: Denies nausea vomiting diarrhea or constipation. Denies abdominal pain. Reports normal appetite.
Neurologic: Denies headache, trauma, dizziness, or changes in mentation.
Respiratory: There is presence of a cough.
OBJECTIVE DATA:
The patient is oriented and alert. Coughs from time to time though able to converse properly and is sitted without signs of discomfort.
The spirometer readings are FEV1/FVC: 87%
For assessment the HEENT: eyes no abnormalities noted, ears no discharge, the tympanic membrane is pearly grey and translucent. The mucus membranes are moist and there’s no drainage in the mouth, no tenderness noted in the sinuses. Cervical lymph nodes are noted on the right side.
No difficulty in breathing and all lung fields are clear. S1 and S2 noted, no murmurs or other sounds.
Vitals
Blood Pressure: 120mmHg/76mmHg
O2 Sat: 96%
Pulse: 100bpm
Resp. Rate-:28
Temperature: 37.2 degrees Celsius
Physical Exam:
The patient is oriented and alert. Coughs from time to time though able to converse properly and is sitted without signs of discomfort.
The spirometer readings are FEV1/FVC: 87%
HEENT: eyes no abnormalities noted, ears no discharge, the tympanic membrane is pearly grey and translucent. The mucus membranes are moist and there’s no drainage in the mouth, no tenderness noted in the sinuses.
LYMPHATICS: Cervical lymph nodes are noted on the right side.
RESPIRATORY: No difficulty in breathing and all lung fields are clear.
CARDIOLOGY: S1 and S2 noted, no murmurs or other sounds.
Vitals
Blood Pressure: 120mmHg/76mmHg
O2 Sat: 96%
Pulse: 100bpm
Resp. Rate-:28
Temperature: 37.2 degrees Celsius
Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)
A possibly bacterial or viral condition. This is due to abnormal findings in the ears, upper respiratory tract and lymphatic region. Conduct a rapid strep test through a laboratory. Patient education on supportive therapy such as soothing teas, gargling warm salty water and topical anesthetics due to the throat condition. Rest should be encouraged with adequate fluid intake. Use of NSAIDS to manage the pain. To avoid the second hand smoke Caregiver to monitor symptoms if they worsen and if they do to seek health care.
Diagnostics: CBC is required to determine the WBC, C- xray find out if patient has Pneumonia, Strep culture to rule out strep throat due to the patient coughing. Spirometry test is also done to determine presence of a respiratory condition. Pharmacology: Ibuprofen 5mls PO every six hours as needed for the pain. Dimetapp 10 mls every 4 hours to manage the cough. Education/Counseling: Inform family on measures of supportive therapy such as soothing teas. Also advise against exposing the child to second hand smoking. Educate patient and family education on signs of worsening symptoms. If symptoms worsen the family should be informed to take the patient as soon as possible to a hospital. Referrals: refer patient to an allergist to rule out presence of allergies.
Differential diagnosis:
Acute viral rhinitis: it occurs due inflammation in the nasal mucosa lining due to a viral infection. Its clinical manifestations include, ear pain, running nose, fatigue and sore throat. Therefore it is likely the patient is likely to have this condition as the clinical manifestations he presents align with this condition (McCance & Huether, 2019).
Acute sinusitis: it occurs due to infection in the patient’s sinuses. The clinical manifestations include cough, ear pain and nasal drainage. This could be a possible diagnosis as it he is manifesting similar symptoms (Hinkle & Cheever, 2014).
Influenza: it is a viral infection commonly affecting children. It is characterized by a running nose, fatigue, cough, eye and ear pain. This makes it a potential diagnosis due to the similarity in clinical manifestations and what the patient presents with (McCance & Huether, 2019).
Acute otitis media: due to the ear pain it is likely the patient is suffering from an ear infection and otitis media in the acute stage being a likely one. It could be as a result of a respiratory infection hence the other symptoms align (Hinkle & Cheever, 2014).
Strep throat: is another potential diagnosis due to the patient coughing and as the respiratory system is affected it could lead to the nasal drainage and if it hadn’t been properly managed it could have led to an ear infection hence the ear pain (McCance & Huether, 2019).
Primary diagnosis: Acute viral rhinitis.
greater than 80%. Pneumonia unlikely due to lack of fever, lack of adventitious breath
sounds, stable vital signs, and presentation of symptoms.
Plan:
Diagnosis: Upper Respiratory Infection
Diagnostics: CBC to assess WBC, C- xray to rule out Pneumonia due to history, Strep
culture to rule out strep throat.
Pharmacology: Robitussin 10ml PO every six hours as needed for cough.
Education/Counseling: Provide education to family on use of medications.
Health Promotion/Anticipatory Guidance: Encourage patient to increase his fluid
hydration, encourage rest. Provide patient and family education on signs of worsening
symptoms. Should patient develop increased shortness of breath, fever, chills, wheezing,
patient to go to nearest emergency room for evaluation.
Referrals: referral to allergist to rule out allergies
Follow-up: Call to schedule apt if no improvement of symptoms in 48-72 hour
ASSESSMENT:
Physical exam and history was conducted properly to determine the likely condition resulting in the patient’s clinical manifestations. The differentials that could be considered included acute viral rhinitis, acute sinusitis, influenza, acute otitis media and strep throat. A thorough HEENT and respiratory exam was conducted to assess the same. The various assessment and lab investigations helped to rule out the various differentials. The treatment plan given out would help in the management of his condition properly.
References
McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology: The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.
Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing (Edition 13.). Wolters Kluwer Health/Lippincott Williams & Wilkins.
Patient Information
Initials: D.R
Age: 8-years old
Gender: Male
Subjective Data:
Chief Complaint (CC): Patient reports of chronic coughing which makes him feel he is sick and needs immediate medical attention.
History of Present Illness (HPI): The patient’s condition Danny Riviera, an 8-year-old boy, arrives at the clinic complaining of a cough that has lasted four days. His cough is watery and clear, according to his description. It worsens at night, interfering with his sleep. As a result, he struggles to concentrate at school and suffers from fatigue. His right ear hurts. The mother chose over-the-counter cough medicine, which provided temporary relief. Dan claims to have a persistent runny nose, as well as a cold and sore throat.
Mr. Riviera, his father exposes him to secondhand smoke. He also had a bout of pneumonia last year. The patient does not report of feeling chills, fever or difficulty in breathing.
Medications: Danny acknowledges that he has been taking some medication at home. He takes a daily dose of vitamin and a cough syrup.
Allergies: The patient has no known drug allergy.
Past Medical History (PMH): Danny has no previous history of asthma however; he acknowledges his battle with pneumonia and coughs in the past.
Past Surgical History (PSH): He has no past history of nay surgical procedure.
Sexual/Reproductive History: There is no known history of reproductive diseases or disorders.
Personal/Social History: Danny acknowledges of a safe upbringing, with a safe home that is near a park where he visits frequently. There are no bets at home and he lives together with his parents and grandparents. His father, Mr. Riviera often smokes in the house.
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Immunization History: His immunization record is up to date.
Significant Family History: The family is composed of a father, mother and both grandparents. He is the only child, and their family has no known history of allergies. Though his father battled with asthma attacks during his childhood.
Review of Systems:
General: While having the interview, the patient appears tired and coughs. He also appears to be in good health. Fever, loss of appetite, weight loss, chills, or nocturnal sweats are all denied.
HEENT: The mucus membrane is wet, and the nasal discharge is clear, but the back of his neck is red and cobblestone. The conjunctiva of his eyes is pink, and his eyes are dull. The right tympanic membrane is swollen and red. The lymph nodes in the patient’s right cervical region are enlarging and painful.
Respiratory: While the bronchoscopy is negative, there is no acute distress, an increased respiratory rate of 28 beats per minute, and clear breath sounds on auscultation. When percussed, his chest wall resonated, yet his fremitus was normal and equal on both sides.
Cardiovascular/Peripheral Vascular: Chest discomfort, tightness, palpitations, edema, cyanosis, and dyspnea are not present.
Psychiatric: There is no history of depression, anxiety, or psychotic problems.
Neurological: He experiences some headache but dizziness, loss of consciousness, or vision problems are denied.
Lymphatics: On palpation, the right cervical lymph nodes are tender.
Objective Data:
On physical examination, the following data was collected.
Vital signs:
Blood Pressure
120/76
O2 Sat
96%
Pulse
100
Resp. Rate
28
Temperature
37.2 c
General: During the interview, the patient appears tired and coughs. But appears to be in good health.
HEENT: The head is normocephalic and unaffected by trauma. He has a moist mucus membrane, clear nasal discharge, and redness and cobblestone at the back of his throat. His eyes are dull, with a pink conjunctiva. The right tympanic membrane is swollen and red. The lymph nodes in the patient’s right cervical region are enlarged and tender.
Respiratory: While the bronchoscopy is negative, there is no acute distress, an increased respiratory rate of 28 beats per minute, and clear breath sounds on auscultation. When percussed, his chest wall resonated, yet his fremitus was normal and equal on both sides.
Cardiology: In both S1 and S2, there were no murmurs, gallops, or rubs.
Lymphatics: On palpation, the lymph nodes in the right cervical region are sensitive.
Psychiatric: There were no signs of mental illness.
Diagnostics/Labs: To assess any evidence of illness, routine lab tests were done, including a complete blood count and a white blood cell count. To assess the extent of the patient’s cough, spirometry and peak expiratory flow measures were taken. To rule out any other possibilities, bronchoprovocation testing was performed. Upper airway provocation studies, sinus imaging, CT scan of the thorax, and bronchoscopy are among the other tests used to detect cough and cold symptoms (Malesker et al., 2017). Nasal-laryngoscopy and a head-and-neck MRI were recommended for a more thorough examination of the ear pain.
Assessment:
Priority Diagnosis
Acute Viral Rhinitis, generally known as the common cold, is a viral infection that affects the nose and sinuses. As a result of a respiratory virus infection, it is linked to nasal mucosa lining inflammation. Sneezing, runny nose, congestion, cough, postnasal drip, sore throat, watery eyes, ear ache, swallowing difficulty, and exhaustion are some of the symptoms that youngsters experience (Malesker et al., 2017). Most of the symptoms listed above were present in the patient in the case study, indicating a common cold.
Differential Diagnosis
Acute sinusitis:
This happens when the patient’s sinuses are infected by a cold virus.
Headache, fever, cough that worsens at night, excessively congested nose, green or thick yellow mucus, itchy and watery eyes, and ear pain are some of the symptoms that the patient may experience. Most of these symptoms were present in the case study patient (Shoukat et al., 2019).
He denied having a temperature, and the nasal discharge was clear and thin, therefore the diagnosis was ruled out.
Influenza (flu)
This is a frequent respiratory viral infection in youngsters.
Fever, headache, runny nose, lethargy, cough, eye, and ear pain are all symptoms of this infection. Most of the aforesaid symptoms were present in the patient in the case study (Badyda et al., 2020). As a result, people with a history of pneumonia, such as those in the case study, are more likely to develop this illness.
Ear Infection
Fluids can accumulate behind the eardrum due to sinus and cold infections.
Viruses and bacteria might proliferate as a result, resulting in ear infection. Ear pressure or fullness, ear pain, leakage, distorted hearing, and loss of balance are some of the symptoms that patients may experience (Badyda et al., 2020). Given that most children’s ear infections begin with a common cold, the patient’s right ear pain and concomitant upper respiratory symptoms could be due to an ear infection.
A Plan for the Treatment of the Patient
Previous Diagnosis: The patient’s previous bouts of pneumonia and cough were well treated.
Present Diagnosis: Acute Rhinitis which is a type of viral rhinitis.
Pharmacological Intervention: Cold medicines such as Dimetapp 10mL every 4 hours up to 6 doses every 24 hours are recommended (Malesker et al., 2017). Acetaminophen is used to relieve pain and fever. Drops containing dexamethasone and gentamicin for ear discomfort.
Non-pharmacological Intervention: The use of honey and saline nose spray can help with sore throats, coughs, and congested noses, respectively (Fernandez, & Olympia, 2017). Extra fluids and a cool-mist humidifier are also required to help manage the patients’ cold symptoms.
Patient Education: Explain to Mrs. Riviera the importance of following the treatment plan. It’s also crucial to inform the patient’s parents about possible side effects and adverse responses that may necessitate medical intervention (Malesker et al., 2017).
Health Promotion: To emphasize to Mrs. Riviera the need to keep the son warm, eat a nutritious diet, and get enough sleep (Badyda et al., 2020).
Follow-up Plan: If the patient’s symptoms increase or if the prescribed drugs do not improve the patient’s symptoms within one week, the patient is advised to return to the clinic.
References
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_
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.
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
Assignment 2: Digital Clinical Experience:
Focused Exam: Cough
In this DCE Assignment, you will conduct a focused exam related to cough in your DCEusing the simulation tool, Shadow Health. You will determine what history should becollected from the patient, what physical exams and diagnostic tests should be conducted,and formulate a differential diagnosis with several possible conditions.
To Prepare
Review this week's Learning Resources and consider the insights they provide related toears, nose, and throat.
Review the Shadow Health Resources provided in this week’s Learning Resourcesspecifically the tutorial to guide you through the documentation and interpretation withinthe Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Coughfound in this week’s Learning Resources and use this template to complete yourDocumentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of theBlackboard classroom.
Review the Week 5 Focused Exam: Cough Rubric provided in the Assignmentsubmission area for details on completing the Assignment in Shadow Health.
Consider what physical exams and diagnostic tests would be appropriate to gather moreinformation about the patient's condition. How would the results be used to make adiagnosis?
Focused Exam: Cough Assignment:
Complete the following in Shadow Health:
Respiratory Concept Lab (Required)
Episodic/Focused Note for Focused Exam: Cough
HEENT (Recommended but not required)
Note: Each Shadow Health Assessment may be attempted and reopened as many times asnecessary prior to the due date to achieve a total of 80% or better (this includes your DCE andyour Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.Submission and Grading Information
By Day 7 of Week 5
Complete your Focused Exam: Cough DCE Assignment in Shadow Health viathe Shadow Health link in Blackboard.
Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review.(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
Once you submit your Documentation Notes to Shadow Health, make sure to copy andpaste the same Documentation Notes into your Assignment submission link below.
Download, sign, date, and submit your Student Acknowledgement Form found in theLearning Resources for this week.
Grading Criteria
To access your rubric:
Week 5 Assignment 2 DCE Rubric
Submit Your Assignment by Day 7 of Week 5
To submit your Lab Pass:
Week 5 Lab Pass
To participate in this Assignment:
Week 5 Documentation Notes for Assignment 2
To Submit your Student Acknowledgement Form:
Submit your Week 5 Assignment 2 DCE Student Acknowledgement Form
What’s Coming Up in Week 6?
Next week, you will evaluate abnormal findings in the area of the abdomen and thegastrointestinal system. In addition, you will appraise health assessment techniques anddiagnoses for the heart, lungs, and peripheral vascular system as you complete your LabAssignment in assessing the abdomen in a SOAP note format.
You will also take your Midterm Exam, which covers the topics in Weeks 1–6. Please review the previousweekly content and resources to help you prepare for your exam. Plan your timeaccordingly.
Week 6 Required Media
Next week, you will need to view several videos and animations in the Seidel’s Guide toPhysical Examination as well as other media, as required, prior to completing your LabAssignment. There are several videos of various lengths. Please plan ahead to ensure youhave time to view these media programs to complete your Assignment on time.
Next Week
To go to the next week:Week 6
Learning Resources
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019).Seidel's guide to physical examination: An interprofessional approach (9th ed.).St. Louis, MO: Elsevier Mosby.
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