Name:

Section:

Week 5               

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): Cough and feeling sick.

History of Present Illness (HPI): Hispanic boy Danny, age 8, is brought in by his Abuela with complaints of a productive cough. He mentions that the cough has been going on for five days now and notes it has a watery and gurgly feel. He claims that the cough that comes about once every two minutes. Along with the cough, he experiences other symptoms including runny nose, sore throat, and right ear pain.  Danny reports that cough that is worse at night, preventing him from having quality sleep at night. He claims there is no discharge from his ear. There have been no alterations to the senses of hearing or smell, and the discharge from the nose is watery and clear. He used a purple cough medicine, one teaspoon each day, but it did not provide any alleviation for his cough. His father is a smoker, and he grows up around it. There were no symptoms of fever, chills, or headaches. Shadow Health Digital Clinical Experience Focused Exam Paper

Medications:

Multivitamin

Purple cough medicine

Allergies: NKA

Past Medical History (PMH): History of pneumonia. No history of hospitalization

Past Surgical History (PSH): Denies surgical history

Personal/Social History: Mr. Rivera is currently studying in the third grade. He lives with his parents and grandmother. His parents both have jobs, so his grandma takes care of him most of the time. The primary language used at home is English; however some Spanish is also spoken.

Immunization History: All vaccinations are up to date.

Significant Family History

Father: Smoker, hypercholesterolemia, hypertension, asthma as a child.

Mother: hypertension, type 2 diabetes,

Maternal Grandmother: Type 2 diabetes

Maternal Grandfather: eczema, smoker,

Paternal Grandmother: Deceased at age 52 in a car accident Paternal Grandfather: No medical history

Review of Systems:

General: Reports fatigue and sick feeling due to coughing. Denies appetite changes. Denies fever, chills, night sweats, or weight change.

HEENT: Denies headaches. Denies vision or hearing changes. Reports right ear pain. Reports runny nose with clear drainage. Reports mild sore throat, denies swallowing problems. Denies dental cavity, gum bleeding, or gingivitis.

Respiratory: Reports a cough. Denies difficulty breathing, wheezing or dyspnea.

Cardiovascular/Peripheral Vascular: Denies chest pain, pressure, or tightness. Denies murmurs, palpitations or edema.

Psychiatric: Denies history of depression or anxiety. He reports that his nighttime coughing prevents him from getting a good night’s sleep.

Neurological: Denies headaches, dizziness or vertigo. Denies loss of coordination, changes in memory patterns, or unsteady gait.

Skin: Denies itching, rash, or lesions.

Hematologic: Denies bleeding problems, blood clotting, or history of anemia

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OBJECTIVE DATA:

Vital Signs: Height: 127 cm Weight: 40.8 kg BMI: 25.3 T: 37.2 C RR: 28 HR: 100 BP: 120/76mmhg  O2 sat: 96% on room air

Physical Exam

Constitutional/General survey: fatigued-looking boy, in no acute distress. Alert and oriented x 3. Clear and coherent speech.

HEENT:

Head: Normocephalic and atraumatic.

Eyes: PERRLA. conjunctiva moist and pink, sclera white. No discharge

Ears: Right auditory canal and tympanic membrane swollen and erythemic. Left auditory canal pink. tympanic membrane pearly grey. No discharge or perforations in both ears.

Nose: mucus membrane moist and pink, clear nasal drainage.

Throat: cobblestoning and erythema in the posterior oropharynx. Gag reflex positive.  Shadow Health Digital Clinical Experience Focused Exam Paper

Neck/Lymph nodes: Neck supple. Full range of motion, no stiffness. Right cervical lymph node swollen with tenderness to palpation.

Respiratory: Productive cough with clear phlegm. Lungs clear to auscultation. Can speak in complete sentences. No rhonchi, wheezing, or bronchophony. Lungs resonant to percussion. Expected fremitus equal bilaterally.

Spirometry: FEV1: 3.15 L, FVC 3.9 L (FEV1/FVC: 80.5%)

Cardiovascular: S1 and S2, regular rate and rhythm. No rubs, gallops, or murmurs.

Neurologic: alert and oriented x3. CN II-XII grossly intact

Diagnostics/Labs: None

ASSESSMENT:

Differential Diagnosis:

Upper respiratory infection: It impacts the upper part of the respiratory system, such as nasal passages and throat. A cough, a sore throat, and a runny or stuffy nose are all indications of an upper respiratory infection. Common treatments for upper respiratory infections comprise getting plenty of rest, drinking plenty of water, and using over-the-counter pain medication (Aplin-Snider et al., 2020). This is a possible diagnosis for Danny because he has a cough, runny nose, and sore throat.

Otitis Media: This is the infection or inflammation located in the middle ear. It can be caused by a respiratory infection, cold, or sore throat. In most cases, Otitis media is brought about by bacteria or viruses. Fever and ear ache are two of the most prevalent symptoms. Hearing loss or discharge from the ear may occur, although these symptoms are far less frequent. In most cases, Otitis media will clear up on its own, but in others, antibiotics may be necessary (Paul & Moreno, 2020).

Allergic Rhinitis: This condition is characterized by inflammation of the membranes that line the nose. Sneezing, itching in the nose, eyes, ears, or palate, a runny nose, or congestion in the nasal passages are some of the symptoms of allergic rhinitis. Allergic rhinitis arises seasonally or year-round. Antihistamine medicine is often prescribed to patients suffering from this ailment in order to alleviate their symptoms (Small et al., 2018).

References

Aplin-Snider, C., Cooper, D., Dieleman, P., & Smith, A. (2020). Development and implementation of an upper respiratory infection treatment protocol in a primary care health clinic. Journal of Primary Care & Community Health, 11, 215013272096681. https://doi.org/10.1177/2150132720966811

Paul, C. R., & Moreno, M. A. (2020). Acute otitis media. JAMA Pediatrics, 174(3), 308. https://doi.org/10.1001/jamapediatrics.2019.5664

Small, P., Keith, P. K., & Kim, H. (2018). Allergic rhinitis. Allergy, Asthma & Clinical Immunology, 14(S2). https://doi.org/10.1186/s13223-018-0280-7

Shadow Health Digital Clinical Experience Focused Exam Paper