Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512N-32

Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512N-32

Assignment 2 Digital Clinical Experience: Focused Exam Cough NURS 6512N-32

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

SUBJECTIVE DATA:

Danny Rivera is an 8 year old Hispanic American male who came to the hospital due feeling sick, coughing a lot and feeling tired as his chief complaint. He lives in a house together with his parents and grandparents. The patient has been brought in by his Abuela.

Chief Complaint (CC):

Feeling sick, coughing a lot and feeling tired.

History of Present Illness (HPI):

The patient’s symptoms started 5 days ago and has stated the cough is worse at night. The cough has been described to be gurgly and watery and he is coughing every few minutes. He has no chest pain or breathing problems. He has also reported pain in his right ear at a scale of 3/10, throat pain at a rate if 2/10 that is felt even as he swallows. He hasn’t experienced a fever and has not been around anyone who is ill. He has been given cough medicine by his mother as a form of relief.

Medications:

He takes multivitamins daily and the cough medicine that he doesn’t know its name given by his mother, a spoonful that is purple in color.

Allergies:

He has no known food or drug or environmental or seasonal allergies.

Past Medical History (PMH):

The patient hasn’t been to the hospital prior to this.

Past Surgical History (PSH):

The patient hasn’t gone under any surgical procedures prior to this.

Sexual/Reproductive History:

The patient is not yet sexually active.

Personal/Social History:

The patient performs well in the third grade. Though doesn’t engage in sports enjoys physical

activity with friends. He lives in a house with his parents and grandparents who care for him. He enjoys video games in the house and hasn’t travelled recently. He has been exposed to second hand smoking by his father and all his immunizations as a child were given.

Immunization History:

All his immunizations as a child were given.

Family History

Mother is alive though suffers from-Diabetes, hypercholesterolemia, hypertension, spinal stenosis, obesity.

Father is also alive still is a smoker and suffers from hypertension, hypercholesterolemia, and asthma as a child.

Maternal Grandmother is alive and has type two diabetes, Hypertension.

Maternal grandfather is alive though has issues with being a smoker, eczema. Paternal grandmother: Deceased – car accident age 52.

Paternal grandfather the history is yet to be obtained.

Review of Systems:

General: admits to increased fatigue, no changes in appetite or activities. Denies fevers or chills, or night sweats. Skin: denies any rashes or skin changes. Head, Ears, Eyes, Nose, Throat

(HEENT): Denies headaches. Denies vision changes, diplopia or blurred vision. Right ear pain 3/10. Denies hearing changes, tinnitus or vertigo. Increased rhinorrhea, clear drainage. Throat pain 2/10.  Respiratory: no history of asthma. Denies shortness of breath or wheezing. Admits to constant cough beginning 5 days ago, worse at night. Cardiovascular: Denies chest pain, tightness, or palpitations. Gastrointestinal: Denies nausea vomiting diarrhea or constipation. Denies abdominal pain. Reports normal appetite.

            Neurologic: Denies headache, trauma, dizziness, or changes in mentation.

            Respiratory: There is presence of a cough.

OBJECTIVE DATA:

The patient is oriented and alert. Coughs from time to time though able to converse properly and is sitted without signs of discomfort.

The spirometer readings are FEV1/FVC: 87%

For assessment the HEENT: eyes no abnormalities noted, ears no discharge, the tympanic membrane is pearly grey and translucent. The mucus membranes are moist and there’s no drainage in the mouth, no tenderness noted in the sinuses. Cervical lymph nodes are noted on the right side.

No difficulty in breathing and all lung fields are clear. S1 and S2 noted, no murmurs or other sounds.

Vitals

Blood Pressure:           120mmHg/76mmHg

O2 Sat:            96%

Pulse: 100bpm

Resp. Rate-:28

Temperature: 37.2 degrees Celsius

Physical Exam:

The patient is oriented and alert. Coughs from time to time though able to converse properly and is sitted without signs of discomfort.

The spirometer readings are FEV1/FVC: 87%

HEENT: eyes no abnormalities noted, ears no discharge, the tympanic membrane is pearly grey and translucent. The mucus membranes are moist and there’s no drainage in the mouth, no tenderness noted in the sinuses.

            LYMPHATICS: Cervical lymph nodes are noted on the right side.

RESPIRATORY: No difficulty in breathing and all lung fields are clear.

            CARDIOLOGY: S1 and S2 noted, no murmurs or other sounds.

Vitals

Blood Pressure:           120mmHg/76mmHg

O2 Sat:            96%

Pulse: 100bpm

Resp. Rate-:28

Temperature: 37.2 degrees Celsius

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

A possibly bacterial or viral condition. This is due to abnormal findings in the ears, upper respiratory tract and lymphatic region. Conduct a rapid strep test through a laboratory. Patient education on supportive therapy such as soothing teas, gargling warm salty water and topical anesthetics due to the throat condition. Rest should be encouraged with adequate fluid intake. Use of NSAIDS to manage the pain. To avoid the second hand smoke Caregiver to monitor symptoms if they worsen and if they do to seek health care.

Diagnostics: CBC is required to determine the WBC, C- xray find out if patient has Pneumonia, Strep culture to rule out strep throat due to the patient coughing. Spirometry test is also done to determine presence of a respiratory condition. Pharmacology: Ibuprofen 5mls PO every six hours as needed for the pain. Dimetapp 10 mls every 4 hours to manage the cough. Education/Counseling: Inform family on measures of supportive therapy such as soothing teas. Also advise against exposing the child to second hand smoking. Educate patient and family education on signs of worsening symptoms. If symptoms worsen the family should be informed to take the patient as soon as possible to a hospital. Referrals: refer patient to an allergist to rule out presence of allergies.

Differential diagnosis:

1. Acute viral rhinitis: it occurs due inflammation in the nasal mucosa lining due to a viral infection. Its clinical manifestations include, ear pain, running nose, fatigue and sore throat. Therefore it is likely the patient is likely to have this condition as the clinical manifestations he presents align with this condition (McCance & Huether, 2019).
2. Acute sinusitis: it occurs due to infection in the patient’s sinuses. The clinical manifestations include cough, ear pain and nasal drainage. This could be a possible diagnosis as it he is manifesting similar symptoms (Hinkle & Cheever, 2014).
3. Influenza: it is a viral infection commonly affecting children. It is characterized by a running nose, fatigue, cough, eye and ear pain. This makes it a potential diagnosis due to the similarity in clinical manifestations and what the patient presents with (McCance & Huether, 2019).
4. Acute otitis media: due to the ear pain it is likely the patient is suffering from an ear infection and otitis media in the acute stage being a likely one. It could be as a result of a respiratory infection hence the other symptoms align (Hinkle & Cheever, 2014).
5. Strep throat: is another potential diagnosis due to the patient coughing and as the respiratory system is affected it could lead to the nasal drainage and if it hadn’t been properly managed it could have led to an ear infection hence the ear pain (McCance & Huether, 2019).

Primary diagnosis: Acute viral rhinitis.

greater than 80%.  Pneumonia unlikely due to lack of fever, lack of adventitious breath

sounds, stable vital signs, and presentation of symptoms.

Plan:

Diagnosis: Upper Respiratory Infection

Diagnostics: CBC to assess WBC, C- xray to rule out Pneumonia due to history, Strep

culture to rule out strep throat.

Pharmacology: Robitussin 10ml PO every six hours as needed for cough.

Education/Counseling: Provide education to family on use of medications.

Health Promotion/Anticipatory Guidance: Encourage patient to increase his fluid

hydration, encourage rest. Provide patient and family education on signs of worsening

symptoms. Should patient develop increased shortness of breath, fever, chills, wheezing,

patient to go to nearest emergency room for evaluation.

Referrals: referral to allergist to rule out allergies

Follow-up: Call to schedule apt if no improvement of symptoms in 48-72 hour

ASSESSMENT:

Physical exam and history was conducted properly to determine the likely condition resulting in the patient’s clinical manifestations. The differentials that could be considered included acute viral rhinitis, acute sinusitis, influenza, acute otitis media and strep throat. A thorough HEENT and respiratory exam was conducted to assess the same. The various assessment and lab investigations helped to rule out the various differentials. The treatment plan given out would help in the management of his condition properly.

References

McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology:    The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical          nursing (Edition 13.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

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 person A young boy named Danny Riviera, who is only 8 years old, visits the medical center because he has been coughing for the past few days. According to what he says, the cough is very clear and has a watery quality to it. His cough is worse at night, which prevents him from getting adequate rest. As a consequence of this, he has trouble concentrating in class and often comes home exhausted. It’s painful in his right ear. The decision his mother made to use over-the-counter cough medicine, which only provided temporary relief, was made. Danny claims that he has a cold and that he suffers from a runny nose on a regular basis. Additionally, he inhales his father’s secondhand smoke on a regular basis. Within the past year, he has also been diagnosed with pneumonia. However, he does not have a fever, difficulty breathing, abdominal pain, chest tightness, or chills. He also does not have 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.

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 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.

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 be