NURS 6512 Week 5 DCE Assignment 2, Danny Rivera Focused Exam: Cough Essay
NURS 6512 Week 5 DCE Assignment 2, Danny Rivera Focused Exam: Cough Essay
Patient details: Daniel Rivera, eight years, Male, Hispanic
Subjective
Chief Complaint (CC): “I’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired.”
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History of Present Illness (HPI): The 8-year-old boy of Hispanic ethnicity was brought to the facility by his grandmother, complaining of a persistent cough for five days. The patient describes coughing every few minutes and producing clear sputum occasionally. His symptoms worsen at night. It is worth noting that the patient’s father is a heavy smoker who sometimes smokes indoors. Despite resting or drinking water, the patient finds no relief from his cough. Additionally, he experiences a runny nose without sneezing; the discharge is clear and thin, with no improvement after using over-the-counter medications. D.R. denies shortness of breath, exposure to animals, or conjunctival discharge while reporting mild right ear pain (rated three out of ten) starting yesterday alongside a sore throat accompanied by mild pain during swallowing.
Home medications: Daily multivitamin
Cough medicine, purple and provided temporary relief
Allergies: none
Immunizations History:
- No influenza vaccine in the last 12 months.
- Completed Hep B 3-dose series at six months
- Finished Hep A 2-dose series at 15 months
- Completed Pneumococcal 4-dose series at 15 months
- Completed DTaP 5-dose series at six years
- Completed MMR 2-dose series at six years
- Finished Varicella 2-dose series at six years
- Complete Polio 4-D dose system completed after completing the sixth year
Medical History:
- No history of surgical procedures
- No prior hospitalizations
- Treated for pneumonia last year in an urgent care clinic
Family History:
- Mother: has Type II diabetes, HTN (hypertension), hypercholesterolemia, spinal stenosis, and obesity.
- Father: smoker with HTN (hypertension), hypercholesterolemia, had childhood asthma.
- Maternal grandmother: has Type II diabetes and hypertension
- Maternal grandfather: is a smoker and has eczema
- Paternal grandmother died in a car accident when she was only fifty-two
- Paternal grandfather: No known history
Social Background
An 8-year-old boy attending 3rd grade. Absent from school for two weeks the previous year due to pneumonia. He resides with both parents; his grandmother cares for him while his parents work. English is the main language spoken at home, although there is some usage of Spanish.
Review of Systems (ROS):
GENERAL: D.R. is experiencing a cough and has noted increased weakness. This has led to difficulties sleeping at night, which is believed to be directly related to the presence of the cough. Additionally, the patient presents with a fever, and their vital signs appear normal without any indications of shortness of breath or respiratory distress. He complained of sore throat and earache but denied any additional problems. Denies experiencing weight loss, fever, chills, weakness, or weariness.
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HEENT:
Eyes: Patient denies having an eye problem or hazy visions and mentions having a test but not needing spectacles.
Ears, Nose, Throat (ENT): no hearing loss, denies nose discomfort other than a runny nose that worsens with coughing, claims earache that started days ago.
SKIN: States that have never had a rash, allergic reaction, or trauma.
CARDIOVASCULAR: No palpitation or chest discomfort. There were no problems during the subjective evaluation.
RESPIRATORY: The patient does not experience any difficulty or shortness of breath. There is no persistent cough, congestion, or pain while breathing.
GASTROINTESTINAL: Although the patient reports frequent bathroom visits, they deny experiencing nausea, vomiting, or stomach pain.
GENITOURINARY: No problems such as burning during urination or decreased urine flow.
NEUROLOGICAL: The patient states feeling weak but can still walk normally. They do not have a headache, and there are no dizziness or vision problems symptoms. MUSCULOSKELETAL: There is no discomfort or complaints in any muscular area. The patient denies having back pain, stiffness, or joint pain.
HEMATOLOGIC: While the patient mentions bruising, no other blood-related problems are reported, and no active bleeding is observed.
LYMPHATICS: There is no history of swollen lymph nodes nor neck tissue inflammation seen in this case; edema is not present either
PSYCHIATRIC: The patient denies feeling stressed or anxious and claims to live with their parents and grandparents without facing mental difficulties themselves
ENDOCRINE SYSTEM: No family history related to diabetes exists here, with the absence of urinary concerns noted.
Physical examination
GENERAL: An 8-year-old Hispanic boy, in satisfactory overall health condition, was overweight at the time of evaluation.
HEENT: Eyes: No blurry vision observed. The sclera is white, and the pupillary response to light and accommodation is normal.
Ears, Nose, Throat: Inflammation is present in the auditory canal and tympanic membrane on the right side: erythemic auditory canal and tympanic membrane in the right ear. No discharge or perforation was noted. Nasal passages are usually pink, with clear discharge—Erythema and cobblestones appearance on the posterior oropharynx. Soreness reported. Erythema was noted on the tonsils, but no exudates.
Lymph Nodes: Cervical palpable nodes on the right side.
SKIN: no skin problems, undamaged, no bruises, no sores, no scrapes
CARDIOVASCULAR: no chest pain, no palpitation, S1, and S2 present during auscultation, no extra sounds.
RESPIRATORY: There is no shortness of breath, a persistent cough, symmetry, and no peculiar sound during auscultation, and there is no respiratory distress.
GASTROINTESTINAL: no abdominal pain.
NEUROLOGICAL: the patient is attentive and oriented; there is no confusion; he follows orders and denies headaches or eyesight problems.
MUSCULOSKELETAL: the patient is mobile, has no pain, no previous trauma, and does not require help while ambulating.
HEMATOLOGIC/LYMPHATIC: Cervical lymph nodes palpable.
Vitals
- BP 120/76 mmHg, O2 Sat 96% Pulse 100 bpm, R.R. 28/min Temp: 37.2 C
- Weight 90 lbs
- Height 4’22”
-
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Diagnostic Findings
By completing influenza, A and b, and streptococcal throat swab tests, the infection can be ruled out due to the painful throat and earache. Since the patient described the bruises, hemoglobin levels should be checked through a CBC to rule out any signs of infection or blood problems. Despite the apparent health of the patient’s lungs and previous observations, it would be beneficial to consider a chest X-ray to ascertain if bronchitis or pneumonia is present. Nevertheless, if there is no improvement in the cough, it becomes imperative for the patient to seek consultation with a pulmonologist. At this stage, an expert recommendation from the pulmonologist may include additional diagnostic procedures such as X-rays or C.T. scans for further evaluation (Mukerji et al., 2022). These advanced imaging techniques could provide valuable insights into any underlying respiratory conditions. An advanced healthcare professional can effectively address cases with minor symptoms, such as cough.
DIFFERENTIAL DIAGNOSIS:
Acute Upper Respiratory Tract Infection
Based on the patient’s symptoms, a viral common cold is the primary and most frequent cause of coughing. The most frequently diagnosed sickness in children is an upper respiratory tract infection (URI), ranging from a mild cough to a severe or even life-threatening condition (Susaman et al., 2021). The primary symptom of a typical viral cold is a cough; there are no fevers or shortness of breath. A viral or bacterial infection of the upper respiratory tract may cause the patient’s painful throat, nasal congestion, clear nasal discharge, erythema, and erythemic tympanic membranes.
Allergic Rhinitis
Sneezing, nasal congestion, itching, and rhinorrhea are all symptoms of allergic rhinitis, the most common type (Jean, 2022). Except in extreme cases of asthma or anaphylaxis, allergic rhinitis is not fatal. However, it can significantly impact one’s health. An individual may experience symptoms such as nasal congestion with clear discharge and erythema in the nasal cavities due to allergens like pollen, dust mites, or pet dander that trigger this inflammatory disorder known as allergic rhinitis. Additionally, cobblestoning in the posterior oropharynx was observed.
Sinusitis
Leung et al. (2020) state sinusitis is an inflammation of the sinuses’ mucosal lining. It can be acute, subacute, or chronic. In some situations, a viral, bacterial, or fungal infection might lead to a common cold complication; for instance, in the patient, a complication of the pneumonia they previously experienced. According to Battisti and Pangia (2020), bacterial sinusitis typically develops after a viral upper respiratory infection, manifesting as chronic symptoms after ten days or worsening symptoms after five days. Sinusitis, an inflammation or infection of the sinuses, may be indicated by tenderness in the frontal and maxillary sinuses and symptoms of nasal congestion, clear discharge, and erythema in the nasal cavities.
Pharyngitis: Pharyngitis is a condition characterized by the inflammation of the mucus membranes in the oropharynx. Common causes include bacterial or viral infections, although allergies, trauma, cancer, acid reflux, and some toxins all play a role (Wolford et al., 2022). The patient may have pharyngitis, which can be brought on by viral or bacterial infections based on their sore throat, throat erythema, and tonsillar erythema.
References
Battisti, A. S., & Pangia, J. (2020). Sinusitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470383/
Jean, T. (2023). Allergic rhinitis: Practice essentials, background, pathophysiology. Medscape.com. https://emedicine.medscape.com/article/134825-overview
Leung, A. K., Hon, K. L., & Chu, W. C. (2020). Acute bacterial sinusitis in children: An updated review. Drugs in Context, 9. https://doi.org/10.7573/dic.2020-9-3
Mukerji, S. S., Yenduri, N. J. S., Chiou, E., Moonnumakal, S. P., & Bedwell, J. R. (2022). A multi‐disciplinary approach to chronic cough in children. Laryngoscope Investigative Otolaryngology, 7(2), 409–416. https://doi.org/10.1002/lio2.778
Susaman, N., Bayar Muluk, N., & Sallavaci, S. (2021). Common cold in children. Pediatric ENT Infections, 417–425. https://doi.org/10.1007/978-3-030-80691-0_36
Wolford, R. W., Goyal, A., Belgam Syed, S. Y., & Schaefer, T. J. (2022). Pharyngitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519550/#:~:text=Pharyngitis%20is%20the%20inflammation%20o
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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?
An 8-year-old boy presented with a cough for 5 days, lungs bilaterally clear, and no shortness of breath. Took some OTC medications but no relief. No medical issues, no allergies to food and medications. No exposure to animals. Had a history of PNA last year, and had vaccinations except for annual influenza vaccinations. Father is a heavy smoker and sometimes smokes inside the house. On physical examination, the eyes are normal, with no conjunctival redness and discharge. The nasal is normal, pink in color, and turbinates are patent. Clear discharges were noted.
The right ear showed an erythemic auditory canal and tympanic membrane; no discharge or perforation was noted. The left ear is normal
Mouth and throat showed erythema and cobblestones appearance on the posterior oropharynx. The patient complained of soreness too. Erythema was also noted on the tonsils, but no exudates were noted.
Cervical lymph nodes were palpable but not noted on both the axillary or supraclavicular. Vitals signs are normal.
This criterion is linked to a Learning OutcomeSubjective 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.
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NURS_6512_Week_5_DCE_Assignment_2_Rubric
| NURS_6512_Week_5_DCE_Assignment_2_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeStudent 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. |
|
60 pts | ||||
| This criterion is linked to a Learning OutcomeSubjective 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. |
|
20 pts | ||||
| This criterion is linked to a Learning OutcomeObjective 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). |
|
20 pts | ||||
| Total Points: 100 | ||||||
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