Focused Exam: Cough Assignment 1
Cough Assignment
Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- 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?
- Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing tReview the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
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?
11/11/19, 3:44 PMFocused Exam: Cough | Completed | Shadow Health
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Focused Exam: Cough Results | Turned In Advanced Health Assessment – Fall 2019, NGR 6002
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Your Results Lab Pass Lab Pass
Document: Vitals Document: Provider Notes
Document: Provider Notes
Student DocumentationStudent Documentation Model DocumentationModel Documentation
Subjective
HPI:Danny reports a cough lasting four to five days. He describe the cough as ” watery and gurgly” He reports being feeling tired because the cough is worse at night and keeps him up. He reports pain in his right ear and mild soreness in his throat. He reports his mother treated his cough symptoms with over the counter cough medicaton that was temporarily effective. He reports frequent cold and runny nose. Patient has had no exposure to sick individuals. Patient denies having allergies
Home medications: Daily vitamin, over the counter antitussive medication
Past medical History: Frequent ear infections as small child. Patient reports last known ear infection was when he was two years old. He reports having pneumonia last that caused him to miss two weeks of school.
Social History: Patient lives in a house with parents and grandparents. Patient reports father smokes cigars in the house. He reports feeling safe in his home. He reports having no barriers to health care .
Review of the Systems Constitutional: Denies fever, denies chillis, denies weigh loss or gain, denies night sweats. Reports feeling “kind of tired”
HEENT: Denies ear popping, Reports history of frequent ear infections. Denies ear surgery or ear tubes. Denies headaches. Denies nosebleeds, Reports runny nose, denies vision problems, Denies dizziness, denies watery eyes, denies eye redness, denies eye pain, denies sinus problems. denies hearing problems. Reports pain in right ear. Reports mild sore thoart.
Respiratory: Reports freqent cough, denies difficulty breathing, denies chest tightness, denies history of inhaler use or breathing
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
Student Survey
Documentation / Electronic Health Record
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11/11/19, 3:44 PMFocused Exam: Cough | Completed | Shadow Health
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treatments.
Cardiovascular: Denies chest pain or chest discomfort
Objective
Mr. Rivera is pleasant and cooperative fatgued appearing young boy seated upright on the examination table. He is in no acute distress. He is alert. His speech is clear and coherent. He maintains eye contact throught the interview and examination. He offers information freely and without contradiction.
HEENT: scleara white, conjuctiva moist and pink bilaterally. Rhinorrhea with clear mucus, nasal mucosa is boggy bilaterally. Right tympanic membrane is erythematous with inflammation. Right cervical lymph node is enlarged with noted tenderness. oral mucosa mosit and pink. Tonsils 2+ with erythema and inflammation. Posterior pharynx is erythematous with cobblestoning. Fine bumps noted on tongue.
Vital signs Blood pressure 120/76 O2 saturation: 96% on room air Pulse 100 Respiratory rate: 28 Temperature; 37.2
Cardiovascular: S1, S2, no murmurs, gallops or rubs. Mild tachycardia
Respiratory: Chest is symmetrical with respirations. Increased respiratory rate. Audible coarse crackles in upper airway; bronchovesicular bilaterally, clears with cough. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1:3.15L, FVC 3.91L( FEV1/FVC: 80.5%)
• 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
My differentials include acute viral rhinopharyngitis. strep throat, allergic rhinitis, acute otitis media, allergies and asthma
My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region.
Plan
Danny will receive a strep throat culture to rule out strep throat.
10 day dose of antibiotics for treatment of acute otitis media.
Refer for allergy tesing and pulmonary function test.
Encourage Danny to increase intake of water and other fluids and educate on frequent handwashing.
Recommend antitussive treatment at night to help with his sleep.
Danny should be referred for an allergy test to rule out allergies as well as a lung function test to rule out asthma. He should receive a strep culture to rule out strep throat. I recommend antitussive treatment at night to help with his sleep in addition to bed rest.
Comments
Rebecca Hall (14 Oct 2019, 10:17 AM CDT): Great interview, very thorough and flowed well. Documentation-you did a great job on your documentation-only comment I have is to include right and left on the exam-document negative findings for left ear and neck as well as pertinent negatives for all systems examined-I know Shadow does not do this but I want you to. include supporting positive or negatives for your differential diagnoses If you have not done so I highly recommend you view the recording of the soap documentation conference. There is much information on accurate and appropriate soap
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documentation and I believe this will help you with you the flow of your interviews and your documentation so you do not miss important items.
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Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain
S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years ROS General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious
Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the
second right inter-costal space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.
Gastrointestinal–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary– Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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| Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. | 5 (5%)Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). No documentation provided. | |
| Objective Documentation in Provider Notes – this is to be completed in Shadow Health Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned A. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). |
