ADV HEALTH ASSESSMENT

Name: Doris Ofodile

Advanced Health Assessment

Week 5

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): Coughing a lot for five days.

History of Present Illness (HPI): D.J is in third grade that lives with both parents The patient's mother brought him to the clinic with his grandmother because he was coughing a lot, had a sore throat, had rhinitis, and had pain in his right ear for five days. He gives two out of ten points for ear pain, saying his cough is wet and he can expectorate clear mucus. He also says nighttime sleep is hard for him. This morning his mother gave him purple cough medicine that did not last long. The patient has often suffered from pneumonia and colds in the past. The patient claims his father forgot to go outside while smoking a cigar, so he inhaled secondhand smoke. His vaccines have been updated, and he says he has no allergies to food, medicine, or the environment.

Medications: Multivitamin,1 tablet PO, daily.

Unknown name of Cough medicine, unknown dosage, PO, PRN for cough

Allergies: NKA

Past Medical History (PMH): Pneumonia previous year

Past Surgical History (PSH): None

Sexual/Reproductive History: Deferred for this visit.

Personal/Social History D.J is in third grade that lives with both their parents and paternal grandmother. Both parents are schoolteachers, and his grandmother cares for him. Sometimes last year, he was out of school for about two weeks with pneumonia. He loves soccer, video games, and watching movies with Kayla. He likes chocolate milk, juice, and popsicle

Immunization History: No influenza vaccine in the last 12 months.

Hep B 3-dose series completed at 6 months.

Hep A 2-dose was completed at 15 months.

MMR - 2-dose was completed at 6 years

DTaP- 5-dose was completed at 6 years.

Polio - 4-dose was completed at 6 years.

Varicella - 2-dose was completed at 6 years.

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Significant Family History):

Mother aged 35years Type 2 diabetes, hypercholesterolemia, obesity

Father aged 38yearss, Current smoker, HTN, Asthma

Paternal grandmother- Type 2 diabetes,

Paternal grandfather- Smoker

Maternal grandmother- Died at 60 years in a car accident 5 years ago.

Maternal grandfather- Died at 68 years in a car accident 5 years ago

Review of Systems:

General: No fevers, no chills. He has been feeling fatigued.

HEENT No headache, feeling of dizziness, or feeling lightheaded. No loss of vision. Nothing hurt or drained. Neither does he wear glasses, nor does he have tinnitus or hearing problems. He denies sore throats or toothaches. His appetite is not affected. He does not have nose problems. While he had rhinorrhea, he says he did not have congestion. There was no post-nasal drainage.

Respiratory: Denies experiencing pain when inhaling. No shortness of breath, presence of cough

Cardiovascular/Peripheral Vascular: No Chest pain, no palpitations, no syncope

Psychiatric: No Suicidal ideations. No family history of psychiatric illness.

Neurological: no headache, no confusion, no tremors

Lymphatics: Reports no lymphatic disease.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Resp Rate 28; Temp 37.2 C, BP 120/76 sitting; O2 sat 96; Pusle 100; Ht 4’2, Wt 90 lbs; BMI 25.3, overweight.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

HEENT: Normocephalic, symmetrical head. Smile-symmetric face. No scalp patch was noticed. Frontal and maxillary sinuses are nonpalpable. There were no visual abnormalities. Clear-pink conjunctiva. Pink, wet conjunctiva; white, erythematous sclera; no discharge. Right tympanic membrane and auditory canal are red. 5:00 is Cone Of Light. None were found. Normal left auditory canal and tympanic membrane. 7:00 Cone of Light. No discharge. Pink nasal cavity. Discharge clear. There was no abnormality. Mid-septum. Pink, moist gums. Posterior Oropharynx and Tonsils are erythematic with cobblestoning. Mid-tongue.

Respiratory: Tachypneic at a rate of 28 breaths per minute. Breathing evenly and without effort. The chest has symmetry. No extraneous breath noises are audible. Expected fremitus equal bilateral. Bronchophony is unfavorable. All regions of the chest resonate with percussion. No dull region was seen.

FVC: 1.78L, FEV1 1/549l(FEV1/FVC:87%)

Cardiology: No edema noted. Normal heart rate is 100. Regular pace and rhythm; S1 and S2 are normal with no murmurs or gallops detected.

Lymphatics: No palpable node was observed on the left clavicle, Axillary, and Supraclavicular nodes.

Integumentary: The skin is still intact and feels warm to the touch.

Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)

1. Nasal aspirates and swabs

2. Rapid strep swabs

3. Otomicroscopy

4. Negative skin-prick or serum sIgE testing to aeroallergens

5. a chest X-ray (CXR)

6. Otoscope

ASSESSMENT:

Differentiate

1. Upper respiratory infection with acute otitis media (right ear),

2. Pneumonia

3. Nonallergic rhinitis

Plan:

1. Chest X-ray to rule out pneumonia. 2. Tylenol 325mg tablet PO every 4 – 6 hours. 3. Prescribe Broad-spectrum antibiotics and stop if strep result is negative 4. Benadryl 25 mg. PO Every 4-6 hrs. PRN 6 capsules in 24 hrs. 5. Cough suppressants should only be used for severe dry coughs for 14 days 6. Education: Parents should advise Smoking should be stopped around the patient or at

home and the danger of secondhand inhalation of smoke. 7. Education: Increase fluids and use a humidifier at night for comfort. 8. Annual Flu vaccine 9. Follow up 7 days if symptoms persist or sooner for worsening symptoms like fever,

hearing l loss, increased ear pain, and lack of sleep. 10. Call 911 or go to the emergency department if you have shortness of breath, chest pain, or

syncope.