Assignment 2: Digital Clinical Experience Cough
ligiarivera
Cough.pdf.pdf
Focused Exam: Cough Results | Turned In Advanced Health Assessment - Chamberlain, NR509-August-2018
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Your Results Lab Pass Lab Pass
This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
Patient: Danny Rivera
Digital Clinical Experience Score
100%
Beginning Developing Proficient
Subjective Data Collection 20 out of 20
Objective Data Collection 12.8 out of 13
Education and Empathy 3 out of 5
Interaction with patient 287 minutes
Post-exam activities 22 minutes
Time 309 minutes total spent in assignment
Student Performance Index 35.8 out of 38
Proficiency Level: Proficient
Students rated as “proficient” demonstrate an entry- level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.
Document: Vitals Document: Provider Notes
Document: Provider Notes
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Self-Reflection
Experience Overview
Documentation / Electronic Health Record
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Student DocumentationStudent Documentation Model DocumentationModel Documentation
Subjective
CC: Cough
HPI Onset: 4-5 days ago
Location: right ear pain
Duration: "a couple of minutes"
Characteristics: sore throat (mild), fatigue
Aggravating factors: night time
Relieving factors: cough syrup
Treatment: OTC cough syrup
Current medications: multivitamins and cough syrup
Allergies: none
PMHx: pneumonia, frequent ear infections during early childhood
Social Hx: The patient lives with his mother, father, and maternal grandmother and grandfather. Father sometimes smoke in the house.
Family Hx: Father had asthma as a child and is a current positive smoker. Maternal grandfather also has a smoking history and diagnosed with eczema.
ROS Constitutional: Positive for fatigue related to cough that keeps him up at night. Denies night sweats, fevers, chills, and weight loss.
HEENT: Denies headaches and dizziness. Denies nosebleeds. Positive for right ear pain. Denies ear drainage. Positive for clear nasal discharge. Denies eye redness, watery eyes, eye pain and visual disturbances. Positive for sore throat.
Cardiac: Denies chest pain and tightness
Resp: Positive for dry cough. Denies shortness of breath.
GI: Denies nausea, vomiting, diarrhea. Denies abdominal pain and discomfort. Last BM was today before school.
Danny reports a cough lasting four to five days. He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. He reports general fatigue due to lack of sleep. He reports pain in his right ear. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, trouble swallowing, nosebleed, phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.
Objective
Danny Rivera is an 8 year old Puerto Rican male who presents to the clinic with a cough. He is alert and oriented to person, place, time and situation. He is answering questions appropriately. He is in no acute distress.
• General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable.
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HEENT: Head is normocephalic and atraumatic. Sclera white, conjunctive moist and pink with no drainage. Right ear positive for pain. Inflammation and redness noted in right tympanic membrane. Nasal cavities pink, patent with clear drainage. Negative for tenderness on palpation at frontal and maxillary sinuses. Oral mucosa moist and pink. Erythema noted to tonsils. Posterior throat is red with cobblestoning. Right sided cervical lymph nodes are tender on palpation.
Resp: Lung sounds are present and clear on auscultation in all lobes. Positive dry cough. Positive tachypnea. Negative for bronchophony. Chest wall is symmetrical and resonant in all areas on percussion. No areas of dullness noted. Fremitus symmetrical and equal bilaterally on palpation. Spirometry result: FEV1/FEVC 80.5%
Cardio: S1 and S2 heart sounds on auscultation. No murmurs, rubs, or gallops detected.
• 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 and 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. Able 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, FVC 3.91L (FEV1/FVC: 80.5%)
Assessment
Cough/Viral rhinitis- dry cough for 4-5 days, sore throat
Strep throat- throat redness, tenderness, and cobblestoning
Viral respiratory infection- clear nasal discharge and dry cough
Asthma- cough, fatigue, frequent exposure to cigarette smoke.
Allergies: clear nasal drainage
Cough. Differential diagnoses include cold, strep throat, rhinitis, allergies, and asthma
Plan
Diagnostics: Order rapid strep test to rule out strep throat. Order sputum culture to rule out an respiratory infection. Consider ordering WBC and PFTs to help rule out asthma.
Medication: Order antibiotics if rapid strep test is positive. Order robutussin DM 5mL every 6 hours PRN for cough for five days, do not administer more than 40mL a day. Order claritin (chewable tabs) 5mg twice daily for five days.
Education: Educate patient to increase fluids. Educate patient to wash his hands frequently, demonstrate appropriate technique and assess return demonstration. Educate patient's mother to wash bed linen weekly. Educate patient to avoid areas of smoke exposure. Educate and emphasize to the adult family members on the importance of not smoking in the house or in any area that the child will likely experience exposure. Educate parents to seek immediate medical attention for a fever >101.5, chest pain or tightness, shortness of breath, and dizziness.
Diagnostics • Implement Centor criteria assessment • Obtain rapid strep test
Medication • Pending rapid strep test results, may order appropriate antibiotic therapy • Initiate Rx or OTC antitussive therapy at bedtime for 10 days
Education • Educate caregiver and patient to minimize exposure to allergens, practice good hand washing, and recommend cleaning bed sheets weekly • Request no smoking in house
Referral/Consultation • Refer to allergy specialist for allergy testing • Refer for lung function testing to rule out asthma
Follow-up Planning • Instruct caregiver and patient to seek immediate
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Referral/Consultation: Refer patient to ENT specialist for allergy testing. Refer patient to an pulmonologist or asthma specialist to rule out asthma.
Follow-up: Have family bring patient back to the clinic in 7-10 days for follow-up.
medical attention if high fever, shortness of breath, chest pain, and dizziness or faintness • Revisit clinic in 1-2 weeks for follow up and evaluation
Comments
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This study source was downloaded by 100000829165196 from CourseHero.com on 10-01-2021 19:56:56 GMT -05:00
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