Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512

Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512

Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512

SUBJECTIVE DATA:

Chief Complaint (CC): “I have been coughing a lot.”

History of Present Illness (HPI):

Danny Rivera is an 8-year-old Puerto Rican boy that presented to the Shadowville Elementary nurse’s office with complaints of cough. He provides subjective data about his health problem. He is responsive and answers appropriately the questions asked during the assessment. Danny reports that he has been coughing a lot for the last three days. The cough is wet, productive, leading to slimy clear phlegm. The cough worsens at night affecting his sleep, as he reports he did not get enough sleep the previous night. The cough lasts a few seconds.

Danny resides in the same house with his grandfather who is a smoker, exposing him to cigar smoke. Danny reports that her mother gave her a table spoonsful of a purple-ish medicine, which soothed his cough. He has no history of using any home remedies for cough. He recently took syrup prescribed by his doctor for cough. He takes multivitamins daily. Danny is usually physically active. However, the cough has reduced his ability to engage in active physical activity, as he feels fatigued. The cough has also affected his ability to concentrate in class since he does not get enough sleep at night. Danny also reported worsening running nose ever since the cough started. The patient reports sore throat but denies sneezing. 

Medications: Danny reports that his mother gave him a purple-ish medicine to sooth his cough this morning. He is not on any other medication.

Allergies: Danny does not have any history of food, drug, or environmental allergic reactions.

Past Medical History (PMH): Danny has a history of pneumonia. He also has a frequent experience of cold, since his rose is runny most of the times.

Past Surgical History (PSH):Danny has no history of surgeries

Sexual/Reproductive History: Danny is an 8-year-old boy with unremarkable sexual or reproductive history.

Personal/Social History: Danny resides with his mother and grandfather. He is a student. He likes engaging in active physical activity. His grandfather smokes cigarette, exposing him to harmful smoke at home.

Immunization History: Danny’s immunization history is up-to date.

Significant Family History (Include history of parents, Grandparents, siblings, and children): There is a history of asthma (his grandfather).

Review of Systems:

General: The patient is alert, responsive, and answers asked questions appropriately. He reports fatigue and denies fevers and chills.

            HEENT: Danny denies headache, vision changes, dizziness, watery eyes, eye redness, eye pain, and sinus pain. The patient reports sore throat, running nose, and itchy nose at times.

Respiratory: The client denies difficulty in breathing. He reports wet productive cough. He also reports occasional sneezing

OBJECTIVE DATA:

Physical Exam:

Vital signs: Not given

General: The patient is alert and oriented to self, place time. He is well groomed for the occasion.

HEENT: The sclera is white with most and pink conjunctiva with no discharge. The nasal cavities are pink with clear discharge. The turbinate is patent. The ears have no abnormal visible findings with cone of light being 7.00, no discharge, and tympanic membranes being pearly grey. The oral mucosa appears moist and pink with erythematous tonsils. The posterior oropharynx appears pink with cobble stoning in the posterior oropharynx texture. There is no postnasal drip.

Respiratory: The breath sounds are present in all the areas with absent adventitious sounds. The lung sounds are clear with fremitus symmetrical bilaterally. Lung function tests: : FEV1: 1.549 L, FVC 1.78 L (FEV1/FVC: 87%)

Cardiology: Auscultation of the bronchoscopy negative with no extra sounds. There is resonance on chest wall percussion with no dullness.

Lymphatics: No lymphadenopathy

Diagnostics/Labs: The additional laboratory and diagnostic investigations needed to develop diagnoses include nasal culture and chest x-ray should the patient demonstrate worsening symptoms. The chest x-ray may be needed to rule out other causes such as tuberculosis and pneumonia if the symptoms worsen.

ASSESSMENT:

Danny’s priority diagnosis is common cold. Common cold is a term used to refer to mild upper respiratory illness. The disease has viral origin. It is self-limiting disease that mainly affects the upper respiratory tract. In severe cases, patients may develop spread of the viral infection to other organs and complications such as those caused by the bacteria. Patients affected by common cold present the hospital with complaints that include sneezing, nasal discharge and stuffiness, sore throat, cough, and fatigue.

The additional symptoms that patients may exhibit include hoarseness, headache, lethargy, and myalgia. The symptoms often last between 1 and 7 days with them peaking within 2-3 days of the infection (Ibrahim et al., 2021; Montesinos-Guevara et al., 2022; Wilson & Wilson, 2021). Danny has present with symptoms that align with those of common cold. For example, he complains of cough, sore throat, and running nose for the last three days, hence, common cold being his primary diagnosis.

Danny’s secondary diagnosis is rhinosinusitis. Rhinosinusitis is a disorder characterized by the inflammation of the nasal cavities and passages. Patients develop this condition following their exposure to potential causes such as smoke, lowered immunity, and asthma. Patients often report symptoms such as nasal congestion, toothache, loss of smell, halitosis, postnasal drip, and runny nose (Chandy et al., 2019; Utkurovna et al., 2022). Danny is frequently exposed to tobacco smoke, which may have led to the development of rhinosinusitis. However, the absence of additional symptoms such as postnasal drip, toothache, loss of smell, and sinus pain or pressure, makes rhinosinusitis the least likely cause of his problem.

The last differential diagnosis that should be considered for the patient is whooping cough or pertussis. Pertussis is a disorder of the upper respiratory system that is characterized by severe hacking cough accompanied by whooping breath sounds. The disease is highly contagious and requires immediate patient isolation to prevent its spread in the population. The symptoms associated with whooping cough include cough, fever, red, watery eyes, nasal congestion, and runny nose. The affected populations are increasingly predisposed to complications such as pneumonia, seizures, brain damage, and dehydration (Zhang et al., 2020). However, pertussis is Danny’s least likely diagnosis because of the lack of hacking, whooping cough and red, watery eyes.

References

Chandy, Z., Ference, E., & Lee, J. T. (2019). Clinical Guidelines on Chronic Rhinosinusitis in Children. Current Allergy and Asthma Reports, 19(2), 14. https://doi.org/10.1007/s11882-019-0845-7

Ibrahim, A. E., Elmaaty, A. A., & El-Sayed, H. M. (2021). Determination of six drugs used for treatment of common cold by micellar liquid chromatography. Analytical and Bioanalytical Chemistry, 413(20), 5051–5065. https://doi.org/10.1007/s00216-021-03469-3

Montesinos-Guevara, C., Buitrago-Garcia, D., Felix, M. L., Guerra, C. V., Hidalgo, R., Martinez-Zapata, M. J., & Simancas-Racines, D. (2022). Vaccines for the common cold. Cochrane Database of Systematic Reviews, 12. https://doi.org/10.1002/14651858.CD002190.pub6

Utkurovna, S. G., Farkhodovna, S. Z., &Furkatjonovna, B. P. (2022). OPTIMIZATION OF THE TREATMENT OF ACUTE RHINOSINUSITIS IN CHILDREN. Web of Scientist: International Scientific Research Journal, 3(3), Article 3. https://doi.org/10.17605/OSF.IO/GYBM7

Wilson, M., & Wilson, P. J. K. (2021). The Common Cold. In M. Wilson & P. J. K. Wilson (Eds.), Close Encounters of the Microbial Kind: Everything You Need to Know About Common Infections (pp. 159–173). Springer International Publishing. https://doi.org/10.1007/978-3-030-56978-5_10

Zhang, J.-S., Wang, H.-M., Yao, K.-H., Liu, Y., Lei, Y.-L., Deng, J.-K., & Yang, Y.-H. (2020). Clinical characteristics, molecular epidemiology and antimicrobial susceptibility of pertussis among children in southern China. World Journal of Pediatrics, 16(2), 185–192. https://doi.org/10.1007/s12519-019-00308-5

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA:

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

History of Present Illness (HPI): The affected individual Danny Riviera, an eight-year-old boy, visits the medical center because he has been coughing for several days. According to him, the cough is very clear and has a watery quality. His cough is worse at night, preventing him from getting enough rest. As a result, he struggles to concentrate in class and frequently comes home exhausted. It hurts in his right ear. His mother made the decision to use over-the-counter cough medicine, which only provided temporary relief. Danny claims that he has a cold and that he frequently has a runny nose. In addition, he regularly inhales his father’s secondhand smoke. He has also been diagnosed with pneumonia in the last year. He does not, however, have a fever, breathing difficulties, abdominal pain, chest tightness, or chills. He also has no chest tightness.

Medications: The patient acknowledges that they do take their medications at home. In addition to that, he takes a vitamin every day. In addition to that, he takes a medication for coughing that is purple.

Allergies: NKDA

Past Medical History (PMH): Denies asthma diagnosis. Identifies immunizations as being up to date. Previous symptoms include chronic coughing and pneumonia.

Past Surgical History (PSH): None reported.

Sexual/Reproductive History:

Personal/Social History: Identifies himself as a member of a household that also includes his parents and grandparents. avers having a sense of well-being while at home. Describes a park with a playground in the neighborhood. It is reported that the father smokes in the house.

Immunization History: Immunizations are current.

Significant Family History: He is supported by his biological parents as well as both sets of grandparents.

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Review of Systems:

General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.

HEENT: The mucus membrane is moist, and the nasal discharge is clear. However, the back of his throat is red and mucus-filled. His eyes are lifeless, and his conjunctiva is a pinkish hue. The right tympanic membrane appears to be inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged and tender.

Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.

              Cardiovascular/Peripheral Vascular:

             

              Psychiatric:

              Neurological:

              Lymphatics:

             

OBJECTIVE DATA:

Physical Exam:

Vital signs:

Blood Pressure	120/76
O2 Sat	96%
Pulse	100
Resp. Rate	28
Temperature	37.2 c

 

General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.

HEENT: The head is atraumatic and has a normocephalic shape. The mucus membrane is wet, and the discharge from the nose is clear. However, the back of his throat is red and clogged with mucus. His eyes are lifeless, and the conjunctiva around them is a pinkish hue. It seems as though the right tympanic membrane is inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged, and they have a certain degree of tenderness.

Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.

Cardiology: In S1 and S2, there were no murmurs, gallops, or rubs.

Lymphatics: When palpated, the lymph nodes in the right cervical region are tender.

Psychiatric: No mental issues noted.

 

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

ASSESSMENT:

 

Based on the findings of the completed physical examination and the observations that were made, the following possible diagnoses can be made.

1. Common cold: The patient complains of having a stuffy nose and a sore throat, which are both symptoms of a common cold. This observation was also supported by the findings of a physical examination, which showed that the patient had swollen lymph nodes.
2. Streptococcus throat infection: The patient’s complaint of a sore throat suggests that they may have strep throat. On the other hand, symptoms like nausea, vomiting, headaches, and fever did not present themselves at any point.

iii. Rhinitis is another condition that could have been causing the patient’s symptoms, as they included stuffy nose, sore throat, and drainage from the nose. In addition to this, the patient has a history of recurrent ear infections throughout their lifetime.

1. Allergies and asthma: The patient does not have a history of allergic reactions. Nevertheless, it is possible that this condition will occur. This condition may have been the cause of the persistent cough. On the other hand, the patient does not exhibit any symptoms of wheezing, chest pain or tightness, or difficulty breathing.

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

Model Documentation
Subjective Danny reports cough lasting two to three days. He described the cough as “watery and gurgly.” He reports the cough is worst at night and keeps him awake. He reported general tiredness because of sleep deprivation.He is experiencing mild soreness in his throat. He reports his mother gave him over-the-counter cough medicine, but it gave him temporal relieve from the cough .He reports frequent cold and runny nose, and states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, ear pain nosebleed, trouble swallowing, sputum or phlegm, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.	Danny reports a cough lasting two to three days. He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. He reports general fatigue due to lack of sleep. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, ear pain, trouble swallowing, nosebleed, phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.
Objective General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable. HEENT: Mucus membranes are moist, nasal discharge, and boggy turbinate. Fine bumps on the togue. Cobblestoning in the back of throat. Eyes are dull in appearance, pink Conjunctiva. Cardiovascular: Mild tarchycardia. S1, S2, no murmurs, gallops or rubs. Respiratory: Respiratory rate increased, but no acute distress. Able to speak full sentences. Breath sounds clear to auscultation.	• General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable. • HEENT: Mucus membranes are moist, nasal discharge, and boggy turbinate. Fine bumps on the tongue. Cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. • Cardiovascular: Mild tachycardia. S1, S2, no murmurs, gallops or rubs. • Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation.

Photo Credit: Getty Images

Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512

To Prepare

Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

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 as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.

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Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512

Submission and Grading Information

By Day 7 of Week 5

Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the 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 and paste the same Documentation Notes into your Assignment submission link below.
Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.
Grading Criteria

Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512

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?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

Next week, you will evaluate abnormal findings in the area of the abdomen and the gastrointestinal system. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system as you complete your Lab Assignment 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 previous weekly content and resources to help you prepare for your exam. Plan your time accordingly.

Week 6 Required Media

Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images

Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Lab Assignment. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Assignment on time.

Next Week

To go to the next week:

Week 6

Week 6: Assessment of the Abdomen and Gastrointestinal System

On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?

Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.

This week, you will explore how to assess the abdomen and gastrointestinal system.

Learning Objectives

Students will:

Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512

Evaluate abnormal abdomen and gastrointestinal findings
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
Identify  concepts, theories, and principles related to advanced health assessment

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.

Chapter 6, “Vital Signs and Pain Assessment”

This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.
Chapter 18, “Abdomen”

In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 3, “Abdominal Pain”
This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis.

Chapter 10, “Constipation”
The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.

Chapter 12, “Diarrhea”
In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform.

Chapter 29, “Rectal Pain, Itching, and Bleeding”
This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

These sections below explain the procedural knowledge needed to perform gastrointestinal procedures.

Chapter 107, “X-Ray Interpretation: Chest (