WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough PDF

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WEEK5 Assignment 2: Episodic/Focused Note for Focused Exam: Cough for a 8 years old boy Danny R., he complains of coughing. He states coughing started 5 days ago. Coughs with clear sputum. Reports sore throat and running nose...

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Episodic/Focused Note for Focused Exam: Cough Master of Science in Nursing, Walden University NURS – 6512N: Advanced Health Assessment & Diagnostic Reasoning Dr. Aimee Kirkendol July 3, 2021

Episodic/Focused Note for Focused Exam: Cough

Patient Name: Daniel Rivera

Age: 8

Gender: Male

SUBJECTIVE DATA: Chief Complaint (CC): " I have been coughing a lot." History of Present Illness (HPI): Danny is a 8-years-old-boy. He states coughing started 5 days ago. Coughs with clear sputum. Reports sore throat and running nose with clear, thin discharge. Reports right ear hurting since yesterday, rated as 3/10 on the pain scale. Denies fever. Mom gives coughing medicine to relieve the symptom. Reports feeling tired at times. Sleep disturbances by overnight coughing. Denies breathing problem or asthma. Current Medications: 1. OTC cough medicine (name unknown). one spoon given. 2. Daily multivitamin (Gummy Bears – name unknown) Allergies: 

Denies any food allergy.

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Denies any medication allergy.

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Denies seasonal allergy.

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Denies allergic to any animals.

Past Medical History: 

No surgical history reported

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No prior hospitalizations reported

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Pneumonia (last year), treated at urgent care.

Social History: Danny, is a 3rd grader and he is the only child in the family. He lives with his mother, father (Security officer), and grandmother. Grandmother provides care when parents are working. Danny enjoys reading, writing, and his best friend is Tony. He likes riding a skateboard,

reading, writing, and creating stories. He was out for 2 weeks due to pneumonia. He speaks fluent English and speaks Spanish at home.Immunization History: 

No flu vaccine in last 12 months.

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Hep B: 3 dose series completed at 6 months.

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Hep A: 2 dose series completed at 15 months.

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Pneumococcal: 4 dose series completed at 15 months.

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DTaP: 5 dose series completed at 6 yrs.

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MMR: 2 dose series completed at 6 yrs.

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Varicella: 2 dose series completed at 6 yrs.

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Polio: 4 dose series completed at 6 yrs.

Family History: 

Mother, a history of T2DM, HTN, high cholesterol, spinal stenosis, overweight.

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Father, smoker, history of HTN, Hyperlipidemia, smokes, had asthma as a kid.

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Maternal Grandmother, T2DM, HTN.

1. Maternal Grandfather, smoker, history of eczema. 2. Paternal Grandmother, died in a car accident at age 52. 3. Paternal Grandfather, no known history. ROS: 

General: Reports feeling tired from coughing every few minutes. Reports sleep disturbances by overnight coughing. Denies weight loss, fever or chills. Denies breathing problem or asthma

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HEENT: Head: No headaches reported. Denies dizziness. Eye: Denies problems with eyes. Denies eye itching, redness, watery or pain. Does not wear glasses. Denies eye vision problem. Ear: Reports history of frequent ear infections. Denies ear surgery history. Reports right ear pain from yesterday rated 3/10, no swelling or drainage from right ear. Denies hearing difficulties. Denies ear popping or crackling.

Nose: reports running nose with clear and thin drainage, no bleeding, or pain. Reports frequent running nose. Denies sinus pain. Throat: Reports sore throat pain rated 2/10 (pain scale) with frequent coughing. Reports coughing every few minutes. Cough is wet with clear sputum. Reports a little difficulty of swallowing 

Cardiovascular: Denies chest pain or chest tightness. No discomfort reported.

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Respiratory: Denies breathing difficulty or shortness of breath. Denies any breathing treatment (inhaler) ever used.

OBJECTIVE VS: B/P:120/76, T-37.2, P-100, R-28, Pox-96%RA, Spirometry: FEV1-3.15, FVC-3.19 = 80.5% Weight: 90 lbs.

Height: 4’2’’

General: AAOx3, cooperative, appropriate to age. Able to answer all questions except medication’s name. Appears tired and coughing every few minutes. HEENT: Head: Normal size and shape, hair evenly distributed, no masses. Eyes: PERRLA, eye lids bilaterally symmetrical, no tearing or purulent drainage, sclera white, conjunctiva moist and pink, no discharge. Ears: bilaterally symmetrical, right tympanic membrane erythema, no discharge, cone at 5:00, free of discharge. Left ear tympanic membrane pearly-grey, free of discharge, cone of light at 7:00. Nose: size and shape bilaterally symmetrical, nasal calvity pink and non-bulging, turbinate patent, with clear excretion. Throat: no sores or missing teeth, no tumors or lesions, tonsils enlarged and red, rear of mouth red with cobble stoning. External palpation of neck and throat elicited pain with slight swelling of nodes. Cardiovascular: S1 and S2 heard on auscultation, no murmurs, no ventricular or atrial gallops.

Respiratory: Clear breath sounds present on all areas. No shortness of breath observed. No posterior masses, bulges, or crepitus felt on palpation. No adventitious breath sounds on auscultation. Lymphatic: palatable lymph nodes on cervical area. Diagnostic Results: 

Throat Swab – negative for streptococcal antigens related to GAS

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Throat Culture – negative for gonococcal

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Covid Rapid Test – negative

ASSESSMENT Danny is having coughing symptoms over 5 days, which can be a common cold. With his past medical history of otitis media, frequent rhinitis, and colds. Suggest an underlying problem that need identifying and treatment. Exposure to the secondhand smoking from his dad at home places him at risk for developing respiratory conditions. Differential Diagnoses: 1. Acute Rhinitis 2. Acute Otitis Media 3. Acute Nasopharyngitis Plan: 1. Refer to an ENT Specialist to assess and identify reasons for continuous ear infection. 2. Give patient a note to be off from school for the next 5 days. 3. Try to use an extra pillow at night to see if it helps to relieve cough. 4. Instruct caregivers continuously monitor Danny for any fever, worsening symptoms of coughing, yellow sputum, short of breath, etc. If getting worse, go to ER or urgent care. 5. Order Tylenol liquid form for pain relief and fever as needed. 6. Use OTC cough syrup to relieve symptoms if needed. 7. Encourage fluid intake and resting. 8. Ensure education materials are provided in both English and Spanish, so that caregivers can fully understand and adherence to treatment. 9. Educate Danny only takes one multivitamin (Gummy bear) a day....