NUR 516 Focused Exam_ Cough _Documentation Latest Updated Graded A

Focused Exam: Cough Results | Turned In Advanced Health Assessment - September 2019, 2019SEP NUR-516-NG001 Return to Assignment Shadow Health will be performing planned maintenance Monday November 11th, from 11:00am u ...

Focused Exam: Cough Results | Turned In Advanced Health Assessment - September 2019, 2019SEP NUR-516-NG001 Return to Assignment Shadow Health will be performing planned maintenance Monday November 11th, from 11:00am until 12 noon Eastern. During this time assignment attempts will be disabled. Thank you for helping us to improve your Shadow Health experience! Your Results Lab Pass Document: Vitals Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Self-Reflection Documentation / Electronic Health Record This study source was downloaded by 100000831988016 from CourseHero.com on 03-19-2022 14:31:03 GMT -05:00 https://www.coursehero.com/file/50721287/Focused-Exam-Cough-Documentationpdf/ Student Documentation Model Documentation Subjective Daniel Rivera (Danny), 8 year old male of Hispanic descent was brought to the clinic today by his Abuela. He is complaining of a cough, runny nose, right ear pain and general feeling of tiredness. HPI: Danny describes a "gurgly and watery" cough that began five days ago. He states that he is feeling tired because the cough is worse at night and preventing him from sleeping properly. Danny stated that his mother gave him cough medicine but he does not know which brand. He did say that it was purple in color. Danny noted that the cough medicine helps for a short amount of time but then the cough comes back. He also complains of a pain in his right ear 3/10 that began one day ago. Danny did state that he suffered from several ear infections as a toddler around the age of two. Danny says that he does suffer from frequent runny noses. Danny denies a recent fever, chills, dizziness, difficulty swallowing or difficulty breathing. Although Danny's daily activities have not been affected by his cough, he did note that he stopped playing during recess and worked on the school computer during that time. Social History: Danny lives with his mother, father and grandmother. His father is a smoker who has hypertension and high cholesterol. His mother has hypertension, high cholesterol and is a diabetic. Allergies: Danny denies any seasonal, food or medication allergies. Medications: Danny states that he takes a children's chewable multivitamin each day and admits to taking more than one to be " super healthy". Immunizations: Danny states that he is up-to-date on all of his immunizations but denies receiving the influenza vaccine this year. PMI: Danny has a history of colds and notes an almost constant runny nose. He suffered from pneumonia at the age of seven. He did have several ear infections as a toddler. He denies ever being diagnosed with asthma. ROS: HEENT: Danny denies itchy eyes but comolains of a ruuny nose, right ear pain and sore throat. Respiratory: Danny denies any shortness of breath. Cardiac: Danny denies any chest pain. Gastrointestinal: Danny denies any recent nausea or vomiting. 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. This study source was downloaded by 100000831988016 from CourseHero.com on 03-19-2022 14:31:03 GMT -05:00 https://www.coursehero.com/file/50721287/Focused-Exam-Cough-Documentationpdf/ Student Documentation Model Documentation Objective General: Danny Rivera is a pleasant 8 year old Hispanic male who is alert and oriented in no acute distress. ROS HEENT: Danny's head and neck are symmetrical. His eyes are clear with pink conjunctiva.Danny's right tympanic membrane is erythemic with cone of light visible at 5. His left tympanic membrane is pearly gray with cone of light visible at 7. Danny's nasal passages are moist with clear nasal discharge. His right cervical lymph node was enlarged with reported tenderness. Danny's throat is erythemic with Cobblestoning at the back. Cardiac: S1, S2 are audible with no murmurs, gallops or rubs. Respiratory: Danny's respiratory rate was increased at 28 but he is not in acute distress. Breath sounds are clear and present in all areas with no adventitious sounds. Bronchophony was negative. His chest was resonant to percussion with no dull areas. Expected fremitis equal bilaterally using "99". Spirometry: FVC 3.91L, FEV1 3.15L. Vital Signs: BP 120/76; R:28; O2: 96; HR: 100: T:37.2 degrees Celsius Assessment: Differential diagnosis: cold; strep throat; allergies Plan: Rapid strep test; if positive prescribe Amoxicillin 40mg per kg per day. Recommend over-the-counter children's cough suppressant and lozenges. Refer patient to an allergist. Education: Warn about possible allergic reactions to amoxicillin. Discuss the proper dosage of cough suppressant. Encourage increase fluid intake. Discuss the possibility of allergies and request that bed sheets are changed weekly. Recommend that there be no smoking in the house or around the child. Speak with grandmother and explain to her that she needs to seek immediate medical attention if Danny spikes a high fever, experiences any shortness of breath, chest pain or dizziness. Request that the patient return to the clinic in 2 weeks time for a follow-up. • 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%) Comments If your instructor provides individual feedback on this assignment, it will appear here. This study source was downloaded by 100000831988016 from CourseHero.c