NR509 Focused Exam: Cough Results Turned In Advanced Health Assessment Chamberlain

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NR509 Focused Exam: Cough Results Turned In Advanced Health Assessment Chamberlain 6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3... 552952 1/4 Focused Exam: Cough Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results L La ab b P Pa as ss s Document: Vitals Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Daniel "Danny " Rivera, 8 year old male of Puerto Rican descent. CC" patience abuela brought him in because he has been feeling sick and coughing a lot and feel kind of tired." HPI: Cough onset 5 days ago, pt describe cough" gurgly and watery" . reports sputum color is clear. Reports coughing every few minutes and worse at night. Patient denies smoking but exposed to secondhand smoke in the house through father and grandfather. Reports does not know what makes his cough worse. Alleviating factors of the cough is some cough medicine in the morning. Reports having cough medicine everything for the past 5 days, describes it as purplish in color one spoon full and giving my mom. Has physical exercise everyday still able to run around and play and cough not making it difficult to play gets bored with easy school work. Reports currently having a runny nose and frequent rhinorrhea denies any sneezing. Reports nasal drainage clear and watery also thin. Reports a 3/10 in Right ear. Denies any pain to the left ear. Patient reports history of frequent ear infections around 2 years of age. Can I use any ear drainage or hearing problems. Had hearing test at school approximately about a month ago. Current Medication: Multi vitamin every day " gummy dinosaur", cough med for the past 5 days 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. Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Self-Reflection Documentation / Electronic Health Record This study source was downloaded by 100000774780401 from CourseHero.com on 08-02-2021 17:12:28 GMT -05:00 https://www.coursehero.com/file/31530124/Focused-Exam-Cough-documentation-pdf/ This study resource was shared via CourseHero.com6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 2/4 Student Documentation Model Documentation one spoonful. Patient reports a sore throat. Denies asthma diagnosis, reports immunizations are current, has a history of pneumonia at age 7 and frequent cough. Denies seasonal allergies, food allergies, and medication allergies. Denies any fever, and cough stays the same with activity Immunizations: up-to-date but has not had the flu vaccine in the last 12 months. Relevant family history father has hx asthma and no family history of allergies Hepatitis B series completed at 6 months, hepatitis A series completed at 15 months pneumococcal vaccine at 15 mts, DTAP @ 6 YEARS MMR@ 6 YEARS Varicilla vaccine@ 6 YEARS Polio Vaccine @ 6 YEARS Allergies: NKDA PHM Hx: pneumonia @ AGE 7 YRS, out patient clinic treatment, no surgeries or hospitalizations SocHx: In the third grade Out for two weeks last year because of pneumonia Live with Mother, Father, grandmother, grandmother cares for child while parents are working Primarily speaks English in the house but sometimes Spanish Fam Hx: Mother: type 2 diabetes, hypertension, hypercholesterolemia, spinal stenosis, obesity Father: smoker, hypertension, hypercholesterolemia, Asthma as a child Maternal grandmother: type 2 diabetes and hypertension Maternal grandfather: smoker, eczema. Paternal grandmother: died at age 52 of a car accident Paternal grandfather: no known history ROS: VS: B/P: 120/76 MMHG (MAP 91 mmhg) RR: 28 HR: 100 o2SAT: 96% RA Temp: 37.2C /98.6 F General: reports frequent colds, and feeling kind of tired. Denies any chills, fever, or night sweats. HEENT: denies any headaches, nosebleeds, vision difficulty, watery eyes, I redness, eye pain, sinus pain. Resp: patient denies difficulty breathing, chest tightness, chest pain. This study source was downloaded by 100000774780401 from CourseHero.com on 08-02-2021 17:12:28 GMT -05:00 https://www.coursehero.com/file/31530124/Focused-Exam-Cough-documentation-pdf/ This study resource was shared via CourseHero.com6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 3/4 Student Documentation Model Documentation Objective VS: b/p 120/76 MMHG RR:28 HR: 100 TEMP 37.2 C/ 98.6 F O2 SAT: 96% RA Spirometry: FVC: 3.91 L FEV1 3.15 L (FEV1/FVC: 80.5%) Increase respiration at 28 Mild tachycardia is 100 bpm Appears fatigued but appear stable, breath sounds clear to auscultation able to speak full sentences. Head and neck lymph nodes enlarged and tender on the right side tonsils noted erythremia cobblestoning at the back of the throat. Rhinorrhea with clear mucus, nasal cavity appears red. • General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable. • 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 1. Productive cough 2. Fatigue 3. Rhinorrhea 4. Allergies 5. Throat irritation Cough. Differential diagnoses include cold, strep throat, rhinitis, allergies, and asthma Plan 1. Prescribed cough suppressant 2. Educate family and the use of Medication 3. Encourage fluid intake 4. Encourage rest 5. Educate family on signs of worsening symptoms 6. Educate family to return a symptoms do not resolve in a few days or worsen 7 educate family on second-hand smoke 8. Follow up in one week 9. Throat culture test for strep 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 [Show More]

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