Focused Exam: Cough Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

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Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Dany is a 8 year old hispanic boy, brought into clinic by his grandmother. He is able to answer the questions independently and maintains eye contact. He reports a gurgly watery cough for the last 4-5 days. His throat is hurting with the cough, and is feeling tired. Difficult sleeping due to the cough. His mother gave him a “purple medicine” this morning, for the cough, although he doesn’t know the name of it. It has helped, but then his cough presents itself again. He has c/o right ear pain, that started yesterday. He has had hx of ear infections when he was 2 yo. He denies fever or chills, or watery eyes but states he gets the “cold” frequently. Denies chest pain or difficult breathing No allergies to meds or pollen Immunizations: updated PMHx; ear infections at childhood Surgical hx: none Social hx: Lives with parents, grandmother assists with care, when parents are at work. does not smoke, exposed to 2nd hand smoke from his Papi. Washes hands before eating or after restroom. No family history of asthma or allergies.

Danny reports a cough lasting four to five days. He describes the cough as “watery and gurgly.” He reports the cough is worse at n and keeps him up. He reports general fatigue due to lack of slee He reports pain in his right ear. He is experiencing mild soreness his throat. He reports his mother treated his cough symptoms wi over-the-counter medicine, but it was only temporarily effective. reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumo in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, trouble swallowing, nosebleed, phleg or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.

Objective

Daniel appears slightly tired, and has been coughing throughout the exam Vital signs stable Spirometer: FEV1: 3.15L FVC 3.91L/ 80.5% Head: Cervical lymph nodes enlarged and tender on right side; Sinus: no tenderness on frontal or maxillary eyes: pink in color, no discharge Ears: right ear redness and inflammed: no d/c nose: clear watery phlem, no odor Throat: oropharynix: cobberstone, redness with postnasal drip Lungs: CTA bilaterally: Breath sounds: clear bilaterally anterior and posterior. bronchophony: negative Chest: S1 and S2 audible, no murmurs or abnormal heart sounds

• General Survey: Fatigued appearing young boy seated on nurs station bench. Appears stable. • HEENT: Mucus membranes are moist, clear nasal discharge. Redness, cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. Right Tympanic membrane is red inflamed. Right cervical lymph node enlarged with reported tenderness. • Cardiovascular: S1, S2, no murmurs, gallops or rubs. • Respiratory: Respiratory rate increased, but no acute distress. A to speak in full sentences. Breath sounds clear to auscultation. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1: 3.15 L, FV 3.91L (FEV1/FVC: 80.5%)

Your Results Lab Pass (/assignment_attempts/6699430/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Vitals Document: Provider Notes

https://aspen.shadowhealth.com/assignments/313480/
https://aspen.shadowhealth.com/assignment_attempts/6699430/lab_pass.pdf
Student Documentation Model Documentation

Assessment

Differential diagnosis: 1. flu-like syndrome or cold 2. strep throat 3. Allergies 4. Allergic rhinitis

My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region.

Plan

Discuss hand hygiene and hygiene ettiquitte when coughing: cough in elbows, and hand hygiene. Strep culture Cough medication to help sleep at night and suppress cough Antihistamine to dry up secretions Encourage fluid intake, avoid dairy products that can make cough worse: phlem may get thicker Refer for allergy testing if antihistamine did not work Educate warning signs for immediate attention like difficult breathing, fever, chills, or cough worsening. Follow up in a week or telephone appt in 3 days to follwo up on progress Educate the family the importance of hand hygiene

Danny should be referred for an allergy test to rule out allergies a well as a lung function test to rule out asthma. He should receive strep culture to rule out strep throat. I recommend antitussive treatment at night to help with his sleep in addition to bed rest.

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