Walden Focused Exam Cough PDF

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Week 5- focused cough exam...

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Name: Danny Rivera Section: Week 5 - Focused Exam: Cough Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA: Chief Complaint (CC): Reports cough, runny nose, sore throat, and right ear pain. History of Present Illness (HPI): Reports cough started five days ago with coughing every few minutes. Reports cough is wet and clear sputum and worse at night. A runny nose is frequent with thin clear discharge. Pain in the right ear is a 3/10 that started after the cough with nasal discharge from the ear. Throat has now become sore with mild pain when swallowing. Medications: Pt. denies daily prescriptions. He takes a daily OTC multivitamin. Today his mother gave him a cough medication that temporarily relieved the symptoms he was experiencing. Allergies: No known allergies to food, medication, or latex. Past Medical History (PMH): History of pneumonia and frequent coughing. Past Surgical History (PSH): No surgical history. Sexual/Reproductive History: No sexual history Personal/Social History: Pt. lives in a home with his mother, father, and grandparents. His father is a cigar smoker, and the patient is exposed to secondhand smoke at times. Pt. reports feeling safe and supported at home. © 2021 Walden University

Immunization History: Childhood vaccinations are up to date. Significant Family History: The mother reports her health is good with no significant concerns. The father smokes tobacco and is moderately overweight, and being monitored for prediabetes. The patient’s grandmother has hypertension. The grandfather has type 2 diabetes controlled with oral medications and diet. Review of Systems: General: Denies fever, chills, or recent weight loss. HEENT: Pt. denies pain in his head. Pt. denies vision changes or eye complaints bilaterally with no report of eye pain, redness, or eye drainage. Pt. reports right ear pain that is 3/10. No left ear complaints. History of frequent ear infections noted, but without the need for ear tubes or surgical intervention. Pt. denies hearing changes. Pt. reports thin clear nasal drainage without congestion. No epistaxis was reported. Pt. reports throat to be sore and experiencing minor pain with swallowing. Respiratory: Denies difficulty breathing. Denies history of asthma. Productive cough with wet clear sputum x 5 days reported. Cardiovascular/Peripheral Vascular: No chest pain or cardiac history. Denies heart palpitations or abnormal activity tolerance. Pt. denies swelling in extremities. Psychiatric: No pertinent psychiatric complaints or history. Neurological: No complaints of headache, dizziness, or seizures. Lymphatics: Pt. denies painful or tender lymph nodes. © 2021 Walden University

OBJECTIVE DATA: Physical Exam: Vital signs: Blood Pressure: 120/76, O2 Sat 96, Pulse 100, Resp. Rate 28 Temp 37.2 Ht. 50 inches, Wt. 68 lbs., BMI: 19.1 General: Pt. is alert and oriented x4. Appearance of appropriate hygiene and grooming noted. Gait steady. Pt. is calm and cooperative during assessment. HEENT: Head: Symmetrical and normacephalic, atraumatic Eyes: Conjunctiva moist and pink, sclera is white with no conjunctival discharge noted bilaterally. No abnormal findings in the orbital area. Ears: Right auditory canal and tympanic membrane erythemic with intact membrane, cone of light at 5:00, and no discharge. Left auditory canal is pink and tympanic membrane is pearly gray and intact with cone of light at 7:00 and no discharge. Nose: Nasal mucosa pink and moist with patent turbinates bilaterally. Clear nasal discharge noted. Throat: Oral mucosa moist and pink, posterior oropharynx erythemic with cobblestoning noted, no post nasal drip present. Tonsils has mild erythema bilaterally. Respiratory: Chest symmetric with no abnormal visible findings. Respirations unlabored. Breath sounds audible and clear in all areas with no adventitious sounds. Negative for bronchophony. Fremitus present and equal bilaterally. No shortness of breath or use of accessory muscles with respirations. Percussion of chest was revealed; all areas were resonant without dullness.

© 2021 Walden University

Cardiology: Heart sounds S1 and S2 audible with regular rate and rhythm. No murmurs, gallops, or rubs. Peripheral pulses present and equal bilaterally. Extremities are perfused adequately with and capillary refill of < 2 seconds and no cyanosis or edema. Lymphatics: Palpable cervical nodes on the right side, not on the left. No palpable nodes in the axillary region. No palpable nodes in the supraclavicular region. No tenderness or pain in the examination. Psychiatric: No emotional concerns observed. Diagnostics/Labs: Chest X-Ray to rule of pneumonia, Covid swab to rule out Covid ASSESSMENT: Diagnosis: Upper respiratory infection: URI common include symptoms of cough, sore throat, and runny nose, which is sufficiently diagnosed through assessment of these common symptoms, especially when more serious respiratory illness is absent such as color phlegm, difficulty breathing, fever, or chest congestion (Thomas & Bomar, 2020). Differential diagnoses: Pharyngitis: Upper respiratory infections often involve the pharynx and cause irritation and inflammation in the pharynx (Thomas & Bomar, 2020). This is a possible differential diagnosis due to the slight sore throat and redness, and cobblestoning noted on assessment. Allergic rhinitis: The reports of cough and runny nose with clear sputum coupled with red cobblestoning throat, an abnormal assessment finding when polygonal cells protrude from mucosal surfaces, could indicate allergic rhinitis due to various allergens. (La Mantia & Andaloro, 2017)

© 2021 Walden University

Covid: In the current state of the Covid pandemic, testing for Covid in light of minimal symptoms may be prudent to prevent the spread of the illness. While Covid cases report a wide range of clinical symptoms, including cough, runny nose, and sore throat, they are often reported and common even in the absence of lung congestion, fever, or discomfort (Arashiro et al., 2020).

References

Arashiro, T., Furukawa, K., & Nakamura, A. (2020). COVID-19 in 2 persons with mild upper respiratory tract symptoms on a cruise ship, Japan. Emerging Infectious Diseases, 26(6), 1345–1348. https://doi.org/10.3201/eid2606.200452

La Mantia, I., & Andaloro, C. (2017). Cobblestone appearance of the nasopharyngeal mucosa. The Eurasian Journal of Medicine, 49(3), 220–221. https://doi.org/10.5152/eurasianjmed.2017.17257

Thomas, M., & Bomar, P. (2020, October 28). Upper respiratory tract infection. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK532961/.

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