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.