NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
Week 5: Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
Patient Information
Initials: D.R
Age: 8 years old
Gender: Male
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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
NURS 6512 Week 5 Assignment 2 Digital Clinical Experience Focused Exam Cough
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.
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.
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.
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 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:
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.
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.
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.
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.
References
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
Assignment 2: Digital Clinical Experience: Focused Exam: Cough
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.
Photo Credit: Getty Images
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.
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 add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
Complete the Code of Conduct Acknowledgement.
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:
Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
Grid View
List View
Excellent
Good
Fair
Poor
Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)
Note: DCE Score – Do not round up on the DCE score.
Points Range: 56 (56%) – 60 (60%)
DCE score>93
Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92
Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85
Points Range: 0 (0%) – 45 (45%)
DCE Score <79
No DCE completed.
Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes 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.
Points Range: 16 (16%) – 20 (20%)
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).
Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language.
Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.
Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
Points Range: 0 (0%) – 5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.
No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
or
No documentation provided.
Objective Documentation in Provider Notes – this is to be completed in Shadow Health
Physical exam: 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).
Points Range: 16 (16%) – 20 (20%)
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.
Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.
Each system assessed is somewhat clearly documented with measurable details of the exam.
Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.
Each system assessed is minimally or is not clearly documented with measurable details of the exam.
Points Range: 0 (0%) – 5 (5%)
Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.
None of the systems are assessed, no documentation of details of the exam.
or
No documentation provided.
Total Points: 100
Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
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