I have provided the template which will guide you now to complete the Case study assessment and examples with all the information regarding the pediatric patient. It is rewriting the information provided.(Cough Assessment Documentation Sample-Solution)
- Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Cough Assessment Documentation Sample-Solution
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
Subjective Data: Cough
Chief Complaint (CC): Coughing a lot of feeling tired
History of Present Illness (HPI)
The patient is an 8-year-old male from Puerto Rico. His grandmother brought him today to the hospital with a persistent cough that started about 4-5 days ago. He rates pain 2/10 and experiences mild sore throat. There is no difference in coughing after taking food or liquid. The patient denies sick contacts or trauma. He reports no muscle aches or fever but experiences a running nose with clear fluid. He rates his mild sore throat at 3/10. His productive cough produces clear sputum, which keeps him up almost every night. He experiences pain in the right ear. The patient reports being given “purple” cough syrup by her mother, but the medicine had minimal help. The patient denies experiencing chills, fever, changes in appetite, and body aches. The patient reports that he regularly washes his hands.(Cough Assessment Documentation Sample-Solution)
Medications: cough syrup, daily multivitamin
Allergies: No allergies
Past Medical History (PMH): Last one around two years old, ear infections as a toddler, Pneumonia in 2020
Past Surgical History (PSH): None
Sexual/Reproductive History: None
Personal/Social History: Patient lives with his parents, grandparents; his grandparents care for him while the parents are away. The patient is a grade 3 student, and Tony is his best friend.
Immunization History: Childhood vaccines are up to date, no flu vaccine in the last 12 months.
Significant Family History: Father-smoker, HTN, Asthma as a child, hyperlipidemia.(Cough Assessment Documentation Sample-Solution)
Review of Systems:
General: Afebrile, breathing non-labored, dry cough every few seconds.
HEENT: Positive for right-year pain, presence of slight sore throat.
Respiratory: Productive cough is positive with clear sputum.(Cough Assessment Documentation Sample-Solution)
Cardiovascular/Peripheral Vascular: No murmurs or rubs, denies the presence of chest pain, no dyspnea.
Psychiatric: Denies being anxious or sad.
Neurological: Denies syncope, seizures, and no head trauma.
Lymphatics: Denies anemia and blood transfusions.
Physical Exam: Vital signs: 37.3, 124/78, 100, 29, 97% on RA, 4’3’’, 94 Ibis, BMI
General: The patient is a well-developed and nourished 8-year-old boy. He is alert and cooperative. He can answer all health-related questions effectively and is a good historian who narrates his life events. He coughs after every few seconds but has no distress.(Cough Assessment Documentation Sample-Solution)
HEENT: Face symmetrical, no eyelid edema, ptosis, allergic shiners, or lesions. Normocephalic, sclera white; conjunctiva pink and moist, no drainage. The left ear is pearly gray; the right tympanic membrane erythema is bulging. Nasal cavities pink with clear discharge reported, turbinate with reduced patency.(Cough Assessment Documentation Sample-Solution)
Respiratory: No wheezing, chest symmetrical with respirations, no crackles or other adventitious lung sounds.
Cardiology: No murmurs, or rubs, RRR
Lymphatics: No lymphadenopathy, no bleeding or bruising.(Cough Assessment Documentation Sample-Solution)
Psychiatric: No anxiety, depression, or sad mood. Patient has calm and appropriate mood.
Diagnostics/Labs: Throat swab to assess and rule out the potential of strep throat, chest x-ray, CBC, and sputum culture.(Cough Assessment Documentation Sample-Solution)
Priority diagnosis: Common cold, which rhinovirus causes. According to Vandana et al. (2019), rhinovirus is among the most critical causes of the common cold resulting from upper respiratory infections. This virus causes throat irritation, sneezing, running nose, and sinus tract inflammation and irritation (Jackson & Germ, 2022), which were observed in the case patient. The common cold symptoms caused by rhinovirus are often accompanied by malaise and fatigue, fever, and muscle aches (Vandana et al., 2019). This diagnosis is supported by the patient’s subjective and objective data.(Cough Assessment Documentation Sample-Solution)
J01. Acute Sinusitis
Acute Sinusitis is characterized by acute inflammation of the sinuses and has a viral etiology such as rhinovirus (Leung, Hon & Chu, 2020). However, this condition can also be caused by y bacterial pathogens, such as H. influenzae and Streptococcus pneumoniae (Nicholas et al., 2020). To reach the diagnosis of Acute Sinusitis, the patient must obtain complete data on the health history and physical exam information. Some of the critical symptoms of Acute Sinusitis, as reported in the study by Leung, Hon, and Chu (2020), include purulent nasal drainage with coupled nasal obstruction. However, the diagnosis of Acute Sinusitis was not fully supported by the subjective and objective data of the patient as the patient did not experience all three critical symptoms of this infection.(Cough Assessment Documentation Sample-Solution)
J30.1. Allergic Rhinitis (AR)
AR is closely related to asthma and conjunctivitis and is characterized by symptoms such as nasal congestion, rhinorrhea, itching, and sneezing (Schuler IV & Montejo, 2021). AR negatively impacts an individual’s quality of life, leading to sleep disturbance and poor social interactions. AR is assessed by performing a thorough history and physical, including identifying primary symptoms. AR diagnosis is enhanced by the trial of antihistamines or nasal glucocorticoid steroids (Schuler IV & Montejo, 2021). The patient’s clinical symptoms in this case study were not suggestive of the AR as he did not report nasal itching or congestion. Even though the patient has rhinorrhea, this only is not adequate evidence to support the diagnosis of AR.(Cough Assessment Documentation Sample-Solution)
According to Ruffles et al. (2021), bronchitis involves inflammation of the bronchial tubes leading to coughing. The common cold or the flu often causes this inflammatory effect. Major bronchitis symptoms, as reported in the study by Ruffles et al. (2021), include shortness of breath, wheezing, chest tightness, and a low-grade fever. The patient in this case study did not report any presence of wheezing, shortness of breath, tightness of the chest, or lower-grade fever. Therefore, his clinical data did not support the diagnosis of bronchitis.(Cough Assessment Documentation Sample-Solution)
Jackson, D. J., & Germ, J. E. (2022). Rhinovirus infections and their roles in asthma: etiology and exacerbations. The Journal of Allergy and Clinical Immunology: In Practice, 10(3), 673-681.
Leung, A. K., Hon, K. L., & Chu, W. C. (2020). Acute bacterial sinusitis in children: an updated review. Drugs in Context, 9(2), 109-114.
Nicolas, R., Morendo, E., Le Treat-Gay, C., Mancini, J., Akkari, M., Mondain, M., … & Triglia, J. M. (2020). Ibuprofen is a risk factor in complications of acute anterior sinusitis in children. European Annals of Otorhinolaryngology, Head and Neck Diseases, 137(2), 99-103.
Ruffles, T. J., Marchant, J. M., Masters, I. B., Yerkovich, S. T., Wurzel, D. F., Gibson, P. G., … & Chang, A. B. (2021). Outcomes of protracted bacterial bronchitis in children: A 5‐year prospective cohort study. Respirology, 26(3), 241-248.
Schuler IV, C. F., & Montejo, J. M. (2021). Allergic rhinitis in children and adolescents. Immunology and Allergy Clinics, 41(4), 613-625.
Vandini, S., Biagi, C., Fischer, M., & Lanari, M. (2019). Impact of rhinovirus infections in children. Viruses, 11(6), 521-528.