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

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

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

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.

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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