Assignment 2: Digital Clinical Experience: Focused Exam: Cough

Assignment 2: Digital Clinical Experience: Focused Exam: Cough

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Section: Focused Exam: Cough

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 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.

 Also Read:


Grading Criteria

SAMPLE 2

Section: Section 5

Week 5               

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): The patient presented with a cough that had been persisting for a few days.

History of Present Illness (HPI): The cough started five days ago and the patient reports coughing every couple minutes. The cough is wet with clear sputum and worsens at night. The patient is unaware of any triggers that may be causing the cough although he reports being exposed to second hand smoke. Drinking water and resting do not relieve the cough. The cough is not aggravated with activity. The patient has a runny nose, frequent rhinorrhea, clear and thin nasal discharge but denies sneezing. Ear symptoms include pain in the right ear that started yesterday. Pain rating for ear pain is 3. No ear discharge.

Throat symptoms: sore throat and a little pain when swallowing.

Medications: Daily vitamins and over-the-counter cough medicine that only provides temporary relief

Allergies: Denies seasonal, food, latex, animal, or any medication allergies.

Past Medical History (PMH): Denies asthma diagnosis and past hospitalizations. Reports frequent coughs and pneumonia in the past. Reports frequent ear infections during childhood.

Past Surgical History (PSH): No surgical history.

Sexual/Reproductive History: Unknown

Personal/Social History: patient’s father smokes cigars hence he is constantly exposed to second-hand smoke.

Immunization History: Reports that all immunizations are current.

Significant Family History: reports that his father had asthma as a child, denies family history of allergies. No pets at home. Patient has not been around anyone ill at home.

Review of Systems:

General: Reports frequent colds and feeling tired due to lack of sleep. Denies fever, chills, night sweats, weight loss, and appetite loss.

HEENT:

Denies headache, nose bleeds, vision problems, dizziness, watery eyes, eye redness, eye pain, sinus pain, hearing problems, ear popping or crackling, ear surgery, or ear tubes. Reports a history of frequent ear infections.

Respiratory: Denies difficulty breathing, chest tightness, and use of inhaler or other breathing treatments. Denies cough aggravation with activity.

Cardiovascular/Peripheral Vascular: Denies chest pain.

Psychiatric: No history of psychiatric disorders, denies feeling sad or depressed.

Neurological: Denies dizziness, vision changes, and loss of sensation.

Lymphatics: Reports sore throat and pain while swallowing. 

OBJECTIVE DATA:

Physical Exam:

Vital signs: HR: 80, RR: 20, BP 112/76, T:98.4, ht: 55 inches, wt: 80 lbs, BMI: 18.6, SPO2: 98

General: the boy appears fatigued but stable. No odors of body or breath, no gait problems, neatly groomed, neutral facial expression, and appears interested in people and things around him.

HEENT: Mucus membranes are most, clear nasal discharge. Redness, cobble stoning in the back of the throat. The eyes have a dull appearance, pink conjunctiva. Red and inflamed tympanic membrane. Right cervical lymph node enlarged with reported tenderness.

Respiratory: Respiratory rate increased, but no acute distress. Breath sounds clear to auscultation, able to speak in full sentences, negative bronchophony, chest wall resonant to percussion, expected fremitus, equal bilaterally. Spirometry: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%).

Cardiology: S1, S2, no murmurs, gallops, or rubs.

Lymphatics: Enlarged right cervical lymph node with reported tenderness.

Psychiatric: Able to speak in full sentences. No signs of stress.

Diagnostics/Labs

Based on the patient’s symptoms, the first diagnostic tests should focus on ruling out any allergic causes. The main diagnostic tests that are required to develop the differential diagnoses include blood test and skin tests. According to Ansotegui et al. (2020), blood tests can help measure the response of the immune system to common allergens by examining the amount of immunoglobin E (IgE) antibodies in the blood stream. Skin tests can help assess whether symptoms are caused by specific allergens. For instance, if a patient is allergic to a specific substance, a skin test may entail exposing a pricked area of the skin to common airborne allergens in small amounts. It is likely that the patient will develop a hive on the specific area which was exposed.

If the patient’s symptoms are not triggered by allergies, other diagnostics such as CT scans and nasal endoscopy may be used. According to Nathan et al. (2021), these tests are used to determine if the symptoms are caused by sinus issues. CT scans provide clear imaging of patients’ sinuses while nasal endoscopies help examine nasal sinuses and passages for any abnormalities. A fractional inhaled nitric oxide (FeNO) test, which assesses the levels of nitric oxide in a patient’s breath may also be used. Pijnenburg (2019) explains that FeNO tests can assess if the airways are inflamed and help in diagnosing airway conditions such as asthma.

ASSESSMENT:

The priority diagnosis for the patient is allergic rhinitis. According to Katotomichelakis et al. (2017), the main symptoms of allergic rhinitis include coughing, a runny or blocked nose, itchy nose, red and watery eyes, and clear nasal drainage. Patel et al. (2020) add that allergic rhinitis may also cause ear pain. Exposure to allergens triggers the release of chemicals such as histamine in the body which irritate sinuses and the nose which in turn may affect the ear. Some patients may experience fluid build-up which may lead to ear infections.

Danny’s symptoms, including fatigue, runny nose, pink conjunctiva, inflamed tympanic membrane, frequent rhinorrhea, clear and thin nasal discharge, and ear pain indicate that he may have allergic rhinitis. He is constantly exposed to second-hand tobacco smoke at home which may be the trigger. Additionally, he has a history of ear infections as a child. The Spirometry results are normal meaning that there is no lung inflammation. The patient also has a history of pneumonia. According to Wee et al. (2022), untreated cases of allergic rhinitis increase the risk of acquiring pneumonia.

The differential diagnoses include asthma, a common cold, and strep throat. As per Doulaptsi et al. (2019), symptoms of childhood asthma include frequent coughing that becomes worse when the child has a viral infection, wheezing, shortness of breath, and chest tightness. The main symptoms of common cold include runny nose (thick green or yellow mucus), itchy throat, sore throat, and fatigue. The main symptoms of a strep throat include sore throat, trouble swallowing, swollen neck glands, headache, and fever. Danny may have asthma based on his family history and the frequent cough. However, he does not have other symptoms such as shortness of breath and the cough is not triggered by exercise or cold air. Danny also demonstrates several symptoms of common cold including fatigue, sore throat, and a runny nose. He also demonstrates several symptoms of strep throat including sore throat and swollen neck glands hence strep throat is a significant differential.

References

Ansotegui, I., Melioli, G., Canonica, G., Caraballo, L., Villa, E., & Ebisawa, M. et al. (2020). IgE allergy diagnostics and other relevant tests in allergy, a World Allergy Organization position paper. World Allergy Organization Journal13(2), 100080. https://doi.org/10.1016/j.waojou.2019.100080

Doulaptsi, M., Aoi, N., Kawauchi, H., Milioni, A., Karatzanis, A., & Prokopakis, E. (2019). Differentiating Rhinitis in the Paediatric Population by Giving Focus on Medical History and Clinical Examination. Medical Sciences7(3), 38. https://doi.org/10.3390/medsci7030038

Katotomichelakis, M., Iliou, T., Karvelis, I., Giotakis, E., Daniilides, G., & Erkotidou, E. et al. (2017). Symptomatology Patterns in Children with Allergic Rhinitis. Medical Science Monitor23, 4939-4946. https://doi.org/10.12659/msm.903136

Nathan, K., Majhi, S., Bhardwaj, R., Gupta, A., Ponnusamy, S., Basu, C., & Kaushal, A. (2021). The Role of Diagnostic Nasal Endoscopy and a Computed Tomography Scan (Nose and PNS) in the Assessment of Chronic Rhinosinusitis: A Comparative Evaluation of the Two Techniques. Sinusitis5(1), 59-66.

Patel, G. B., Kern, R. C., Bernstein, J. A., Hae-Sim, P., & Peters, A. T. (2020). Current and future treatments of rhinitis and sinusitis. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 1522–1531. https://doi.org/10.1016/j.jaip.2020.01.031

Pijnenburg, M. (2019). The Role of FeNO in Predicting Asthma. Frontiers in Pediatrics7.

Wee, J., Min, C., Jung, H., Park, M., Park, B., & Choi, H. (2022). Association between chronic rhinosinusitis and pneumonia: a longitudinal follow-up study using a national health screening cohort. Scientific Reports12(1). https://doi.org/10.1038/s41598-022-09552-8

 

 

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