NRS 420 Shadow Health Focused Exam Cough
NRS 420 Shadow Health Focused Exam Cough
In this assignment you will be conducting a focused exam on a patient presenting with cough. Interview the patient, assess the related body systems, and then complete post-exam activities. Within the Shadow Health platform, complete the Focused Exam: Cough Results. The estimated average time to complete this assignment each time is 1 hour and 15 minutes. Please note, this is an average time. Some students may need additional time GCU.
You can attempt this assignment as many times as you would like. After completing this focused exam, you will be awarded a Digital Clinical Experience (DCE) score. The DCE score will appear on your Lab Pass which you will submit to the classroom drop box. The DCE score will be used as your percentage grade for this assignment GCU.
You are not required to submit this assignment to LopesWrite.
American Association of Colleges of Nursing Core Competencies for Professional Nursing Education
This assignment aligns to AACN Core Competency 2.8.
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation Example
SUBJECTIVE DATA:
Chief Complaint (CC): Cough
History of Present Illness (HPI): Danny is an 8-year-old Puerto Rican male who was brought in today by his grandmother with a persistent productive cough that started about 4-5 days ago. He reports a mild sore throat, rates pain 2/10, food and liquid do not make a difference in his cough. He denies trauma or sick contacts. No fever or muscle aches. He reports a runny nose with clear drainage, with mild throat soreness that he rates a 2/10. He has a productive cough with clear sputum, that keeps him up at night. He also reports right ear pain. He states his mother gave him “purple” cough syrup, but it helped minimally. He denies fever, chills, body aches and has no change in appetite or ability to swallow. He also denies sick contacts and reports he washes his hands frequently.
Medications: Daily multivitamin; cough syrup
Allergies: None
Past Medical History (PMH): Frequent ear infections as a toddler, last one around 2 years old;
Pneumonia 2020 (treated at urgent care clinic)
Past Surgical History (PSH): No surgical history or prior hospitalizations
Sexual/Reproductive History:
Personal/Social History: Danny is in the 3rd grade, missed 2 weeks of school last year due to
Pneumonia. He lives with his mother and father, who work during the day and his grandmother provides childcare while his parents work. English is the primary language spoken in the home; however, some Spanish is used.
Immunization History: Current and up-to-date with all age-appropriate vaccinations. No flu
vaccine in the last 12 months.
Significant Family History: Mother: type 2 diabetes, HTN, hypercholesterolemia, spinal stenosis, obesity. Father: smoker, HTN, hypercholesterolemia, asthma as a child. Maternal grandmother: type 2 diabetes, HTN. Maternal grandfather: smoker, eczema. Paternal grandmother: died at age 52 in a car accident. Paternal grandfather: history unknown.
Review of Systems:
General: Breathing non-labored, afebrile, coughs every few seconds, cough is dry, coarse
and non-productive while in the clinic.
HEENT: Positive for R ear pain, slight sore throat
Respiratory: Positive for productive cough with clear sputum,
Cardiovascular/Peripheral Vascular: Denies chest pain, no murmurs or rubs, no dyspnea Psychiatric: Denies being sad or feeling anxious.
Neurological: Denies seizures, syncope, no head trauma reported
Lymphatics: Denies blood transfusions, denies anemia
OBJECTIVE DATA:
Physical Exam: Vital signs: 37.2, 120/76, 100, 28, 96% on RA, 4’2″, 90 lbs., BMI
General: This is a well-developed, well-nourished 8-year-old Puerto Rican boy who is alert and
cooperative. He is a good historian and answers all health questions appropriately. He coughs every few minutes but is in no distress.
HEENT: Normocephalic, face symmetrical. No ptosis, eyelid edema, lesions, or allergic shiners; sclera white; conjunctiva pink and moist, no drainage. Right tympanic membrane erythemic,
bulging, cone of light 5:00, left ear pearly gray, cone of light 7:00, no drainage, erythema, Nasal
cavities pink with clear discharge noted turbinates with decreased patency.
Respiratory: Chest symmetrical with respirations, no wheezing, crackles, or other adventitious
lung sounds.
Cardiology: RRR, no murmurs, or rubs
Lymphatics: No bruising or bleeding, no lymphadenopathy, no
Psychiatric: No depressed or sad mood, no anxiety. Mood calm and appropriate.
Diagnostics/Labs: Chest x-ray, throat swab to rule out strep throat, sputum culture and CBC.
Primary diagnosis
Common Cold: J00
Based on the provided clinical information, the primary diagnosis for the 8-year-old patient is likely the common cold caused by the Rhinovirus. The patient’s presentation of a persistent productive cough, clear nasal discharge, mild sore throat, and absence of high fever or severe symptoms is consistent with this viral upper respiratory infection. Additionally, the ineffectiveness of over-the-counter cough syrup aligns with the typical course of the common cold, which is often self-limiting and resolves within a week or two (Araki et al., 2021).
Differential diagnosis
Acute Otitis Media (AOM) H66.90: Acute Otitis Media is a prevalent ear condition, especially in children, characterized by ear pain (otalgia) and possible associations with upper respiratory infections. AOM occurs when the middle ear becomes infected and inflamed, often as a result of viruses or bacteria ascending the Eustachian tube from the upper respiratory tract. The patient’s right ear pain is a key symptom, and AOM should be considered in the differential diagnosis. In AOM, examination of the affected ear may reveal redness, a bulging eardrum, and the presence of fluid behind the eardrum, known as effusion. These findings can be accompanied by temporary hearing loss due to the impaired mobility of the eardrum caused by the effusion. Children, in particular, may become irritable and have difficulty sleeping due to the pain and discomfort (Suzuki et al., 2020).
Strep Throat (Streptococcal Pharyngitis) J02.0: Streptococcal Pharyngitis, commonly referred to as strep throat, is a bacterial infection of the throat caused by Group A Streptococcus bacteria. While the patient does not exhibit a high fever, severe sore throat is a hallmark symptom of this condition and warrants consideration in the differential diagnosis. Strep throat typically presents with a sudden and intense sore throat, which may be accompanied by pain while swallowing (odynophagia). Small, pus-filled patches may sometimes develop on the back of the throat and tonsils (Touitou et al., 2023). It can cause general discomfort and malaise. Diagnosing strep throat often involves a throat swab to identify the presence of Group A Streptococcus bacteria.
Respiratory Syncytial Virus (RSV) Infection B97. 4: Respiratory Syncytial Virus (RSV) is a viral infection that can closely resemble common cold symptoms, making it a noteworthy differential diagnosis, especially in young children. RSV is known to cause significant respiratory distress, particularly in infants and toddlers. While both RSV and the common cold share symptoms like cough, runny nose, and nasal congestion, RSV infections can be more severe, leading to wheezing and increased respiratory effort. In infants, it may result in bronchiolitis, which is characterized by inflammation of the small airways in the lungs (Rainisch et al., 2020). Symptoms can range from mild to severe, and RSV can be particularly concerning for those with weakened immune systems.
Influenza (Flu) J10. 1: Influenza, or the flu, is another viral respiratory illness that initially shares common symptoms with the common cold. While the patient lacks high fever, the flu is known for causing more pronounced and systemic symptoms, making it an important consideration in the differential diagnosis. Influenza often begins with symptoms such as cough, runny nose, and sore throat, which can be similar to the early stages of a common cold (Homagk & Hornung, 2023). However, it typically progresses rapidly, including high fever, severe muscle aches, fatigue, and weakness. Individuals with the flu may experience chills, headaches, and a general sense of malaise. Although the absence of these severe symptoms in the patient makes the flu less likely, it should still be considered in the differential diagnosis.
References
Araki, Y., Momo, K., Yasu, T., Ono, K., Uchikura, T., Koinuma, M., & Sasaki, T. (2021). Prescription pattern analysis for antibiotics in working-age workers diagnosed with common cold. Scientific Reports, 11(1), 22701. https://doi.org/10.1038/s41598-021-02204-3
Homagk, L., & Hornung, L. (2023). New findings to describe the decrease of influenza A/B In 2021. Medical Research Archives, 11(7.1). https://doi.org/10.18103/mra.v11i7.1.4123
Rainisch, G., Adhikari, B., Meltzer, M. I., & Langley, G. (2020). Estimating the impact of multiple immunization products on medically-attended respiratory syncytial virus (RSV) infections in infants. Vaccine, 38(2), 251-257. https://doi.org/10.1016/j.vaccine.2019.10.023
Suzuki, H. G., Dewez, J. E., Nijman, R. G., & Yeung, S. (2020). Clinical practice guidelines for acute otitis media in children: A systematic review and appraisal of European national guidelines. BMJ Open, 10(5), e035343. http://dx.doi.org/10.1136/bmjopen-2019-035343
Touitou, R., Bidet, P., Dubois, C., Partouche, H., Bonacorsi, S., Jung, C., & Cohen, J. F. (2023). Diagnostic accuracy of a rapid nucleic acid test for group A streptococcal pharyngitis using saliva samples: Protocol for a prospective multicenter study in primary care. Diagnostic and Prognostic Research, 7(1), 13. https://doi.org/10.1186/s41512-023-00150-4
