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WK 5 Focused Note Cough Danny Rivera
Advanced Health Assessment (NURS 6512)
Walden University
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Name: Danny Rivera Section: NURS 6512
Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA: Cough
Chief Complaint (CC): Cough History of Present Illness (HPI): This is an 8-year-old Puerto Rican male, who was brought in today by his grandmother with a persistent productive cough that started about 4-5 days ago. He reports a mild sore throat, rates pain 2/10, food and liquid do not make a difference in his cough. He denies trauma or sick contacts. No fever or muscle aches. He reports a runny nose with clear drainage, with mild throat soreness that he rates a 2/10. He has a productive cough with clear sputum, that keeps him up at night, he also reports right ear pain. He states his mother gave him “purple” cough syrup, but it helped minimally. He denies fever, chills, body aches and has no change in appetite or ability to swallow. He also denies sick contacts and reports he washes his hands frequently. Medications: Daily multivitamin; cough syrup (purple?) Allergies: None Past Medical History (PMH): Frequent ear infections as a toddler, last one around 2 years old; Pneumonia 2020 (treated at urgent care clinic) Past Surgical History (PSH): No surgical history or prior hospitalizations Sexual/Reproductive History: Personal/Social History: Danny is in the 3rd grade, missed 2 weeks of school last year due to pneumonia. He lives with is mother, father who work during the day and his grandmother provides child-care while parents work. English is the primary language spoken in the home, however some Spanish is used. Immunization History: Current and up to date with all age appropriate vaccinations. No flu vaccine in the last 12 months. Significant Family History : Mother: type 2 diabetes, HTN, hypercholesterolemia, spinal stenosis, obesity. Father: smoker, HTN, hypercholesterolemia, asthma as a child. Maternal grandmother: type 2 diabetes, HTN. Maternal grandfather: smoker, eczema. Paternal grandmother: died at age 52 in a car accident. Paternal grandfather: history unknown.
Review of Systems: General: Breathing non labored, afebrile, coughs every few seconds, cough is dry, coarse and non-productive, while in clinic. HEENT: Positive for R ear pain, slight sore throat Respiratory: Positive for productive cough with clear sputum, Cardiovascular/Peripheral Vascular: Denies chest pain, no murmurs or rubs, no dyspnea Psychiatric: Denies being sad or feeling anxious Neurological: Denies seizures, syncope, no head trauma reported Lymphatics: Denies blood transfusions, denies anemia
OBJECTIVE DATA:
Physical Exam: Vital signs: 37, 120/76, 100, 28, 96% on RA, 4’2”, 90 lbs., BMI General: This is a well-developed, well nourished 8 year old Puerto Rican boy who is alert and cooperative. He is a good historian and answers all health questions appropriately. He coughs every few minutes but is no distress. HEENT: Normocephalic, face symmetrical. No ptosis, eyelid edema, lesions or allergic shiners; sclera white; conjunctiva pink and moist, no drainage. Right tympanic membrane erythemic, bulging, cone of light 5:00, left ear pearly gray, cone of light 7:00, no drainage, erythema Nasal cavities pink with clear discharge noted, turbinates with decreased patency. Respiratory: Chest symmetrical with respirations, no wheezing, crackles or other adventitious lung sounds. Cardiology: RRR, no murmurs, or rubs Lymphatics: No bruising or bleeding, no lymphadenopathy, no Psychiatric: No depressed or sad mood, no anxiety. Mood calm and appropriate.
Diagnostics/Labs: Chest x-ray, throat swab to rule out strep throat, sputum culture and CBC.
ASSESSMENT: Priority Diagnosis: Common Cold caused by Rhinovirus: Belonging to the Enterovirus (EV) genus, is the most common cause of upper respiratory infections, like the common cold (Royston & Tapparel, 2016). Rhinovirus causes sneezing, throat irritation, rhinorrhea or runny nose, and ear and sinus tract inflammation and irritation (Vundavalli, 2018). Onset of symptoms usually occurs 1-2 days after becoming infected and can last up to 14 days (Vundavalli, 2018). The symptoms are usually
References Correl, R. (2021, August 22). How cold and flus are diagnosed. verywellhealth/cold-flu-
diagnosis-
Buensalido, J. A. (2019, July 30). Rhinovirus infection (common cold) workup.
emedicine.medscape/article/227820-workup
Small, P., Keith, P. K., & Kim, H. (2018). Allergic rhinitis. Allergy Asthma and Clinical Immunology, 14(51).
doi/10.1186/s13223-018-0280-
Vundavalli, S. (2018). Rhinovirus infections. Retrieved January 4, 2022, from
healthychildren/English/health-issues/conditions/ear-nose- throat/Pages/Rhinovirus-Infections
DeBoer, D. L. & Kwon, E. (2021 ). Acute Sinusitis [StatPearls Internet]. Treasure Island.
ncbi.nlm.nih/books/NBK547701/
National Heart, Lung, and Blood Institute. (n.). Bronchitis. nhlbi.nih/health/bronchitis
Medline Plus. (2021). Acute bronchitis. medlineplus/acutebronchitis.html
WK 5 Focused Note Cough Danny Rivera
Course: Advanced Health Assessment (NURS 6512)
University: Walden University
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